Clinical audits: a dentistry case study

Imagine this clinical scenario: it is the last consult of the day. The client, a sensible cat owner, is having problems giving her cat the antibiotics that had been prescribed. When checking the clinical notes, you can see that the cat had been admitted earlier in the week for feline oral resorptive lesion extractions. You notice that the patient did not receive local anaesthetic nerve blocks at the time, contrary to practice protocol. During the consultation, examination shows that the mouth is sore and the patient requires further analgesia. There is no sign of infection, so you advise the owner to stop the antibiotics and dispense analgesia instead. How should the team get together to discuss the case?

The team hold monthly clinical governance meetings to discuss ways to improve clinical standards, journal articles and evidence, cases and recent CPD that the team has completed. In the next meeting, the team discussed the case and the importance of providing multimodal analgesia for cats, as they commonly mask pain and may continue to eat and drink while experiencing pain. The practice protocol was that all feline dental procedures requiring extractions received local anaesthetic nerve blocks for analgesia; therefore, the team discussed how a clinical audit could be carried out to investigate the use of appropriate analgesia during dental extractions.

Clinical audits are a measurement process that is repeated regularly to find out if clinical care meets quality standards and to measure ongoing engagement

Clinical audits are a measurement process that is repeated regularly to find out if clinical care meets quality standards and to measure ongoing engagement. They enable you to gather data in a robust, methodical manner that can be compared at a later stage. Clinical audits bring the team together, working towards a common goal to ultimately improve patient outcomes.

At the meeting, it was decided to audit the use of local anaesthetic blocks, starting with a retrospective audit to see what standard the team were working at. The aim was for 100 percent of patients to be receiving them.

The first audit

Information was obtained from the practice management system and the clinical notes to see if local anaesthetic blocks had been given over the past month. The audit showed that only 25 percent of cat dental extractions received local anaesthetic blocks.

The main reason given was a lack of confidence in the techniques needed. In response to this, team training was provided to refresh skills and build confidence

A meeting was held and the team were asked to share their thoughts on why the target was not being met. The main reason given was a lack of confidence in the techniques needed. In response to this, team training was provided to refresh skills and build confidence. Local anaesthetic block charts were placed in the dental room so that the veterinary surgeons had easy access to the information, and the veterinary nurses felt empowered to remind the vets of this task. A re-audit was scheduled.

Re-audit

Results from the re-audit showed an increase to 58 percent of patients receiving local anaesthetic blocks for extractions. While ideally 100 percent of patients would be receiving anaesthetic blocks for all extractions, confidence can take time to grow, so training was continually provided, with repeat training scheduled for newer members and those who had an extended period of leave.

Confidence can take time to grow, so training was continually provided, with repeat training scheduled for newer members and those who had an extended period of leave

At a second re-audit, six months later, 78 percent of patients were receiving local anaesthetic blocks. While it is fantastic to see such an improvement, the team continues to remind each other to use anaesthetic blocks, and will continue to re-audit every six months until the target of 100 percent is reached.

Wider impacts

The audit also identified a variety of other factors. Since local nerve blocks were introduced as routine, the number of post-operative complications linked to extractions had reduced. Team members also reported increased confidence in performing the procedure.

One of the veterinary surgeons had recently attended CPD that suggested that antibiotics should not be given routinely, so the team discussed a retrospective audit to obtain a benchmark for the practice and see where improvements could be made

While looking at the dental records, it was also identified that antibiotic use during dental extractions is something that could be investigated further. Patients had been injected perioperatively and sent home on a short course of clindamycin. One of the veterinary surgeons had recently attended CPD that suggested that antibiotics should not be given routinely, so the team discussed a retrospective audit to obtain a benchmark for the practice and see where improvements could be made. The audit showed that 87 percent of patients who had dental extractions were given antibiotics. In a meeting to discuss the results, the veterinary surgeon who attended the CPD hosted a clinical talk, and it was decided that antibiotics should not be routinely used and should only be used where an infection is evident or there is sound clinical reasoning to do so. The vet also went on to assist the rest of the team with their techniques and encouraged the use of an oral rinsing solution. At a re-audit, completed six months later, there was an 88 percent decrease in the use of antibiotics. Another re-audit, a year later, indicated that no patients were routinely sent home with antibiotics if there was no clinical reason to do so.

Reflections

Overall, clinical audits are deemed a useful tool for the team, as they ensure that clinical standards are kept the same for all patients, although all vets still have clinical freedom to follow what is best for each individual patient.

In this case, auditing acted as a reminder to the team to continue training and enable clear clinical guidelines, particularly for new graduates and members of the team who were feeling less confident.