Clinical audit for referral guidelines: A problem solving tool

Transcription

1 Clinical audit for referral guidelines: A problem solving tool Denis Remedios Northwick Park Hospital, Harrow, UK RCR Clinical Radiology Audit Sub-Committee

2 Clinical audit: definition From Clinical Audit in Radiology 100+ recipes. RCR The systematic, critical analysis of the quality of medical or clinical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient.

3 Clinical guidelines: definition From Clinical Audit in Radiology 100+ recipes. RCR Statements of principle which have been developed in order to assist practitioner and patient decisions about appropriate health care in specific clinical circumstances. Guidelines are concepts of good practice against which the needs of the individual must also be considered. Guidelines are not rigid constraints upon clinical practice. They are usually produced and agreed by a national body.

4 Clinical audit in the UK: responsibility and resource

5 Clinical audit and guidelines Clinical Audit in Radiology: 100+ Recipes. Editors: R Godwin, G de Lacey, A Manhire. RCR ISBN

6 Clinical audit and continuous quality improvement Clinical Governance and Revalidation: A Practical Guide for Radiologists. Editors: G de Lacey, R Godwin, A Manhire. RCR ISBN

7 Audit for guideline dissemination Clinical Audit in Radiology: 100+ Recipes. RCR 1996.

8 Audit for guideline compliance Clinical Audit in Radiology: 100+ Recipes. RCR 1996.

9 Audit Live 2008: Guidelines for standards Your IVU Radiograph Series Number of radiographs obtained during intrav enous urography (IVU). IVU Examination Times Examination times for intravenous urography (IVU). Resuscit ation Skills Resuscit ation skills within the Department of Clinical Radiology. A risk management audit. Resuscit ation Awareness Audit of pract ical knowledge of advanced resuscitation skills expected of medical st aff in a radiology department Training in Gall Bladder Ultrasound Adherence to department al protocol during routine examination of the gall bladder by those in training. Needlestick injury Contaminat ed needlestick injury to a member of staff or the public is a serious health risk and could lead to litigation. Pre-Op CXR for Elective Surgery Pre-operativ e chest radiographs prior to elective surgery. Bone Scan Images Image qualit y of bone scans. GP Chest Radiography Appropriateness of request s for chest radiography from GPs. Lumbar Spine Lumbar spine radiography. Out-of-Hours Imaging Appropriateness of out-of-hours examinations. W aiting and Appointment Times W aiting time of patients prior to appointment. Staff Dosimetry W earing of f ilm badges during fluoroscopic procedures. Fire Training Attendance of staff at fire lectures. Head CT Lens Exclusion Exclusion of the lens of the eye in routine head CT examinations. Securit y Staff ID Departmental securit y staff identif ication ( ID). Invest igation of asymptomatic microscopic haematuria in adult s Assessment of compliance with agreed protocol for investigation of asymptomat ic microscopic haematuria in adult s. Contrast and Drug Recording Recording of dose, make, batch number and expiry date for contrast medium used for intravenous urograms (IVUs). Foreign Body Radiography Presence of a localising marker in radiography for presence of foreign bodies. GP ref errals: are the report s addressing the quest ions posed? Audit of generic reporting and effective communication with GPs. Consent for a Radiological Examination Adequacy of consent for radiological procedures. Pregnancy Questioning The exclusion of pregnancy in patient s who are undergoing radiography (application of the 28 day rule). Radiology Reporting by Other Doctors Effect iveness of arrangement s to transfer the responsibilit y for the reporting of specif ied plain radiographs to ref erring clinicians. Finger Doses Radiation dose to the pulp of the index finger of staff handling syringes containing radionuclides. Urgent CT Brain Scans and LPs Lumbar puncture (LP) following requests for urgent CT brain scans. Radiography in Acute Back Pain Request s for lumbar spine radiography in patients with acute lowback pain. GP Ultrasound Requests Indications for GP ref errals for ultrasound (US) examination of the upper abdomen. Majax Call-In Department of Clinical Radiology call-in list for use in case of a major accident (majax). Adequate Completion of Radiology Request Forms Adequacy of completion of radiology request forms. Gonad Protection II Use of gonad protection. Imaging in symptomatic breast disease An audit to assess compliance with imaging guidelines within the symptomatic breast clinic. Cancer St aging Staging of common cancers using CT or MRI. Reporting: GP referrals for plain radiography General practitioners depend upon timely and accurat e report s for the management of their patients. An individual radiologist s workload The number of reports issued by an individual radiologist.

10 AuditLive

11 RCR AuditLive: Guideline compliance

12 Guidelines and audit: encouraging local projects RCR annual scientific meeting invites submissions of local Internal audit projects for competition 103/295 RCR audit poster entries used a standard based on a guideline 20 Audits were based on RCR referral guidelines, Making the best use of clinical radiological services

13 Audit poster competition: RCR Guidelines for standards Reducing the demand for lumbar spine radiography from General Practice Dr Christopher Keeling-Roberts 1st 2003 An audit of unenhanced multislice CT (CT KUB) for investigation of acute renal colic in Leeds Dr F U Chowdhury 2006 Awareness of Radiation Doses Incurred in Diagnostic Investigations Dr Karen A Duncan 2006 Ultrasound requests: Are we being inappropriately overloaded? - An audit. Dr Andrew Winterbottom 2006 Are abdominal radiographs being overused in the assessment of acute abdominal pain? Dr Daniel J Bell 2005 Making the best use of Imaging in Stroke patients Dr Sriram Vundavalli 2005 An Audit of Water Soluble Contrast Enema Referrals Dr S D Allen 2004 An audit of body CT for investigation of occult malignancy Dr S D Allen 2004 Optic nerve ultrasound in assessment of raised intracranial pressure - its role in clinical practice. Dr LC Bamford 2003 Mento-Occipital Facial Radiographs: A Waste Of Time? Dr L.C. Bamford 2003 An Audit of adherence to IRMER regualations in requesting and assessing chest radiographs permormed on acute medical admissions. Dr Brendan Barry 2003 Current day utilization of abdominal radiographs Dr K Gopal 2003 An Audit Of Carotid Artery Doppler Ultrasound Requests Dr RP Houghton 2003 Lumbar spine xray audit Dr L A Kurban 2003 An Audit of a Scaphoid Fracture Protocol Dr J Larsen 2003 Audit of Skull Radiography in Paediatric Head Injury at Blackpool Victoria Hospital Dr Demetris A. Patsios 2003 Audit of Doctors' Knowledge of Radiation Exposure Dr J Steel 2003 In suspected subarachnoid haemorrhage (SAH) how many patients have a lumbar puncture (LP) after a negative CT? Dr A Basu 2002 Justification in out of hours radiology Dr J D Birchall 2002 Acute Abdomen Imaging - An Audit Dr Soo Mak 2002

14 Local audit for justification

15 RCR Audit Competiion: Awareness of Radiation Doses Incurred in Diagnostic Imaging

16 RCR Audit poster winner 2008: lumbar X-rays reduced by 70%

17 York s local measures to ensure appropriate use of lumbar X-rays: justification, communication & audit

18 Value of local clinical audit for justification Potential to reach aspirational targets for improvement rather than a minimum governance level Ability to target problem areas which have low levels of compliance Motivates local referring and radiological practitioners to improve Inexpensive to perform

19 National audit and statistical process control All departments are invited to submit Use of control limits (usually at 3 sigma) to identify outliers with special cause for variation in performance below (or above) mean May be applied to a cross-sectional sample of (funnel plot) or as a comparison over time (control chart)

20 Control charts Control limits differentiate between common cause and special cause variation Useful to identify departments needing special measures for improvement & also those with model performance who may have novel ways of working Mohammed et al. Br J Gen Pract September 1; 55(518):

21 Funnel plot: common cause variation. Overall process requires improvement 100% 90% 80% 70% 60% Departments 50% Mean UCL LCL 40% 30% % % % Sample size

22 Funnel plot: special cause variation. Outliers identified and improved 100% 90% Percentage of routine orthopaedic cases reported within 13 weeks 80% 70% 60% 50% 40% 30% 20% Departments Mean UCL LCL 10% 0% Department IDs

23 Clinical audit & justification: Take home points Local internal audit is inspirational & aspirational Identification of time and responsibility essential Statistical process control may help to identify where & when to intervene