Commentary: Validity of assessing change through audit

Obstetric anaesthesia: an approach to improving the standards of services

There has been considerable discussion about obstetric anaesthesia standards and about the role of peer review in quality improvement. We carried out two postal surveys in 1990 and 1991 in major obstetric departments in Northern England, in order to assess practice and facilities against professionally derived standards, with the aim of stimulating and reviewing change. The reference standards were a local adaptation of those produced by the Obstetric Anaesthetists Association, and covered operating facilities, anaesthetic equipment, management and manpower, training, and protocols. In 1990, considerable variation in practice and facilities was identified with deficiencies in all hospitals. After feedback of the results of the first survey, a further survey conducted in 1991 identified improvement in 23/26 standards. Reference to standards was widely included in business plans and contracts for services. Following further feedback of the second survey and some revision of standards, a third survey was carried out using site visits. This revealed further improvement in 8/26 standards, but apparent deterioration in 11/26. The overall change from the first to the third survey was of apparent improvement in 15/26 standards and deterioration in 6/26. Surveys of practice against professionally derived standards and the targeted feed back of results can lead to improvements in practice and facilities.

Description of local adaptation of national guidelines and of active feedback for rationalising preoperative screening in patients at low risk from anaesthetics in a French university hospital

OBJECTIVE

To describe the effect of local adaptation of national guidelines combined with active feedback and organisational analysis on the ordering of preoperative investigations for patients at low risk from anaesthetics.

DESIGN

Assessment of preoperative tests ordered over one month, before and after local adaptation of guidelines and feedback of results, combined with an organisational analysis.

SETTING

Motivated anaesthetists in 15 surgical wards of Bordeaux University Hospital, Region Aquitain, France.

SUBJECTS

42 anaesthetists, 60 surgeons, and their teams.

MAIN OUTCOME MEASURES

Number and type of preoperative tests ordered in June 1993 and 1994, and the estimated savings.

RESULTS

Of 536 patients at low risk from anaesthetics studied in 1993 before the intervention 80% had at least one preoperative test. Most (70%) tests were ordered by anaesthetists. Twice the number of preoperative tests were ordered than recommended by national guidelines. Organisational analysis indicated lack of organised consultations and communication within teams. Changes implemented included scheduling of anaesthetic consultations; regular formal multidisciplinary meetings for all staff; preoperative ordering decision charts. Of 516 low risk patients studied in 1994 after the intervention only 48% had one or more preoperative tests ordered (p < 0.05). Estimated mean (SD) saving for one year if changes were applied to all patients at low risk from anaesthesia in the hospital 3.04 (1.23) mFF.

CONCLUSIONS

A sharp decrease in tests ordered in low risk patients was found. The likely cause was the package of changes that included local adaptation of national guidelines, feedback, and organisational change.

Investigation of microbial keratitis: an audit from 1988-1992

An audit was performed of the investigation of 263 cases of microbial keratitis severe enough to be admitted to the Manchester Royal Eye Hospital over the 5-year period, 1988-1992. A pathogen isolation rate of 37% was noted during the first year which increased to 79% (p < 0.05) by the final year of audit. In late 1991 a new method of inoculating enrichment broths was introduced, which also contributed by increasing the yield from corneal scrapes. The audit process resulted in the development of and adherence to our investigation protocol, improved communication between Manchester Royal Eye Hospital and the microbiology laboratory, the implementation of a new investigatory method, and a significantly improved microbial isolation rate.

Comparison of short term outcomes of open and laparoscopic cholecystectomy

OBJECTIVE

To compare the three month outcome of open and laparoscopic cholecystectomy.

DESIGN

Prospective assessment of outcome for a series of patients encompassing the introduction of the laparoscopic technique.

SETTING

One teaching hospital.

PATIENTS

269 patients admitted for open cholecystectomy between January 1989 and March 1992 and 122 admitted for laparoscopic cholecystectomy between January 1991 and March 1992.

MAIN MEASURES

Patients' reported symptoms and self assessed scores with the Nottingham health profile before operation and at three month follow up. Incidence of complications and adverse events after discharge.

RESULTS

Similar improvements in symptom rates and health scores were seen regardless of surgical technique. A lower rate of postoperative complications was seen in the patients given laparoscopic surgery (6/95(6%) v 45/235(19%)), and their mean length of stay was lower (4.5 v 9.8 days). Similar results were obtained when the analysis was restricted to a subset of fairly uncomplicated cases (patients aged 60 or less without other illnesses on admission who were not undergoing emergency or urgent surgery), which constituted a larger proportion of the group given laparoscopy (35/95(37%) v 40/235(17%)). Between these two groups no significant difference was seen in the frequency of relevant readmissions to hospital or visits to general practitioners or accident and emergency departments.

CONCLUSION

Ideally, a new surgical technique would be evaluated in a randomised trial. In the absence of such a trial, this observational study provides some evidence that the switch from open to laparoscopic cholecystectomy has brought benefits, particularly in terms of reduced length of stay in hospital. A range of clinical and patient derived indicators suggests that these gains have not been associated with a reduction in the quality of the outcome at three months.

Effect of guidelines on management of head injury on record keeping and decision making in accident and emergency departments

OBJECTIVE

To compare record keeping and decision making in accident and emergency departments before and after distribution of guidelines on head injury management as indices of implementation.

DESIGN

Before (1987) and after (1990) study of accident and emergency medical records.

SETTING

Two accident and emergency departments in England.

PATIENTS

1144 adult patients with head injury in department 1 (533 in 1987, 613 in 1990) and 734 in department 2 (370, 364 respectively).

MAIN MEASURES

Recording of relevant symptoms and signs as determined in the guidelines; presence of, indications for, and rates and appropriateness of skull x ray examination and admission.

RESULTS

The median number of guidelines variables recorded for all study periods ranged from 7 to 9 out of a possible maximum of 27. For key decision making variables the presence or absence of penetrating injury was least likely to be recorded (< or = 1%) and that of loss of consciousness most likely (> or = 75%). Altogether, the proportion of patients receiving skull x ray examination or admitted varied from 25%-60% and 7%-23% respectively; overall, 69% (1280/1856) and 64% (1177/1851) of patients were managed appropriately. However, no consistent change occurred in the departments between the study periods. For instance, in department 1 the proportion of appropriate x ray examinations rose significantly after distribution of the guidelines (from 61% (202/330) to 73% (305/417)) and appropriate decisions on whether to x ray or not also rose (from 65% (340/522) to 72% (435/608)). There was no significant change in department 2, although the proportion of appropriate admissions fell (from 33% (55/166) to 15% (19/130)).

CONCLUSIONS

Recording practice and decision making were variable and had not consistently improved after dissemination of the guidelines. Strategies are required to ensure effective implementation of guidelines.