Surgical Audit Introduction Notes

Surgical Audit

Competency Of Surgical Audit

Describe the planning and conduct of surgical audit.

Surgical Audit Introduction

• Surgical audit can be defined as the systematic unbiased review of surgical practice with the objective of recognizing deficiencies and improving standards of care.
• It involves critical analysis by peers and any lapses or deficiencies detected during the course of the treatment of the patient are listed. An audit should aim at improving the standards laid down in the respective departments.
• It should also aim at studying morbidity and mortality. An audit is helpful in studying not only the quality of services provided by the department but is also useful to the individual surgeon to keep track of his/her own personal outcome data.
• Contributing to a clinical database ensures that a surgeon’s own performance is monitored continuously. It should be compared to national data to ensure the accepted standards are achieved.

Read And Learn More: Basic Principles Of Surgery Notes

Examples For Surgical Audit

Example 1: National database of laparoscopic cholecystectomy shows that in about 3–4% of cases, laparoscopic surgery needs to be converted to open surgery.

• However, if a surgeon’s own data records show more than 10% conversion rate, he needs to audit and find out the reason behind this high failure rate.
• Thus, an audit helps improve treatment policies, standard of care and may be more economical.

Example 2: A hospital may have set certain standards for thyroidectomy such as “identification of the recurrent laryngeal nerve (RLN) should be done in all cases and that is the best method to avoid injuries to this nerve”.

• Audit of recurrent laryngeal nerve paralysis after total thyroidectomy would include a careful check of the operative notes to see how many surgeons identified the RLN at surgery and how many did not.

Audit Types

Essentially, two types of audit may be encountered:

National Audits And Local/Hospital Audits.

• Both are designed to improve the quality of care. National audits should be driven by needs identified during the local and hospital-based audits that are closest to the patient.
• Recently an audit of treatment given to COVID-19 patients was done to check whether all the guidelines given by the government were followed.
• Topics for hospital-based audits are often identified at the departmental morbidity and mortality meetings, where issues related to patient care are discussed. Tuberculosis is a notifiable disease and it is a national issue.
• So, hospitals can audit these types of cases. After report from the local hospitals, a national audit can be designed to be completed by the local audit department and surgical teams.
• Audit can also be categorised and used to study different aspects of patient care. For example, an audit of smoking behaviours of patients can be categorised into:

Structure Of Care:

Refers to the resources required, e.g. the availability of a smoking cessation clinic in a locality.

Process Of Care:

Refers to the actions and decisions taken by practitioners together with users, e.g. waiting times for an appointment at the smoking cessation clinic.

Outcome Of Care:

Measures the physical or behaviour response to an intervention, e.g. the number of smokers who quit smoking for 1 year.

Audit Cycle

Important steps of audit cycle (audit process) are as follows:

1. Define the audit question in a multidisciplinary team.
2. Identify the evidence and current standards or guidelines.
3. Design the audit to measure performance against agreed standards based on strong evidence. One needs to seek advice and ensure that institutions have agreed to undertake the audit.
4. Define an agreeable timeline.
5. Conduct the audit.
6. Analyse results and compare performance against agreed standards.
7. Undertake gap analysis:
   • If all standards are reached, reaudit after an agreed interval.
   • If there is a need for improvement, identify possible interventions such as training and agree with the involved parties.
   • Implement the changes.
8. Allow sufficient time for changes to be included in the new guidelines.
9. Reaudit, analyse, and discuss whether the practice has improved.

What To Audit?

• Surgeons can decide about the topics based on the need/ requirement. It is a good idea to find out the common surgical procedures done in the hospital and select a topic related to the procedures. Some examples are given below.

Simple questions with straightforward outcomes:

Example: Did all patients receive antibiotic prophylaxis prior to surgical incision?

Simple measurements and interventions:

Are all patients appropriately assessed for possibility of deep vein thrombosis (DVT) risks and received appropriate prophylaxis during their hospital stay? How many lymph nodes are removed after modified radical mastectomy performed for carcinoma breast or hemicolectomy for carcinoma colon.

Audit anything that you are not certain about:

Fluid requirements in acute pancreatitis or non-operative management of splenic injuries, etc.

What Makes A Good Audit Topic?

Priorities in your hospital/department:

• For example: Diabetic ulcer on the leg is common not only in our hospital but also in India and it is a relevant topic.
• A topic in an area of medicine that interests you and you may choose the topic.

Re-audits of previous projects:

If there is a previous audit that was never re-audited and the loop was not closed, then this is a good audit.

What Is Not An Audit?

1. Comparison of treatment or interventions: Example: Comparing antibiotics followed by drainage versus antibiotics without drainage for breast abscess.
2. Outcomes of novel treatment: Example: Results of endoscopic cystogastrostomy.
3.  Outcomes of novel service: Example: Role of CECT scan in nutrition.
4. Pure research or service evaluation: Example: Finding a new technique for hernia repair.
5.  Census work

All these are considered original research work and not an audit.

Steps Of Audit

The audit process is divided into five official steps and the cycle is only considered complete if all steps are performed. The five steps of audit cycle are as follows:

Step 1: Define the standard to be reviewed—American College or Royal College guidelines, or in sepsis— Surviving Sepsis Campaign 2021 guidelines, etc. It is important to consider local policies also.

Step 2: Decide what data to be collected? Who will be collecting the data and is it retrospective or prospective?

Step 3: Compare standard current practice with the actual performance data collected from the department. Evaluate how well the standards were met and if not, identify reasons for this.

Step 4: Recommend a change, if required, agree to the changes and then implement. Example: After an audit from the hospital, it is found that when clindamycin
was used, ulcers healed faster in diabetic patients.

Step 5: Close the audit cycle loop—once the suggested change is implemented, one cycle of audit is closed.