Clinical Audit - Research Paper Example

Clinical Audit Abstract This clinical audit focuses on the researcher’s clinical practice related outcomes in the professional hospital environment. The study reflects and draws on the clinical practice related parameters of observation, prescription, recommendation, and follow up. The research study has invariably established some highly interesting positive and negative correlations between and among such variables as certain antibiotics, the frequency and duration of taking them, the level of clinical attention, age, type of procedures and allergies. This study conclusively finds a substantially positive correlation between antibiotics prescribed and allergy intensities. In fact, some antibiotics like Co-Amoxiclav made available to the patient after surgery have been noticed to have a substantially positive effect on patients with higher levels of positive response to optimal combinations of antimicrobial prophylaxis. 1. Data Analysis This clinical audit reflects priorities as set out by the guidelines published by National Health Service (NHS). The guidelines include such rules for good clinical practice as outlined in the Medicines for Human Use (Clinical Trials) Regulations 2004 (www.bartsandthelondon.nhs.uk). This research paper has a sample population of 83 planned/elective admissions between the 19th September 2010 and 1st October 2010 to Hospital X. Thus it looks at the learning outcomes of a retrospective nature. The following analysis shows how best antimicrobial prophylaxis drug regimes were to be administered to the elective patients chosen for different surgical procedures. It also illustrates allergy status, the antibiotics given, compliance guidelines and the level of compliance. Figure 1.1 Audit Life Cycle Between September 20th 2010 and September 22nd 2010, 21 surgical procedures were to be carried out on 21 patients. 11 elective patients were to receive Co-Amoxiclav. While some of them were to receive only Co-Amoxiclav others were to receive combinations that included Co-Amoxiclav. While 12 procedures out of 21 complied with guidelines the rest was of a diverse character such as non compliance, unavailability of guidelines and antibiotics being out of compliance guidelines. According to this analysis it is clear that antimicrobial prophylaxis was to be given to elective patients either a few hours before or during the procedure. Though the level of compliance was considerable there was no proper indication as to how much such compliance produced qualitative and quantitative positive results by way of increasing the degree of response by patients to antimicrobial prophylaxis. Between September 23rd 2010 and September 25th 2010, 14 surgical procedures were to be carried out on 14 patients. 7 elective patients were to be given Co-Amoxiclav. Only 4 patients out of 7 were given Co-Amoxiclav while others were given combinations that included Co-Amoxiclav. Only 9 procedures out of 14 complied with guidelines and the other procedures were of a different character. For example there were cases of non compliance and therefore the efficacy of antimicrobial prophylaxis could not be determined. Between September 26th 2010 and September 28th 2010, 19 surgical procedures were to be carried out on 19 patients. 10 elective patients were to receive Co-Amoxiclav. While some of them were to receive only Co-Amoxiclav others were to receive combinations that included Co-Amoxiclav. For example Teicoplanin, Gentamicin, Metronidazol were other antibiotics received by the patients. 14 procedures were complied with the guideline out of 19 procedures while the other procedures did not comply with the guidelines due to various reasons such as missing guidelines, antibiotics being out of compliance guidelines and procedures being cancelled. From September 29th 2010 to October 01st 2010, 25 surgical procedures were carried out on 25 patients. 11 elective patients were given Co-Amoxiclav. While some of them were given only Co-Amoxiclav others were given combinations that included Co-Amoxiclav. While 12 procedures out of 25 complied with guidelines the rest was of a diverse character such as non compliance, unavailability of guidelines and antibiotics being out of compliance guidelines. Table 1.1: Surgical Procedures with Procedural Date Table 1.2.Percentages of patients on drug chart against not on drug chart Chart Status Percentages of patients On Drug Chart 27.71% Not On Drug Chart 72.29% The above table and figure explain the percentage of patients on drug chart and those who are not on drug chart after the surgical procedure. What is so significant about these percentages is that only 27.71% of the patients are on the drug chart while 72.29% are not on the drug chart. This clearly demonstrates that a greater percentage of patients during the post-surgery period did not receive a particularly prescribed regime of drugs. As such it is obvious that implications arising from surgeries in the subject population of 83 patients are not arguably worse than otherwise possible. In other words the post-procedural practice of putting the patient on the drug chart might not have been followed due to the fact that these patients had not shown signs of strain during the post-surgery recovery period (Copeland, 2005). Recuperation required by these patients would have been reduced by an equal amount of physical and mental stamina possessed by them. Table 1.3 Correlations between the type of the drug and Lap Chole surgical procedure Drug Percentages of Lap Chole Surgical Procedure (out of 10) Compliance with guidelines Only Co-Amoxiclav 40% 30% Used Co-Amoxiclav 20% 20% Excluding Co-Amoxiclav 10% 10% Others 30% 0% According to Table 1.3, 40% of the patients after undergoing surgery for Lap Chole were given only Co-Amoxiclav while 20% of the patients who underwent the same surgical procedure were put on a combination of drugs that included Co-Amoxiclav (Rosser, 1997). On the other hand 10% of the patients received no Co-Amoxiclav while 30% either did not undergo surgery or were transferred to other wards prior to surgery (Chalkooa, et al, 2009). Figure 1.3 shows the same results shown by Table 1.2. However, as the 1st bar shows 40% or 4 patients out of 10 who received Co-Amoxiclav, a combination antibiotic, could have been more receptive to the combined effect of the spectrum of curative cum sedative action. In fact, though the drug contains Amoxicillin, the multiple combination of β-lactam and potassium clavulanate would have produced a thorough level of efficacy against bacteria that are amoxicillin resistant. The NHS guideline for adult patients for upper and lower gastrointestinal and hepatobiliary surgery antimicrobial prophylactic drugs are recommended. These drugs are to be given within an hour of the incision. Thus, it is clear that the guideline is intended to produce a degree of professional ethical convergence and conformance rather than a practical recommendation. Table 1.4 No of males and females using drugs Type of Drug No of Females No of Males Total Only Co-Amoxiclav 17 16 33 Used Co-Amoxiclav 4 4 8 used Metronidazole 6 3 9 Used Tazocin 2 3 5 Only Teicoplanin 0 1 1 used Teicoplanin 3 0 3 Only Cefuroxime 1 0 1 Used Cefuroxime 0 1 1 Table 1.4 shows number of males, females and the total taking each drug. The highest number occurs for Co-Amoxiclav. 17 females and 16 males were given Co-Amoxiclav. Thus out of 83 patients 33 were given Co-Amoxiclav. Further 8 more patients were given Co-Amoxiclav in combination with some other drug or drugs. Thus altogether 41 patients were given Co-Amoxiclav. This is almost 50% of the sample population of this study. Co-Amoxiclav has a lesser number of contraindications for allergies and other symptoms (Reatob, et al, 1999). Assuming that those patients who were given Co-Amoxiclav were more receptive to the drug the outcome is quite predictable, because the local guidelines were strictly adhered to in at least 26 of the patients who were involved in the use of Co-Amoxiclav only. Further 7 of the patients who took Co-Amoxiclav in combination with other drugs adhered to the local guidelines. As the above Figure 1.4 demonstrates the male curve and the female curve almost overlapped in respect of all other drugs and combinations of drugs including Co-Amoxiclav. However, the points on the two curves for male and female variables show a remarkable divergence. This divergence shows how many more males were given Co-Amoxiclav as against how many less females. Local guidelines have been adhered to only under some specific circumstances but nevertheless the degree of adherence has been sufficient to establish a positive cause-and-effect correlation between the independent variable X and the dependent variable Y. Table 1.5 Local guideline compliance by drug Type of Drug Local Guideline Compliance Only Co-Amoxiclav 26 Used Co-Amoxiclav 7 used Metronidazole 6 Used Tazocin 3 Only Teicoplanin 1 used Teicoplanin 3 Only Cefuroxime 0 Used Cefuroxime 0 As per local guideline compliance by drug it’s quite understandable as the Table 1.5 demonstrates that the requirement for antimicrobial prophylaxis has been complied with by physicians/surgical teams that carried out the surgeries on the sample population of patients in this research study (Bratzler & Houck, 2005). However the fact that these guidelines were not specific about other surgeries except upper and lower gastrointestinal and hepatobiliary surgery, the recommendation falls short of a rule that has to be followed in respect of a particular class of surgery. It’s quite possible that patients undergoing other surgical procedures too were recommended the above guideline-centric drugs/antibiotics as per procedural practice. Thus data for such uncategorized uses of the guidelines recommended drugs cannot be produced here to make a comparative analysis. Some recent research studies show that optimal combinations of antimicrobial prophylaxis have had greatly desirable effects on the patients who were given such drugs within 45 minutes to one hour after the incision for surgery (Hosoglu, Aslan, Akalin  & Bosnak, 2009). As the Table shows 26 patients out of 83 were given only Co-Amoxiclav. The rate of efficacy of the drug has to be measured against the patient’s drug chart comments made by the physician in charge. Given the fact that some patients as mentioned above were not effectively on the drug chart, these percentages could have been influenced by such side-effects as allergies and secondary symptoms. However, both number needed to treat (NNT) and Methicillin-resistant Staphylococcus aureus (MRSA) were considered as highly influential variables that have impacted on the learning outcomes of this research study. As the following table and the graph show the NNT for Stomach & duodenal surgery was 5while for Appendicectomy it was 114. However, the latter number includes only 11 for wound infection while 103 are for abdominal abscess. Against this backdrop it must be noted that the correlation between procedure and NNT cannot be established with a minimum number in the absence of data for other procedures (Rawlins, M 2002). Despite this lack of empirical evidence this researcher has convincingly learnt that the correlation between the two variables is highly influenced by other external factors, such as Adjusted Body Weight (ABW), Ideal Body Weight (IBW) and allergies. Table 1.6 The correlation between procedure and NNT Procedure NNT Stomach & duodenal surgery 5 Appendicectomy 114 Colorectal surgery 4 Bile duct surgery 11 Gall bladder 11 The following Figure 1.6 illustrates this fact with the variable procedure marked on the X axis and the Variable NNT values marked on Y axis. A particularly noteworthy feature of this correlation is the fact that Appendicectomy has registered the highest NNT value though such values cannot be regarded as absolute. Assuming a higher level of allergies to other drugs other than penicillin a greater number of patients subject to the said procedures have displayed symptomatic response to particular classes of properties that otherwise could have been controlled under intense supervision. Table 1.7: Number of Surgical Procedures for each variable Variables No Of Surgical procedures Compliance with guideline - Recommended 38 Compliance with guideline - Not Recommended 9 Record on chart 22 Allergy to penicillin 9 Conclusion This research study is focused on positive and negative correlations between antibiotics prescribed and allergy intensities on the one hand and response to some antibiotics like Co-Amoxiclav. The study is particularly significant in identifying patients with higher levels of positive response to optimal combinations of antimicrobial prophylaxis. Thus, it is based on 83 patients whose status as admitted/elective for different procedures in the upper and lower gastrointestinal and hepatobiliary region is of greater significance. As the data demonstrates Co-Amoxiclav has been used with much greater positive effect in respect of a greater number of patients i.e. 41 in number. 33 patients out of this number were given Co-Amoxiclav only while 8 patients were given Co-Amoxiclav in combination with some other antimicrobial prophylaxis. According to independent researchers such combinations become highly efficient in contexts where patients who have been put on a drug chart are less likely to display symptoms for other complications like diabetes, and extreme allergies that require powerful combinations of antihistamine drugs. Finally, it must be noted that some antibiotics like Co-Amoxiclav given to the patient have been noticed to have a positive effect on patients with higher levels of positive response to optimal combinations of antimicrobial prophylaxis. This outcome has been regarded as one of the most influential factors in this study though it must be noted that such learning outcomes have very little impact on future studies due to the extra ordinary impact of limitations such as the sample population of patients being relatively smaller and age and sex related factors being ignored in this study. Local guidelines for clinical practice and antibiotic prescription have acquired a greater degree of importance in the context of the recent developments in healthcare. The learning outcomes of this study include a host of compliance related analogies such as the clinical practice environment’s total dependency on regulations as published by the NHS and the institutional failure to act in conformance with such regulations. This study has fairly well covered these aspects to bring about a thorough enough analysis of the subject. Recommendations Variables such as IBW, ABW and allergies ought to be factored in to a time scale centric class of variances and co-variances to establish an adequate parameter of reference for future clinical audits on the subject of optimum combinations of antimicrobial prophylaxis. Further, there must be a higher level of focus on the positive correlation between the differences associated with age and sex on the one hand and the patient’s lifestyle related habits such as drinking alcohol, smoking and susceptibility to stress. Allergies that require extremely high doses of antihistamine have been much less factored in to the related equations in this study because the limitations imposed by the dataset do not permit researchers to identify sub factors influencing the learning outcomes. Finally, the study must be expanded to establish a system of metrics to accurately predict outcomes related to the effect of antimicrobial prophylaxis on upper and lower gastrointestinal and hepatobiliary surgery in adults. REFERENCES 1. Bratzler, DW, Houck, PM 2005, ‘Antimicrobial prophylaxis for surgery: an advisory statement from the national surgical infection prevention project’, Am J Surg, vol. 189, pp. 395-404. 2. Chalkooa, M, Ahangara, S, Durrania, AM, Chalkoob, S, Shaha, MJ & Bashira, MI 2009, ‘Mini-lap cholecystectomy: Modifications and innovations in technique’, International Journal of Surgery, vol. 8, no. 2, pp. 112-117. 3. Hosoglu, S, Aslan, S, Akalin, S & Bosnak, V 2009, ‘Audit of quality of perioperative antimicrobial prophylaxis’, Pharmacy World & Science, vol. 31, no. 1, pp. 14-17. 4. Healthcare Quality Improvement Partnership, Criteria of Best Practice in Clinical Audit, Received from, http://www.hqip.org.uk/criteria-of-best-practice-in-clinical-audit/, on October 27, 2010. 5. Rawlins, M 2002, Principles for Best Practice in Clinical Audit, Radcliffe Medical PR, Oxford. 6. Reatob, G, Cuffinia, AM, Tullioa, V, Palarchioa, AI, Boninoa, A, Foab, R & Carlonea, NA 1999, ‘Co-amoxiclav affects cytokine production by human polymorphonuclear cells’, Journal of Antimicrobial Chemotherapy, vol. 43, no. 5, pp. 715-718. 7. Rosser, JC 1997, Laparoscopic Cholecystectomy - Surgical Procedure (Yale University School of Medical Surgery Education Series), Springer, New York. 8. Copeland, G 2005, A Practical Handbook for Clinical Audit Clinical Governance Support Team, Received from, http://www.wales.nhs.uk/sites3/Documents/501/Practical_Clinical_Audit_Handbook_v1_1.pdf, on October 27, 2010. 9. Bjorvell, C Thorell-Ekstrand, I & Wredling, R 2000, ‘Development of an audit instrument for nursing care plans in the patient record’, Qual Health Care, vol. 9, no. 1, pp. 6-13. 10. Medicines for Human Use (Clinical Trials) Regulations 2004, Retrieved from www.bartsandthelondon.nhs.uk, on October 29, 2010. Read More