Clinical_Auditing

An audit is a means of measuring the care that is being provided in a day to day clinical practice (Swage 2004). Using a standard audit criteria undertake a clinical audit in your area of practice. Support you work with relevant literature. Introduction: Clinical audits have a history stretching back to Florence Nightingale in the eighteen hundreds, when she monitored mortality and morbidity rates in hospitals. This assignment will endeavour to examine the processes involved in completing a clinical audit. It will examine the benefits to stakeholders and how the clinical auditing process affects them, using standard auditing criteria set out by the Health Service Executive. The article could have used the policies set out by one specific body within the executive but felt that given the HSE is the governing body which controls, sets policies and provides guidelines for all processes that take place within hospitals, health facilities and in communities across the country, it would be prudent to follow their guidelines on clinical auditing. The assignment will also attempt to look at the auditing process and the benefits it has to the overall care of patients and healthcare processes in general, looking specifically at the nurses role within a chosen topic. The topic chosen for the audit will be scrutinised and the assignment will analyse the rationale behind its choice, examining best practice and providing a body of supporting literature. The results of the audit will be contained within the assignment and these findings will be examined to see if any recommendations can be made for improvements in the future. What is a clinical audit: Sneddon et al (2006) defines an audit, as one of the main tools used to establish whether clinical practice reflects recommended standards of care. The Commission on Patient Safety and Quality Assurance (2008,) refers to clinical audits as: a clinically led, quality improvement process that endeavour to improve patient care and outcomes though the systematic review of care against clear criteria and to act to improve care when standards are not met. Clinical audits follow a cycle and consider three questions: what is happening in practice' What should be happening in practice' And what changes are needed to improve practice' Cooper and Benjenin (2004) maintain that to successfully complete an audit, all three aspects of the audit cycle must be addressed. The Health service executive (HSE, 2013) recommend a five stage approach to all clinical audits maintaining audits are a cyclical process which can be outlined in five stages: Planning for audit, standard/criteria selection, measuring performance, making improvements and sustaining improvements. In 2003, the Health Information and Quality Authority (HIQA) was formed to improve and maintain the quality of care through a health service reform program. HIQA was created to supervise the quality of healthcare in Ireland. Its aim is to improve standards through clinical auditing, assessing and reporting on the quality and standards of care and procedures that are in place in various health care setting. An equivalent body to (HIQA) called Healthcare Quality Improvement Partnership (HQIP) was set up in the UK in 2008 to carry out national clinical audits in England and Wales. HQIP (2012) state, national clinical audits are concerned with promoting change and the enhancement of clinical practice. The Cochrane systematic review on the traditional concept of audit and feedback surmise that the effects of an audit are variable but are in the main small to moderate (Jamtvedt et al 2006). Foy et al (2005) and Jamtvedt et al (2006) maintain, the evidence base for impact of audits on performance improvement is relatively weak. Johnston et al (2000) refers to audits as being ineffective because of the conditions under which they are carried out. Johnston et al (2000) maintains, that audits create a number of barriers which limit their success, barriers like, poor relationships between professional groups and agencies, lack of trust between clinicians and managers; and a lack of integration with other activities and priorities. Even though Johnston et al’s review is dated it cannot be dismissed. Although it does highlight the importance of the involvement of staff in a clinical audit is imperative for the findings to be gratified, or where needed, improved upon (Stewart and Rao 2003). The Audit Process: Planning: An Bord Altranais (2000) relates various different competences to registered nurses, one of these being that all registered nurses should, establish and maintain precise, clear and current records within a legal and ethical framework. Before the audit was carried out, permission was sought and gained from the clinical nurse manager to analyze patients various different records. It was felt it was vital that stakeholders where involved from the start of this audit, Gustin (2005) states that, obtaining stakeholders involvement is critical in securing the correct inputs for audits. According to the HSE (2013) a stakeholder is anyone involved in providing or receiving care during a clinical audit, in this case the staff of the ward are involved from the beginning of the process. Topic: The ward staff helped identify and select the topic that was to be audited and they helped in the creation of the auditing questionnaire. Questions from Ashmore et al (2011a) were used to help in the selection process; they assisted in prioritising audit topics. Questions like, are there apparent and obvious variations in clinical practice and will auditing the problem advance healthcare outcomes as well as assist with improvements' It was therefore decided after some deliberation that the recording of fluid balance charts would be the topic of the audit. Fluid balance records were chosen given the importance they play for nurses monitoring patients in an acute ward setting. It was also highlighted by some stakeholders that there were variations in clinical practice and auditing the topic may highlight these variations and improve healthcare outcomes. Parkinson and Brooker (2004) identify fluid balance charts as a record all fluid intake and fluid output over a 24-hour period. They state, amounts are totalled and balances calculated over 24 hours from midnight and the fluid intake means all fluid inclusive of oral, nasogastric and percutaneous endoscopic gastrostomy feeding, and infusions given either intravenously or subcutaneously. Parkinson and Brooker (2004) also refer to output recorded, to include, all urine, vomit, nasogastric aspirations, diarrhoea and fluids from a stomas or wound drain should also be recorded. The aim of choosing record keeping and documenting records as part of a clinical audit in practice was to analyse and examine the quality of nursing record keeping in the specific clinical area, and to improve the quality of documentation were needed, to ultimately improve overall patient care. Fluid Balance Charts: Fluid balance charts are widely used within the hospital setting and in many cases they are used to record the administration of intravenous fluids. Like with any medical chart, fluid balance charts need accurate and regular updating, Dimmond (2005b) maintains that keeping accurate records needs to be considered as an intrinsic part of nursing practice. Many Patients’ receive maintenance IV fluids to prevent dehydration, treat or prevent hypovolemia, or to provide a medium for nutritional or pharmaceutical agents (Grocott et al., 2005; Baid, 2010). There are complications which may occur during the administration of intravenous fluids; these include electrolyte abnormalities, peripheral and tissue edemas, and organ dysfunction (Hilton et al., 2008; Crawford & Harris, 2011). Hilton et al., (2008) and Baird (2010) assert that these complications are avoidable by regularly weighing the patients, and maintaining a fluid balance chart in conjunction with regular monitoring of serum electrolytes. Fluid balance charts provide documentary evidence of the type and amount of fluids administered and lost by a patient (Scales & Pilsworth, 2008). Baid (2010) and Crawford & Harris (2011) highlight the inaccuracies associated with fluid balance documentation maintaining that daily body weight records reflect insensible fluid losses in patients. In an observational audit carried out by Walsh and Walsh (2006) of patient being administered IV fluids their findings revealed that 17% of patients experienced at least one iatrogenic complication related to fluid management, seven patients experienced tachyarrhythmia, and five developed fluid overload. Walsh and Walsh (2006) attributed these incidences of iatrogenic morbidity to excessive fluid administration and a lack of sufficient patient monitoring. Tang and Lee (2010) in a prospective study carried out in the UK, maintain that fluid balance charts are useful monitoring tools of a patients hydration status. However they can be counterproductive and dangerous if the documentation is poor and doctors interpretation incorrect. Nevertheless there are numerous studies showing the importance of fluid balance monitoring and it is for this reason this audit will examine the maintenance and recording of fluid balance charts on an acute ward in Ireland. The Audit. When the audit topic has been selected, the next essential step is to review the available evidence identifying the standards against which the audit will be conducted. The audit was carried out in an acute ward in Letterkenny General Hospital. A total of eight patients charts were examined over a twenty four hour period, allowing for a qualitative study of the topic. The eight charts chosen, included patients with several different medical issues and entries were recorded by numerous different staff members. These staff members included registered nurses, pre registered nurses, third and fourth year student nurses and healthcare assistants, therefore entries in the charts gave the best overall picture of how records were being maintained on the ward without bias. The purpose of an audit is to evaluating actual care against the care that should be provided, therefore each question should have an expected level of performance assigned to it (Ashmore, Ruthven and Hazelwood, 2011a). The questions listed below were selected to be as unambiguous as possible; the study of records selected would provide a yes or no answer. The following questions were used to analyse the charts. Adapted from - Guidelines for the Recording of Fluid Balance / Intake – Output (Western Health and Social Care Trust 2008) 1. Patient Name and PCN on chart – (each chart should be named with PCN) 2. Each nursing entry dated correctly - (each chart should be dated correctly) 3. Each nursing entry timed correctly - (each chart should be timed correctly) 4. Black pen is used in the charts - (all records should be recorded in black ink) 5. Fluid restrictions identified – (only some patients are on fluid restrictions) 6. Rational. The patient understood the significance of recording their input and output -(Given that some patients may not have the cognitive ability to understand, due to illness or unconsciousness) 7. No diet recorded on chart - (food should not be recorded on fluid balance charts) 8. All records totaled – (each chart should have a final intake and output total) 9. Totals balanced – (each chart should have the input and output totaled and balanced) Findings and results from the clinical audit on recording fluid balance charts. See appendix 1 Measurements: A total of nine questions were reviewed on the eight Fluid balance charts. Answer where recorded as yes (Y) or no (N) where neither were applicable N/A was recorded but on analysis N/A was recorded (Y) as a E.G Fluid restrictions identified – (only some patients are on fluid restrictions). Percentages were rounded up or down when applicable. 80.55% becomes 81%, 80.45% becomes 80%. Limitations of the audit. There are some limitations to this audit, the small sample of only eight records and in particularly the small number of patients on a restricted fluid intake. The fact that a number of patients may have had reduced cognitive abilities, meant that scoring relied on a certain degree of subjectivity from the perspective of the auditor. Making improvements: The aims of this audit was to assess the clinical practice being delivered to the patients against standards of practice, assessing the current practice and uncovering where and why faults are appearing (Rawlins 2002). The audit provided both positive and negative elements on the recording of fluid balance charts within the ward. The management and the staff of the ward where presented with the findings and met to discuss the findings and how to improve on them. Many of the staff gave a rationales for the weakness in the area of recording food on the chart, maintaining that it was not necessary for specific patients to be put on dietary intake charts but patient care involved making sure the patient received and had a sufficient dietary intake. It was also highlighted that those on a strict fluid intake, scored 100% in the audit, staff felt that this was due to the fact there was a specific rationales for the intake charts being in place as opposed to simply making sure a patient was properly hydrated. The discussions also focused on recommendations for improving standards in recording of fluid balance charts and where change could be applied. Hysong (2009) maintains that audit improvements where significantly increased when feedback and recommendations were delivered with specific suggestions for improvement, in writing, and frequently. Therefore recommendations for improvements have been put in writing and forwarded to the ward manager. Sustaining Improvements: Staff agreed that the future recording of fluid balance charts should be continuously audited and monitored, it was agreed that a clinical re-audit be carried out in twelve months’ time. All staff agreed to adhere to the guidelines and to comply with all policies put in place for documentation and report writing and this adherence will be evident in the continuous audits to be carried out. It was also agreed that a new format of the chart be looked at to incorporate, patients dietary intake. Ball et al 2010 maintain, if structured systems are put in place to assess standards of practice in a clinical area, the probability of sustained high standards increases. Conclusion. As stated in the introduction, this assignment set about completing a clinical audit within an acute ward setting. It examined the processes involved in carry an audit and the stakeholder’s interpretations of the audit. The audit itself highlighted numerous statistics that indicated flaws within the clinical practice of those recording information on fluid balance charts. Reports and studies on fluid balance charts have indicated their importance but the audit has also highlighted nurses rational for deviating from policy on said charts. Through discussion within stage four, recommendations will be submitted by the staff to management as to how improvements can be made and sustained. References: An Bord Altranais (2000) Code of Conduct for Professional Nurses. An Bord Altranais, Dublin. Ashmore, S., Ruthven, T., and Hazelwood, L. (2011a). Stage 1: Preparation, planning and organisation of clinical audit. In Burgess, R. (ed) NEW Principles of Best Practice in Clinical Audit. Healthcare Quality Improvement Partnership (HQIP). Abingdon, Radcliffe Medical Press, pp 23-58. Baid, P. Fluid assessment and associated treatment. In: Creed F, Spiers C (eds). Care of the Acutely Ill Adult (2nd edn). Oxford: Oxford University Press, 2010; 205–240. Ball, M. J. (2010) Nursing Informatics, Where Technology & Caring Meet, 4th Edn., Springer. Cooper, J and Benjamin, M., (2004) Clinical Audit in Practice, Nursing Standard., vol 18(28) p.47-53 Crawford, A. H. (2011) H. I.V. fluids What nurses need to know. Nursing; 41: 30–38. Department of Health and Children (2008) Building a Culture of Patient Safety. Report of the Commission on Patient Safety and Quality Assurance. Dublin, Stationary Office. Dimond, B. (2011) Legal Aspects of Nursing and Healthcare 6th ed, Pearson Education, UK  Foy, R,. Eccles, M. P. Jamtvedt, G., Young, J., Grimshaw, J. M and Baker, R. (2005) What do we know about how to do audit and feedback' Pitfalls in applying evidence from a systematic review. BMC Health Serv Res.  Jul 13;5:50. Grocott, M. P. W., Mythen, M. G and Gan, T. J. (2005) Perioperative fluid management and clinical outcomes in adults. Anesthesia & Analgesia Apr;100(4):1093-106. Gustin, G. (2005) Once you have identified your risk areas, it’s time for an effective audit methodology. Journal of Health Care Compliance. 7, 4, 47-48. Health Service Executive (2013) A Practical Guide To Clinical Audit. Accessed 12/10/2013http://www.hse.ie/eng/about/Who/qualityandpatientsafety/Clinical_Audit/clauditfilespdfs/practicalguideclaudit2013.pdf Healthcare Quality Improvement Partnership (2012). Template for Clinical Audit Strategy. Available from: http://www.hqip.org.uk/template-policy-strategy Hilton, A., Pellegrino, V and Scheinkestel, C. Avoiding common problems associated with intravenous fluid therapy. Medical Journal of Australia. 189: 509–513. Hysong, S. J. (2009). "Meta-analysis: audit and feedback features impact effectiveness on care quality." Medical Care 47(3): 356-63. Jamtvedt, G., Young, J. M., Kristoffersen, D. T., O’Brien, M. A and Oxman, A. D. (2006) Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database of Systematic Review Issue 2. Art. No.: CD000: 10.1002/ 14651858. CD000259. Johnston, G., Crombie, I.K., Davies, H. T. O., Alder, E.M and Millard, A. (2000) Reviewing audit: barriers and facilitating factors for effective clinical audit. Quality in Health Care; 9: 23–36. Parkinson, J and Brooker, C. (2004) Everyday English for International Nurses 1st ed. Elsevier, UK   Rawlins, M. (2002) Principals for Best Practice in Clinical Audit, illustrated, reprint, Radcliffe Publishing. Scales, K and Pilsworth, J. (2008) The importance of fluid balance in clinical practice. Nursing Standard; 22: 50–57. Seddon, M and Buchanan, J. (2006) Quality improvement in New Zealand healthcare. Part 3: achieving effective care through clinical audit. New Zealand Medical Journal 119(1239):U2108. Stewart, A and Rao, J.N. (2003) Clinical Audit and Epi Information, Radcliffe Publishing. Tang, V. C. Y and Lee E.W.Y. (2010) Fluid balance chart: do we understand it' Clinical Risk; 16: 10–13 Walsh, S. R and Walsh, C.J. (2005) Intravenous fluid-associated morbidity in postoperative patients. Annals of the Royal College of Surgeons of England 87: 126–130. Western Health and Social Care Trust (2008) Corporate Nursing Document. Policy for the recording of fluid balance/intake – output. Directorate of Nursing. Accessed22:17 09/10/13 http://www.westerntrust.hscni.net/pdf/Recording_of_Fluid_Balance_Intake-Output_Policy.pdf Appendix 1 | Questions | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | Compliance % | 1 | Name and PCN | Y | Y | Y | y | Y | Y | Y | Y | 100% | 2 | Entry dated | Y | Y | Y | Y | Y | N | Y | Y | 88% | 3 | Entry timed | Y | Y | Y | Y | Y | N | Y | Y | 88% | 4 | Black pen used | Y | Y | Y | Y | Y | Y | Y | Y | 100% | 5 | Rational | N/A | N/A | Y | Y | Y | N | Y | Y | 88% | 6 | Fluid restrictions identified | Y | N/A | N/A | N/A | Y | N/A | N/A | Y | 100% | 7 | No diet recorded | N | Y | N | N | Y | N | N | Y | 38% | 8 | Records totaled correctly | Y | Y | N | N | Y | Y | Y | Y | 75% | 9 | Total Balanced | Y | Y | N | N | Y | N | N | Y | 38% | Compliance % | 89% | 100% | 67% | 56% | 100% | 44% | 78% | !00% | 81% |