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  1. 1. Audit Workshop  Why the need for audit again? Last year’s figures • 22 projects submitted • 12 passed at 1st level • 10 went to 2nd level • 2 passed • 8 had to be resubmitted Reasons for resubmission • Lack of understanding of criterion • Lack of understanding of standards • Criteria not justified • Results not compared with standard • Overcomplicated – confused results  Lack of GPR understanding?  Criteria not explicit enough?  GPTs not clear on audit for SA? Introduction to Audit Handout
  2. 2. Identifying Acceptable Audit Criteria and Standards If you were planning to audit the following areas, please indicate whether you think any of the written statement could be used to describe acceptable audit criterion or standards: Acceptable Audit Criterion? Yes No Aspirin is know to prevent secondary coronary heart disease Children requesting attention for urgent problems will be seen on the same day Prescribing antibiotics for acute sore throat is only partially effective The appointments system needs to work efficiently The notes of the patients sensitive to penicillin should be clearly marked 75% of GPs’ medicine bags should contain a supply of in-date adrenaline Acceptable Audit Standard? Yes No Blood pressure should be recorded at least once every 5 years 50% of registered asthmatics should have a management plan Patients will be offered a non-urgent appointment with any doctor 70% of women presenting with menorrhagia should have a pelvic within 48 hours examination 100% of GP referral letters should contain all appointments should be The percentage of patients who fail to keep relevant information minimised Patients aged 16 years and over should have their smoking status recorded Most patients with Atrial Fibrillation should be investigated by ECG HeartEchocardiogram should have a regular medical review and failure patients Patients taking long-term thyroxine should againstTFT 60% of patients on aspirin are protected have a possible stroke or TIA 80% of patients requesting an urgent appointment will be able to see a doctor as soon as possible Referral letters will be sent within 72 hours or consultation in 90% of cases Surgeries should start and finish on time as often as possible An up-to-date summary sheet should be at the front of 90% of patients’ notes 95% of patients attending with acute sore throat should be given Paracetamol 10% of patients with Type II Diabetes should have had a fundoscopy in the past 12 months 90% of patients with a stroke should be cared for in line with SIGN guidelines
  3. 3. SUMMATIVE ASSESSMENT AUDIT PROJECT Effective monitoring of thyroid function in chronic amiodarone treatment
  4. 4. Practice List Size: 12,720 What is the title of your audit project ? Effective monitoring of thyroid function in chronic amiodarone treatment. Why did you choose it ? This audit was chosen for the following reasons: a) Guidelines are available for monitoring of Thyroid function tests (TFTS) on those taking amiodarone. The aim was therefore to produce a clear policy for the practice. b) Only a small group of patients affected, 19 out of a list size of 12720. Hence relative ease of obtaining audit information, making subsequent changes and following these up. c) Any changes in TFTs can be easily monitored by a simple blood test. d) The majority of patients are on long term treatment and will therefore be kept under regular review. Which criterion/criteria have you chosen ? The criterion chosen was that patients on chronic amiodarone i.e. > 3 months, should have their TFTs checked every 6 months.
  5. 5. Why did you choose it/them ? Amiodarone has been used in cardiology for more than 20 years. It is effective in the treatment of anydmias such as paroxysmal SVT, atrial fibrillation (AF) and atrial flutter. It is safe in patients with significant left ventricular dysfunction and is often used where other treatment has failed e.g. digoxin for AF, or where the patient has been intolerant of other antiarrythmics. However, amiodarone has a well recognized side effect profile - it can cause comeal microdeposits, cutaneous hiperpiginentation, peripheral neuropathy, hepatotoxicity and thyroid dysfunction. Amiodarone has a complex effect on thyroid physiology due to its structural resemblance to thyroid hormones. Chronic treatment i.e. > 3 months is usually associated with high - normal or raised T4 and fT4, low - N T3 and fT3, low - N TSH and high rT3 concentrations. Despite altered TFTs, most patients remain clinically euthyroid, however up to 15% of patients in the UK develop amiodarone induced hypothyroidism or thyrotoxicosis. Once detected referral to a specialist endocrinologist is recommended. The drug can be discontinued as part of the management but often this option is not a feasible one - as most physicians only use amiodarone as a last resort. The recommendations support baseline thyroid function testing before commencing treatment (T4, T3, TSH and thyroid antibodies) followed by TSH concentrations every 6 months. If there is clinical suspicion of hypo/hyperthyroidism the TSH should be checked sooner. Hyperthyroidism would reduce TSH and hypothyroidism would increase TSH T3 and T4 levels would serve to confirm the diagnosis. If the patient is clinically euthyroid with equivocal biochemical results then these should be repeated in 6 weeks. Hypothyroidism is easily managed by adding thyroxine and continuing with amiodarone. Hyperthyroidism treatment is more complex and should as previously mentioned be referred on. What standard(s) have you set ?
  6. 6. The following standard was set: 90% of patients taking amiodarone should have had TFTs checked in the preceding 6 months and should have these recorded in the notes. One month was given to achieve this standard. Why did you choose this standard ? This high standard was chosen because: a) Only a small group of patients were involved and it would be easier to reach our target. b) The significant side effect i.e. thyroid dysfunction was deemed to merit a high standard for patient review. c) One month was considered adequate by the staff again because of the small numbers involved. What preparation and planning did you undertake for your audit project ? This firstly involved choosing an audit which I felt was feasible in terms of time parameters, would produce an outcome and would allow introduction of long term changes/follow up beneficial to patients. Initial discussions with my trainer gave me further ideas on how to implement change and involve all practice members. The audit assistant was able to identify all patients taking amiodarone/cordarone by using the G-Pass computer system. I then undertook study of the relevant case notes. Helped by one of the reception stall I was able to run a medline search on the chosen topic. I was able to download various extracts and then contacted the local hospital librarian who obtained the full articles for me. All the staff including the medical practitioners, practice manager, district nurses and receptionists were informed of the proposed audit
  7. 7. and their expected involvement by letter. They were made aware that patients would be contacting the practice for appointments for blood tests and should be given the option of seeing the practice nurse, their own doctor or another or failing that may be allocated a home visit by doctor or district nurse. The practice nurses were given a list of patient names at their request. A standard letter was then sent to each individual patient briefly outlining the recommendations on biannual TFT checks, reasons why and how this would be done by a simple blood test. The patients were also asked to contact the surgery at their earliest convenience and to state their preference in submitting the blood test. First data collection • Twenty patients were identified by the G-Pass system. • Of these one had recently been discontinued off amiodarone. • This left 14 females and 5 males. Age varied from 58 to 86 years. • Reasons for being commenced on amiodarone included atrial flutter, SVT/VT, paroxysmal AF, AS and atrial flutter, and paroxysmal AF and pacemaker. • Length of time on amiodarone varied from 3 months to 5 years. • Two patients were taking amiodarone and thyroxine - one was identified as having amiodarone induced hypothyroidism, the other had undergone thyroid cystectomies twice and was therefore on thyroxine. • Only 4 patients out of 19 had M results from previous 6 months recorded in there case notes - this included Ms checked by the practice and/or hospital. • One patient had been commenced on amiodrone in Jan 99 but no TFT results were noted in her case notes. How does this compare with your standard(s) ?
  8. 8. 21% versus 90% What change(s) are you implementing ? a) Introducing and establishing a system whereby the practice will now monitor this group of patients on a biannual basis - May and November. This will be done by identifying all patients taking amiodarone via the practice computer. Then checking the date of their latest TFT. If 5/6 months have elapsed, since the last blood test then a standard letter will be issued asking the patient to attend. b) To emphasize the importance of 6 month checks to the patient the first blood tests will be followed by an individual letter indicating present results and next planned review. It is hoped patients will contact the surgery themselves for their 6 monthly blood tests, but a failsafe mechanism will be in place. c) Providing written feedback from this audit to the practitioners and practice nurses. Also highlighting the importance of identifying new patients being commenced on amiodarone so this can be logged on the computer. Second data collection. • This was done I month after the letters were posted out to patients. • Unfortunately in the intervening time one patient had passed away and was therefore excluded from the list leaving 18 patients.
  9. 9. • 17 patients out of 18 responded to the letter and submitted blood tests. • One patient was discovered to be hypothyroid and commenced on thyroxine with appropriate follow up. • One was identified to be clinically euthyroid but with slightly elevated TSH of 10.46 and normal T4. This would be repeated in 6/52. • All others including the 2 previously known to be on thyroxine had normal TFTs. • One patient did not respond to the letter but happened to be the one commenced on amiodarone in Jan 99. Compare with data collection (1) and standard. We not only achieved our set standard but improved on it: What conclusions have you drawn from this completed audit cycle ? As a practice we were able to identify a shortcoming in terms of patient care, instigate appropriate change and subsequently better even our expectations in reaching the standards set; all with fairly minimal effort. This was done as follows: a) Educating both staff and patients.
  10. 10. b) Making it as easy as possible for patients to comply with our request for blood tests. c) The willingness of all the practice members in helping with the audit. Problems still to be addressed: a) The patient that is a non responder. After discussion we decided this would be best tackled by the patients own doctor phoning the patient directly and explaining the importance of follow up. b) Possibly a more effective handover of patients being discharged from hospital out patient clinics to their GPs. This was the largest group who were not up to date with their TFTs. Maintaining the standards set: a) The practice has an audit assistant whose responsibility will be to identify all patients taking amiodarone every 6 months. She can easily check the latest TFTs for each of these patients as all blood tests are now logged on computer. Any patients identified whose TFTs have not been checked in the last 6 months will be sent out a standard letter requesting them to attend. The audit has been justified by us being able to identify 2 patients from this small group - 1 who required thyroxine supplementation and the other more frequent follow up. This will hopefully allow us to continue to provide an improved standard of care for this particular group of patients. References: 1) Effects of Amiodarone on Thyroid Function Kishore J Hailai, MD, and Angelo A. Licata, MD, PHD Annals of Internal Medicine January 1997 2) Amiodarone and the Thyroid: a practical guide to the management of thyroid dysfunction induced by amiodarone therapy. C M Newman,
  11. 11. A Price, D W Davies, TA Gray, A P Weetman. Internal Medicene 1998 3) Effects of Amiodarone on Thyroid Function Ph Caron. Presse Med 1995
  12. 12. SUMMATIVE ASSESSMENT AUDIT PROJECT Dipstick urinalysis in hypertension
  13. 13. What Is The Title Of Your Project? Dipstick urinalysis as a routine investigation in the assessment of a hypertensive patient Why Did You Choose It? Hypertension – important disease, common, treatable Topical – updated guidelines published by The British Hypertension Society in September 1999 listed the routine investigations of the hypertensive patient that should be done including Dipstick urinalysis Dipstick testing – simple, cheap, quick, effective It was noted on seeing existing hypertensive patients that many had never had a dipstick urinalysis checked either when they were diagnosed as hypertensive or subsequently. Which Criterion/Criteria Have You Chosen? All hypertensive patients should have at least one documented dipstick urinalysis since the diagnosis of hypertension Why Did You Choose It/Them? British Hypertension Society guidelines state that urine strip test for blood, glucose and protein should form part of the initial assessment of all hypertensive patients. Porteinuria and microscopic haematuria may result from renal arteriolar necrosis in hypertensive patients. The test may also help identify intrinsic renal disease. The ABC of Hypertension, a BMJ publication states that “dipstick urinalysis is the simplest and often the most revealing of the basic investigations of hypertension”. What Standards Have You Set?
  14. 14. 80% of hypertensive patients should have at least one documented dipstick urinalysis. Why Did You Choose These Standards? This standard was chosen as patients are often unable to produce a urine sample at the time of consultation and often forget to hand one in later, or forget to bring a sample to the nurse when they come back for follow up blood pressure checks. What Preparation And Planning Did You Undertake For Your Audit Project? A literature search for urinalysis in hypertension was done. I was unable to find any published papers that looked at the role of dipstick testing in the assessment of hypertensive patients The ABC of Hypertension, a BMJ publication, stated that dipstick urinalysis is “the simplest and often the most revealing of the basic investigations of hypertension. British Hypertension Society guidelines state that urine strip test should form part of the initial assessment of all hypertensive patients. It was agreed after a practice meeting with the doctors and nurses that the audit would be worthwhile. The practice manager produced a list of all patients on the hypertensive disease register. A random sample of 30 patients were picked from this list. The receptionists helped in pulling the case notes and a search was done through this sample of notes looking for documentation of dipstick testing. First Data Collection: Date: 24.12.99 14 out of 30 i.e. 47% of patients had a documented urinalysis in their case notes since diagnosis. How Does This Compare With Your Standards? The results of the first data collection fall short of the standards set by 33%.
  15. 15. What Changes Are You Implementing? The above results were discussed at a practice meeting. Part of the reason for the results were attributed to the doctors not specifically asking the patients to hand in a urine sample at the time or not asking the practice nurse to check it when the patient returns for a follow-up blood pressure check. A practice protocol for the assessment and management of hypertension was drawn up that included dipstick urinalysis as part of the initial assessment. This was agreed by all the doctors and distributed to the nurses. Everyone was asked to keep an eye out for existing patients that had not had a dipstick test done. Second Data Collection: Date 22.3.00 16 out of 30 i.e. 53% of hypertensive patients had a documented urinalysis. Compare With Data Collection (1) And Standard The second data collection only shows a slight improvement of 6%. Part of the reason is that only a few new patients are diagnosed and added to the hypertensive register in such a short period of time. The other reason is that many patients are no longer follow up periods for rechecking their blood pressures and consequently have not been in contact with either doctor or nurse since the initial data collection. What Conclusions Have You Drawn From This Completed Audit Cycle? Dipstick urinalysis is one of the simplest and most revealing of basic investigations in assessing a hypertensive patient. It is an important test in excluding secondary causes of hypertension. This audit demonstrated that dipstick urinalysis is frequently overlooked as a basis investigation in hypertensive patients It is likely that the standard will improve as more patients return for review of hypertension and blood pressure checks. It would be valuable to re-audit in 6 months time to ensure that improvements are ongoing.
  16. 16. Summative Assessment Audit – The 8 Criteria Criteria When has it worked well? What have been the barriers? Solutions Reason for choice of audit Criterion/Criteria Chosen Standards set Preparation and Planning Data Collection (1) Change(s) to be evaluated Data Collection (2) Conclusions