1. AUDIT IN ANAESTHESIA
-DR. RAVIKIRAN H M
Introduction:
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.
Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against
explicit criteria.
Where indicated, changes are implemented at an individual, team, or service level, and further monitoring is
used to confirm improvement in healthcare delivery.
Audit measures practice against standards. Unlike research (which asks the question, ―what is the right thing to
do?‖), clinical audit asks, ―are we doing the right thing in the right way?‖
Every surgical activity poses some element of risk to the public and should include a quality control initiative.
Surgical audit is one strategy used to maintain and/or improve standards in surgical care.
Audit is included in the foundation programme to allow you, as junior doctors, to gain an understanding of how
to obtain, maintain, and improve the services you deliver now and in the future. Performing an audit may also
help you in your own learning and understanding of the healthcare process in a particular field. It may also
allow you to contribute to constructing or refining a clinical protocol.
History:
The process of auditing has probably been present for as long as people have needed some measure of their
resources.
An example from the British Navy in 1811 showed that as a consequence of a quarterly audit of punishment,
Admiral Laforey, working in the West Indies, was checked for excessive whipping in his warship.
Florence Nightingale appears to have been the first person to use clinical audit in a medical setting. During the
Crimean War, she recorded a reduction in mortality rates from 43 to 2%, within 6 months of improved
sanitation being used at a military hospital in Istanbul. Whereas it has been suggested that some aspects of her
later work in London were statistically flawed, her use of a method akin to clinical audit for measuring change
in practice showed a significant improvement in the care of war victims.
Definition:
The systematic critical analysis of the quality of medical care, including the procedures used for diagnosis and
treatment, the use of resources and the resulting outcome and quality of life for the patient.

2. This definition is from the government white paper Working for Patients (1989) which marked the increase in
clinical audit activity.
Integrated into an activity known as ‗clinical governance‘. Clinical governance aims to address all the
processes that contribute to the improvement of health care and services such as risk management, research and
development, professional training, clinical effectiveness and transparency, as well as clinical audit.
Audit can include assessment of:
1. The structure of care—for example, resources such as the presence of a dedicated stroke unit
2. The process of care—for example, waiting times in clinics
3. The outcome of care—for example, blood pressure reduction in response to therapy.
Audit should also be transparent. It should not be confrontational or judgmental—it is not an opportunity to
name, shame, and blame.
Types:
There are several ways in which health information can be evaluated, depending on the outcomes required. A
description of different types of audit follows:
1. Clinical
2. Critical events
3. Outcome or research
4. Training or logbook
5. Survey
Clinical audit is one type of medical audit, expressly requiring the definition of standards (review criteria), and
a cyclical process whereby data are collected and evaluated against the standards, with changes being
implemented where gaps between practice and the standards are identified.
Clinical audit may only involve one cycle or can be an ongoing process.
Clinical audits can be used to monitor the uptake of new and innovative models of care and ensure that
all patients receive the most effective, up-to-date and appropriate treatment, delivered by clinicians with
the right skills and experience.
A different type of audit is that used for monitoring critical incidents (also known as adverse event reporting),
which aims to capture information relating to infrequent events.
In so doing, it may be possible to uncover system failures, inadequate facilities and service management
errors.

3. The process involves obtaining complete reporting of critical incidents (and ‗near misses‘) so that an
analysis of such events can lead to an improvement in safety standards and procedures, with a reduction
in adverse patient events.
A third audit model is the ‗outcome’ or ‘research’ audit. This type of audit aims to address specific research
questions, such as the long-term safety and effectiveness of a procedure.
An outcome audit can provide an alternative to controlled trials, where, for instance, it is not pragmatic
or ethical to conduct such a trial or where questions remain unanswered following a trial, or where the
cost of such a long-term trial would be prohibitive.
It may also be able to determine whether the benefits expected from the evidence provided by a
randomized controlled trial were achieved when a procedure is adopted into the wider framework of
regular clinical practice.
For such an outcome audit to minimize bias, particularly with a low level of failure, the audit must
prospectively capture close to 100% of all events being measured.
Another type of medical audit is the logbook or training audit. This audit is for trainees to record their own
activity and progress and ensure that they meet the required components of training.
The logbook helps trainees to show that they are building their professional competence and identify
whether they would benefit from additional development.
Surveys can also be used as an auditing tool. For a survey to provide a reliable estimate of the distribution of a
characteristic within a population, it must effectively deal with biases arising from coverage, sampling,
measurement (inaccurate responses stemming from poor wording etc.) and non-response errors.
Audits can be carried out at a local or national level.
Local audits take place within individual hospitals or treatment units.
A criticism of local audits is that:
1. The technical expertise required to design valid studies is rare and audits may include too few cases
2. The design of data pro forma, assurance of data quality and interpretation of statistical results may be of
low standard
3. If results are retained within individual units, there is little pressure to affect improvements
4. The audit loop is frequently not closed meaning that repeat audit may not be used to ensure better
outcomes
5. Local audits do not provide any opportunity to compare results across hospitals and regions.

4. Audit cycle:
Principles for Best Practice in Clinical Audit by NICE:
Stage One: preparing for audit
Identify problem and local resources for audit: high volume, high risk to patient/staff, high cost
Locate relevant information
Stage Two: selecting criteria
Determine what you are trying to measure
Define ideal standards
Stage Three: measuring level of performance
Collect data
Compare performance with criteria
Stage Four: making improvements
Implement change
Stage Five: sustaining improvement
Repeat the audit
Develop tools to sustain improvements

5. Figure 1: A staged approach to clinical audit: criteria to be considered during the course of a clinical audit.
The following are examples of issues that could be audited for a better performance:
1. Admission selection (polices)
2. The length of stay Management guidelines
3. Responsibilities
4. Daily assessment and plan
5. Discharge policies
6. Readmission prevention
7. Interhospital transfer
8. Bed blockers prevention.

6. Outcome:
Address something you are not happy with, Meeting standards (what if there are no standards), Agree audit
methodology in advance, A real life problem justifiably taken even for the first time, Even if no successful
outcome at least people are aware or there is a trial to solve the problem. Solution may be by: protocol,
identifying responsibilities, rota changes.
The main barriers to clinical audit:
1. Lack of resources
2. Lack of expertise or advice in project design and analysis
3. Relationships between groups and group members
4. Lack of an overall plan for audit
5. Organizational impediments
 Weak leadership with limited powers and credibility (interestingly one of the surgeons, who was later to be
struck off, had held positions of leadership in medical and clinical audit)
 Lack of organizational responsibility for quality
 Misdirection of funding: Funding was used for information technology (IT) and not for employing skilled
audit personnel (the role of audit staff was seen to be a relatively unskilled one)
 Inadequate use of gathered data
 No central responsibility was taken to ensure rigorous and effective approaches to audit
 Concern about confidentiality resulted in limited access to data and a secretive approach to audit and its
results
 Monitoring and reporting did not work effectively. Not all departments provided the quarterly returns
requested
Challenges:
1. Support
2. Time
3. Realistic: optimum rather than ideal
4. Baseline adherence to recommended practice is low and feedback is delivered more intensively
Ethics and Privacy:
Clinical audit is an important quality assurance activity that necessarily involves actively monitoring the results
of individuals or medical units. Areas of concern relating to the use of an individual‘s information include its
use in medical negligence litigation, disclosure causing embarrassment or adversely influencing practice or
legal action arising from third-party review of other practices.

7. Voluntary and informed patient consent should be obtained before using an individual‘s information as part of
an auditing activity. Often patients sign a general consent form on admission to hospital. In private practice,
patient consent should be obtained where any identifying patient information or patient records are to be used
for quality assurance purposes.
Clearly, clinical audit must be conducted within an ethical framework of confidentiality. By definition, clinical
audit should do good and not do harm. A clinical audit should not involve anything being done to a patient that
is beyond the normal clinical management. For this reason, in the UK and Australia, clinical audit does not
necessarily require formal ethical approval by a full human research ethics committee.

8. Reference:
1. Boult M et al. CLINICAL AUDITS: WHY AND FOR WHOM. ANZ J. Surg. 2007; 77: 572–578.
2. Benjamin A. THE COMPETENT NOVICE. Audit: how to do it in practice. BMJ | 31 MAY 2008 |
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