Lou the Vet Nurse tells us why she finds clinical audits so useful, and how you can follow in her footsteps.
At first you might think of a clinical audit and automatically think ‘boring’! However, the evidence and data it brings can be extremely useful and interesting in practice when it comes to improving clinical standards. This is also a great way of performing surveillance and trouble-shooting problems.
Two years ago I took on the role of Clinical Nurse Lead within my practice. At first we did not know what this would entail, but having now developed the position, my current duties include:
- Reading up-to-date evidence-based medicine and clinical nursing journals to review them against what we are currently doing
- Providing nurse training and support
- Setting, undertaking, reviewing and reporting our clinical audits to the team
- Monitoring whether clinical protocols and standards are maintained
- Organising additional CPD/training for the team
- Trouble-shooting accidents/mistakes with the Head Nurse & Head Vet
We all get used to doing the same tasks, day in, day out, but when was the last time you stopped and reviewed if they are effective? How many of your bitch spays have required rescue analgesia? How many dog castrates have come back with infected op sites due to misunderstanding of the treatment plan by the owner – or was this due to the pre-operative scrub technique? Do you keep having errors with your dispensed prescriptions? Is it because they get completed in a busy part of the practice where it is hard to concentrate? Do you keep having patients coming back to kennels from theatre with hypothermia? What warming techniques are being used? This is where audits come in.
Sometimes we need to STOP, gather information, review what we are doing and why. Sometimes you will find that no changes need to be made, but often you will discover you can help influence important changes to improve patient care and welfare.
How did I start doing audits?
I started off using the vetAUDIT spreadsheet to monitor the complications seen in our post-operative dog and cat neuters. This spreadsheet is quick and easy to complete. At the end of each month I review the percentage of problems we encounter and send a report to the team.
We found that we were often having problems with post-operative wound care with our dog castrates due to patient interference, so we reviewed the way we give post-operative advice and gave owners alternative options to prevent licking. It also highlighted other complications like suture reactions and gastrointestinal disturbances.
At the end of the first year of auditing I reviewed our statistics against the benchmarked figures published by RCVS Knowledge on the vetAUDIT website. Our month-to-month statistics were largely average but our overall 12-month figures appeared to be slightly better than the benchmarked percentages. We are continuing to review all elements of our post-operative care advice.
In 2017 I completed an anaesthesia certificate. It was excellent and, unsurprisingly, I came back wanting to make changes to update and improve the way we did things. Understandably, without evidence of ‘why’ things should be changed, many were keen not to change. But now that we have the results of our audit, and have discussed the findings, we have made a lot of improvements collectively, as a team.
Other audits we completed looked at lots of different elements of what we do, reviewing things such as analgesia choices, additional analgesia requirements, drug choices and any complications such as hypotension or hypothermia. The results highlighted some important points and gave us evidence which we discussed as a team to decide what changes should be made to our anaesthesia and analgesia protocols.
For example, in some cases, blood pressure monitoring was not being completed for feline patients due to a lack of available monitors. Of those who did have their blood pressure monitored, many were hypotensive for some, or part, of their procedures. This made us stop, review the drugs we were using, and troubleshoot other influencing factors. It was also evidence for our practice that additional monitoring equipment was very much required. In addition, we found that cats were, on average, having IV catheters placed less often than dogs. We discussed this and concluded that from now on, all feline patients should have IV catheters placed to enhance patient safety and improve efficiency if intravenous fluids were required in the perioperative period. Now, you may be shocked to read that the practice that ‘Lou the Vet Nurse’ works in didn’t place IV catheters in every cat neuter – but this is the reality of many practices. We believe that our practice provides a high standard of care, but we are always striving to be even better and improve what we do.
This is how audits can help you use the evidence you gather and the data you review to understand the level of care that you and your team are providing. Once you know this, you can understand where and how you can make improvements which can lead to better outcomes for your patients, clients and to your own working environment. As I said above, you won’t always need to change, but sometimes it might really open your eyes!
But Lou, what sort of thing can I do an audit on?
When it comes to audits you can really look at just about everything…
– Post-operative wound infections
Was this due to misunderstanding of the treatment plan by the owner? Skin prep technique? Do you need to change the timings of when you see patients back?
– Post-operative temperatures (specifically looking at the incidence of hypothermia)
What warming methods were used? Are patients pre-warmed? Did this impact the patient’s anaesthetic? Did this impact the patient’s recovery?
– Pain-scoring bitch spays on recovery (how many needed additional analgesia)
Do many bitches require additional analgesia? Do protocols need to be revised?
– Pain-scoring for cat spays on recovery (how many needed additional analgesia)
– Frequency and severity of post-operative gastrointestinal disturbances
Did the patients eat on recovery? Did they eat once home? Are they being dosed their NSAIDs accurately?
– Pets not being brought back for post-operative check ups
Are pets being brought back in? Are clients aware the check is free of charge? Why are they not coming in?
How you can get started in your practice
Audits are a great tool. You can keep it basic then choose to work on key areas of your practice. Time management is always a big consideration, so I try to allocate one to two hours per week to record and review the gathered data.
You can get started the same way I did, by using vetAUDIT (www.vetaudit.rcvsk.org) to measure post-operative complications of neutering. Take part by submitting your data, which will be anonymised and analysed free of charge. RCVS Knowledge will then send the consolidated results back to you so you can compare them to your own.
To take your clinical auditing one step further, you can use the tools provided by RCVS Knowledge on their website (www.rcvsknowledge.org/quality-improvement), including templates, step-by-step guides and even e-learning courses to introduce you to the basics of benchmarking, guidelines, checklists and the various types of audits.
Audits are not there to ‘point the finger’ at individuals; they are there to screen for problems to help us work better together. Get your team involved, share your findings and encourage everyone to speak up with their ideas and use their trouble-shooting abilities to improve whatever the area is that you are working on. Be your own governance advocates; be your own knowledge champions!
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