“When you realise your routine post-op neutering results may be far from routine!”

In this blog for Clinical Audit Awareness Week 2019, Knowledge Award winner Lou the Vet Nurse tells the story of how she discovered the inherent value of conducting audits in veterinary practice. 

Two years ago I started using vetAUDIT to help my practice look at our post-operative complication rates. At first, I really didn’t think it would highlight much, and that it was probably a big waste of time. Oh, how narrow-minded I was!

When you work in a busy practice like me, you may have up to three or more people consulting at a time. If each person sees one patient with a complication in a day, on the surface they will think ‘oh well, it’s only one’ — but when you audit, it can reveal that it is, in fact, a much bigger problem.

When I got to the end of the first month (back in October 2017), I was really surprised how many patients had minor post-op complications. At this point, I went onto the vetAUDIT website to compare my statistics. vetAUDIT provides the results of collated data from other practices, so you can see if your practice is above or below average. All practices involved are invited to submit their anonymised data, and it is added to a huge database. From this database, vetAUDIT calculates the average figures, guiding us to the current national benchmarks.

Over the first six months, we were slightly better than the national average, and I thought GREAT! However, over the next six months, things got worse… before they got better again!

For a while, our statistics didn’t hugely improve – and yes I did find it a bit frustrating — but I’ve learnt that it takes time to embrace quality improvement (QI), to think about what was causing the problems, to plan how to take action and to then get my team on board.

From just the first few months, I was really surprised to see how many complications (although only minor!) we were seeing — and my team were surprised too.

So what were the most common complications seen in our post-op neutering audits?

Minor complications:

• Erythema
• Swelling
• Seromas
• Clipper rash

More serious complications:

• Wound infections
• Suture reactions
• Patient interference/self-suture removal
• Wound breakdown
• Diarrhoea and/or vomiting
• Prolonged lethargy
• Inadequate analgesia

Over the two years since, our results have varied month-to-month, but overall we have made changes which have been reflected in our audit results.

Each of the complications listed above were reviewed:

• Why did it happen?
• What can we do to prevent it happening again?
• Why does it keep happening?

We have found that most of our complications are minor and usually are a result of patient interference.

To start with, we were having some canine patients returning with post-operative wound infections.

Was it to do with what we were doing? Was it to do with post-op care at home? Both needed to be reviewed!

Skin preparation for surgery

To begin with, we reviewed our skin prep and wound management; I organised an evidence-based CPD session on surgical skin preparation for our nursing team. Following this, we adapted our skin-prep technique. We also ordered gentler, small cat clippers to help protect the fragile scrotal skin from clipper rash.

Preventing patient interference

When patients were discharged, we gave owners the options of having either a buster collar or pet shirt, and we have found that we get much better owner compliance with the pet shirts. Better compliance means less licking of surgical wounds and less post-op wound infections, which equals better statistics and, therefore, better treatment!

Post-op gastro upsets

Do you ever see patients back with diarrhoea 24-72 hours after having an anaesthetic? Have you ever considered why? This is one of the complications sometimes seen in our audits.

There are many factors which may cause a stomach upset, so it is important to think through what steps we can take to reduce the frequency of this occurring.

For example, when a patient comes in for an operation we often feed them a different diet to what they normally have. We should always ask owners if their pet has a sensitive stomach or if they are on a special diet before we feed them post-operatively. If either of these are the case, ensure you have some of their usual food available to feed them. This is a question to add on to your consent form, if you don’t have it on there already.

Nosocomial infections

Nosocomial infections are obviously not what we want! Make sure all patients that have diarrhoea and/or vomiting are barrier nursed and isolated from healthy patients. Due to the risk of salmonella, all raw-fed patients (even healthy ones) should be barrier nursed. Make sure any food bowls used to feed raw patients are disinfected and washed separately from others.

Infection control screen

Is it time for an infection control review, and for swabs of the practice to be taken, to ensure you are not growing any nasties? Within my practice, we appointed two nurses as infection control ambassadors. They went on an infection control CPD day and have since reviewed, audited and updated our infection control protocols.

Why else might they get diarrhoea post-op?

Are they having gastrointestinal hypoperfusion peri-operatively? Is this why we have had a loss in GI integrity? Are we monitoring blood pressure (BP)? If not, why not? Blood pressure monitoring should be performed in every patient under anaesthesia.

NSAIDs can alter GI blood flow, so it may be worth discussing with your veterinary surgeon when the most appropriate time to administer them is:

• Pre-op if BP is normal?
• Peri-op once you know BP is maintained and stable?
• Post-op once they are awake and BP is normal?
• Post-op once they have eaten?

This is, of course, for your vet to decide!

Pre-emptive analgesia is advantageous, but ensuring normotension is important too. Consider multimodal analgesia and discuss other analgesic techniques for the peri-operative period.

Stress?

As you probably well know, when we get scared or excited, we can get diarrhoea due to stimulation of the sympathetic nervous system. This may play a part in our patients too if they are worried or stressed.

Who knew an audit could make you spend so long thinking about poo!

Factors out of our control

We also considered other potential influencing factors that may be more out of our control.

How we give post-operative information to owners is worth looking at. Do you routinely give written instructions or just talk them through their pet’s post-op care? Written instructions should always be provided for them to refer to once home. We provide them with so much information, and we should consider that many people may be unable to retain all the post-op information that we take for granted. I often talk them through their pet’s post-op care, leave them to read the discharge sheet whilst I go and collect their pet, then answer any questions they may have when I return.

Other things to think about… do dogs have a clean, freshly washed bed at home to lay their surgical wound on? Is it time to request owners wash their dog’s bed prior to their operation? Perhaps it is!

We also always tell owners to rest their dogs – but have you ever tried to ‘rest’ a young dog? It is hard! Follow up by ensuring you give owners help and advice on how to keep their pets stimulated and occupied during this period. Why not tell them about interactive feeders and toys which make them use their brain?  We can wear them out mentally instead. Otherwise, owners may be tempted to let them run around – and what does that cause? Big swollen scrotums or seromas!

The weather even seems to play a part!

Interestingly, in the summer months (April–July) we have more complications than in winter months. Why is this? Because warm and moist weather is a better condition for pathogens? Are owners less likely to rest their dogs because they just want to get outside and enjoy the weather? Quite possibly.

Complication percentages in cats have been far lower than in dogs. Complications we have seen have been:

• Erythema
• Self-suture removal (when skin sutures are used)
• Seroma
• Suture reactions (spays)
• Diarrhoea and/or vomiting

Key changes have been made after reviewing the above. All cat spays now have intradermal sutures placed, and we find wound interference is far less of a problem. As with our bitch spays, we also offer owners medical pet shirts for the cat spays to go home in. Compliance does seem to be better than when a buster collar is used. However, ‘cats being cats’ and the sensitive animals that they are (!) means that pet shirts are not always tolerated either.

Looking at our year-to-year statistics, our cat spay complication rate has been better than the national average — which is great.

At present, we do not routinely always see cat castrates back for their post-op check unless their owner is concerned. This is something I am keen to change in the future, as, although ‘no news is good news’, we could miss key abnormalities that have not been detected or perceived by the owner.

I have learnt so much over the past two years, and it has inspired me to audit and look at other key areas of my practice. Even if you complete an audit and find that you are doing great, there is always room for improvement!

You might look at our results and think, ‘Well Lou, they’re not ground-breaking…’ but, as mentioned earlier, there are many things that are out of our control. Progress is progress!

However, we must take responsibility and review the areas we can investigate. QI is a work-in-progress and a continuous process.

Veterinary nursing is a very reflective job – we should all be thinking about how ‘X’ went, and how we might do things differently next time.

Can you see how auditing your post-op ‘routine’ patients  can create so much for you to think about and review? Until you look, you just don’t know!

Get your team on board and think about what their individual areas are – can you delegate the different  areas of the audit? You don’t have to be a veterinary nurse or surgeon to undertake an audit… all members of your team could become QI ambassadors and champion positive change and improvements in practice.

What can YOU do? What can WE do? How is YOUR PRACTICE doing?

Time to start auditing!