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
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
The appointments system needs to work efficiently
The notes of the patients sensitive to penicillin should be clearly
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
100% of GP referral letters should contain all appointments should be
The percentage of patients who fail to keep relevant information
Patients aged 16 years and over should have their smoking status
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
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%
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
95% of patients attending with acute sore throat should be given
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
Effective monitoring of thyroid function in chronic amiodarone treatment
Practice List Size: 12,720
What is the title of your audit project ?
Effective monitoring of thyroid function in chronic amiodarone
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.
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
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
What standard(s) have you set ?
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
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
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
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
• 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
• 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) ?
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
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
Second data collection.
• This was done I month after the letters were posted out to
• Unfortunately in the intervening time one patient had passed away
and was therefore excluded from the list leaving 18 patients.
• 17 patients out of 18 responded to the letter and submitted blood
• 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
• All others including the 2 previously known to be on thyroxine had
• 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.
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
1) Effects of Amiodarone on Thyroid Function Kishore J Hailai, MD,
and Angelo A. Licata, MD, PHD Annals of Internal Medicine January
2) Amiodarone and the Thyroid: a practical guide to the management of
thyroid dysfunction induced by amiodarone therapy. C M Newman,
A Price, D W Davies, TA Gray, A P Weetman. Internal Medicene
3) Effects of Amiodarone on Thyroid Function Ph Caron. Presse Med
Dipstick urinalysis in hypertension
What Is The Title Of Your Project?
Dipstick urinalysis as a routine investigation in the assessment of a
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?
80% of hypertensive patients should have at least one documented
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
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
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
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
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.
Summative Assessment Audit – The 8 Criteria
Criteria When has it worked well? What have been the barriers? Solutions
Reason for choice of audit
Preparation and Planning
Data Collection (1)
Change(s) to be evaluated
Data Collection (2)