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Improving patient safety and protocols in practice

Clinical audits are essential for ensuring patient safety and well-being, and finding those little inconsistencies which can slip through the net

When I first started reading and hearing about clinical audits, I must admit there was a huge part of me which was thinking “really, more paperwork?” Looking back, I think part of this was down to being, like many, a busy head nurse with an ever-growing pile of paperwork, but also, though I hate to admit it, part of it was down to my age! I thought “we’ve never done this previously, why the sudden need for this?” However, nearly three years on from my first audit, I have to admit… I’m sold!

My first audit was on post-operative complications. Using my practice management system, we added a composite product on all post-op checks and suture removal procedures, which allowed us to log a post-operative complication. This in turn allowed me (and still does) to search for any complications, record them and monitor for any patterns or worrying anomalies. Although this audit didn’t throw up any major problems, there was an action needed to prevent patient interference, as we didn’t routinely use buster collars on our patients. So now we stock and offer body suits to patients as a kinder option to minimise interference with a wound on the body.

Following this audit my brain got ticking and I started to think about other areas in the practice which I could look at and audit to ensure it was working as effectively and safely as possible. Now I carry out 12 audits once a month, as well as the ongoing post-op complications audit which is continuous. Below are some of the topics I audit and why I do so. Some may not be relevant to every practice, but we are a busy mixed animal practice and I want to cover all areas.

Missed telephone calls

I find this audit particularly interesting as it can be used to address potential needs for altering shift patterns or even, ultimately, more staff. We are able to log into our phone system via the internet and we can extract all sorts of data including number of calls received in a day, and also the number of calls which are missed or unanswered. Obviously, missed calls are not desirable in veterinary practice as it could have been someone with a sick or injured animal, but also from a business perspective it is not good to have repeated missed calls. This audit did highlight to us in practice some times where the percentage of missed calls was higher, which required a shuffle around of shifts to ensure more phone operatives were available at those times. The other insightful thing as a business was that it demonstrated there were actually quite a few times out of hours – when our phones are manned by an answering team – that they went unanswered. This audit is something which I now do twice yearly.

Pain scoring

In this six-monthly audit, we look at the pain scores of dogs and cats following routine neutering procedures. Information collected includes species, procedure, vet, pain relief given, any complications and post-operative pain score. The pain score is done once the patient is awake enough to be walked out or fed. The analysis of the audit not only allows for us to see if there is a need for a change to our pain-medication protocols, but would also highlight if there was a link between certain surgeons and a worrying pain score trend, or if we are actually managing patients well for pain control.

Post-operative temperature

This is something which is crucial to ensuring our patient safety and well-being when in for a surgical procedure. Again, this audit is done twice yearly to allow for differences in environmental temperatures. From our anaesthetic monitoring charts, we gather the patient’s age, procedure, species, vet and nurse, lowest and highest temperatures, and temperature when returned to a recovery kennel. This allows us to spot any trends which may occur, such as not preparing for younger or older animals being unable to regulate their body temperatures as well, patients not being adequately warmed or if there are certain staff members who maybe don’t provide enough warming actions to their patients.

Blood pressure under general anaesthesia

This, like the temperature audit, is done twice yearly and records the patient’s age, species, procedure, vet and nurse, and highest and lowest blood pressures.

This audit was a real eye opener for me and is something which we are still very actively working on in practice. We have only had blood pressure monitors to use in theatre for the last two years, and for all the nurses working there this was a completely new concept. The first audit showed some huge areas of concern with lots of low blood pressure measurements. As a result, we instigated some basic CPD training to ensure everyone knew how to use the machine correctly, why a BP over 60mmHg is crucial during anaesthesia, things to check if receiving a low reading and the actions to be taken. The re-audit did show some improvement; however, there were still some issues, so we spoke to the nursing team and discussed why this is worrying, and what we wanted them to do about it. We also spoke to the vets, to ensure they were actually asking the nurses what the BP readings are, so if low they could question it and recommend action. The next audit showed a marked improvement and I more often see the nurses using fluids, lowering anaesthetic agents and actually discussing the BP with the vets, which is great for patient safety.

Equine ACTH medication and monitoring

We are really strict about medicine assessments for our small animal patients on long-term medications; however, one day when looking at a medication request for an equine patient who was receiving medication for Cushing’s disease, I was shocked to see that this patient hadn’t actually been seen for nearly two years, and when she was last seen for bloods the levels were really high and the medication dose adjusted. This led me to look at all patients prescribed this equine Cushing’s medication and it revealed a huge hole in our dispensing system: multiple horses had shown high blood test levels and either started medication or had their medication altered, and then had never been seen again. So we implemented a practice protocol regarding the frequency of blood tests for these patients. The vets and other clinical staff were all amazed at how this had been slipping through the net, but then surely that’s the point of the audits!

Equine faecal egg counts

Once yearly I audit all equine patients who have had a faecal egg count performed – this is something which we recommend and promote quarterly to our horse owners to minimise the overuse of antiparasiticides – and analyse whether, from the results, the horses had needed worming or not, to prove whether it is worth the printing and postage of flyers to equine clients.

Now this may seem a bit boring and in the grand scheme of things a little pointless; however, in my most recent audit of this, a high percentage of the horses tested had required worming, and when looking at these patients, a high percentage had actually recently suffered from colic. This gave us the excellent opportunity to relay this information to our equine clients, not only to prevent parasiticide resistance, but also to help prevent parasite-induced colic.

Puppy worming

Our practice’s worming regime is monthly from eight weeks of age until six months of age. I run puppy school and had noticed a few people mentioning that they hadn’t been told to worm monthly, but quarterly (which is our adult worming recommendation). When we dispense our worming medication, there is the option of two labels, already preloaded with directions: one with the adult dosing which comes up first and one with the puppy dosing which comes up second. An audit of all puppies seen in a three-month period revealed that a huge percentage of puppies were not having the correct label selection placed on their worming medication. This is a concern on many levels: the well-being and health of the puppy as they need regular worming to break any lifecycles; the potential zoonotic risk to the owners if their puppies aren’t kept up to date with worming; and also the business implication of missing out on seeing that puppy monthly to weigh it, dispense a worming medication and discuss any developmental issues the owners may notice.

In summary

The other few audits I do are really business focused around our specific practice, but hopefully the examples and information above will spur on your inner clinical auditor. Get the team involved – my nursing team helps me collect information and data, and then, once the audit is performed, I message the whole clinic with the results. This includes when there has been an improvement or a positive outcome seen, as people need to hear the good as well as the negative.