A retrospective audit of the timescales involved in the diagnosis and management of suspected Achilles tendon ruptures at a single National Health Service trust: A quality service improvement and redesign project

Abstract

Introduction The Achilles tendon is the most frequently ruptured tendon. Prompt diagnosis of this injury ensures optimal management decisions are instituted early ensuring the best outcome and patient experience, at minimal cost to the United Kingdom National Health Service. Despite this, regional and national variations to diagnosis and management exist, with anecdotal evidence of inefficiencies in the local patient pathway. To explore this further, a retrospective departmental audit of timescales from presentation to ultrasound diagnosis and definitive treatment decision was undertaken. Methods All suspected Achilles tendon ruptures in 2018 were identified through electronic and written patient records, and information on timescales involved in the diagnosis and management of each compiled. Descriptive statistics were used to map each step of the pathway and timescales involved, with performance assessed against local departmental standards and the Swansea Morriston Achilles Rupture Treatment (SMART) protocol. Results In total, 119 patients were identified, of which 113 received an ultrasound examination. Local departmental standards were met in the majority of cases, with 78% (n = 88) diagnosed by ultrasound within one week of the request and 83% (n = 91) given a treatment decision within two weeks of presentation. However, this was suboptimal when compared with timeframes utilised for developing the SMART protocol, with only 7% (n = 8) scanned within 48 hours of presentation. Conclusions Key areas of the patient pathway were identified for quality service improvement and redesign, with multidisciplinary discussion resulting in the development of a revised patient pathway which expedites diagnosis and treatment for these injuries.

Audit in ultrasound: An introduction and overview

“…An example is to review a care pathway to identify how to improve the time from presentation to diagnosis and treatment in a Achilles tendon rupture within an English NHS trust, 14 the process audit steps are described below. The advantage of process audits is their ability to identify areas for improvement and provide evidence to support anecdotal observations seen in day to day clinical activity.…”

“…6.1 | Preparing for the audit/identifying the topic Audit requires investment in both time allocation, skill mixes, staffing and occasionally monetary funding. Audit preparation requires clear, welldefined aims 3,14 where time is required to choose and hone the topic or theme and scope of audit. Without a clear focus, it becomes difficult to pinpoint any focus areas and subsequently implement any successful changes.…”

“…An example is to review a care pathway to identify how to improve the time from presentation to diagnosis and treatment in a patient group. Using Williams et al's audit of timescales related to Achilles tendon rupture within an English NHS trust, 14 the process audit steps are described below. Determine clear audit objective—What are the current timescales involved in the diagnosis and management of suspected Achilles tendon rupture? Determine criteria of good practice—a comparator to recognised standards (Swansea Morriston Achilles Rupture Treatment [SMART] protocol) 14 Determine assessment criteria—timescales from presentation to management decisions, accessed from patient information records. Identifying improvements—key areas of the patient pathway are identified for redesign/improvement Plan for sustaining improvements—implementing new pathway with audit cycle to be repeated in 1 year to re‐evaluate changes made and identify any further improvements or changes. …”