Guest Editorial

chokkalingam

Clinical Audit: An introduction, Why and How to do one

Dr. S. Chockalingam,

Senior Consultant in Orthopaedics

Clinical Audit Lead, Kauvery Hospital, Trichy

Total knee replacements are one of the commonest and most successful surgeries in Orthopaedics. It is a major surgery and hence associated with post operative pain which needs to be managed well for successful outcome.

Traditionally we had used opiates for pain management which unfortunately led to either nausea and vomiting, hence often under used. Patient controlled analgesia, a significant progress in 1970s, took time to reach practice. We were using it routinely in our practice in 1990s.

An analysis of post operative pain relief showed that quite a number of patients were experiencing significant pain in spite of the patient-controlled opiates administration. In 2002, We looked into practice elsewhere and introduced epidural analgesia for post operative pain relief. This showed significant improvement with good post operative pain control and reduction of opiates induced side effects. This was a first step to Pre-emptive analgesia.

At Kauvery hospital, we were doing total knee replacements routinely under epidural analgesia. We did a great service offering this successful surgery for many years. When we decided to analyze our patients on the post operative pain relief after this surgery, we realized that the post op pain was higher than we expected.

We looked into the practice elsewhere in reputed centres, and in published literature, and found that intra joint infiltration of cocktail of medicines were giving better pain relief. In 2015, We changed our practice by introducing Peri articular injection of analgesia (PIA) and repeated the analysis of our patients. This showed better pain control as compared to epidural analgesia, and yielded more satisfaction from our patients. This was presented at our state conference. [1]

We can understand from the above description, Change is the only Constant .

Health care is constantly evolving over many centuries with the primary aim of improvement towards excellence.

That needs making changes regularly to how health care is delivered. We have to accept to review our current practice and identify areas of improvement. This improves the quality of health care.

This can be phrased as a quality improvement process. To make changes, one needs standards against which existing practice is measured or assessed. This mandates creation of standards by a learned body of experts, which are either published or implied. In real life, we as a profession continually improve our practice in a Kaizen way. However, periodically we have to review our existing practice against the standards which can be either protocols or guidelines.

This way of reviewing existing practice against what should be done is Audit, which is not new. The word Audit is used in many disciplines for many years. The verb to audit dates back to sixteenth century. [2] It meant official systematic examination (of accounts in financial sector) to ensure transparency and regularise the transactions. Other disciplines such as defence, aviation, Management also followed this practice. In healthcare, it is called Clinical audit.

According to the National Institute for Clinical Excellence,

a clinical audit is

A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. [3]

Clinical audit is often misunderstood with the term Research. Research involves setting up a hypothesis and working to find what is right or better in practice. For example, research may aim to assess whether a new medicine can be better, or to find new way of diagnosing a condition and so on. Research is concerned with discovering the right or better way for a problem.

Clinical audit is much straightforward in its outlook. It is performed with an aim of ensuring that right or better thing is done in clinical practice. The basis of this is knowing and accepting a right or better thing based on available evidence in publication or in practice elsewhere. [4]. We have to seek and accept this right or better way. The next step would then be, is to implement this in our clinical practice. The logical next thing to do is prove that the change has indeed improved our health care delivery and outcome.

 

The above explanation can simply be illustrated in the figure 1 as an audit cycle. It is a cycle as it the loop has to be completed for it to be considered as clinical audit. We can also refer to the resource article on Clinical Audit in the Kauverian [5]

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References

  1. Krishna Kumar MJ, Chokalingam. Pain relief patient satisfaction after Total knee arthroplasty with modified pain protocol. TNOACON Madurai 2019
  2. A V Pollock. What is audit and how to start it? 96(2):51-5.
  3. https://www.nice.org.uk/media/default/About/what-we-do/Into-practice/principles-for-best-practice-in-clinical-audit.pdf
  4. https://www.sign.ac.uk/
  5. https://www.kauveryhospital.com/kauverian-scientific-journals/clinical-audit-a-simplified-approach#:~:text=Clinical audit provides practitioners with and implementing plans for change.

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