A systematic review of clinical audit in companion animal veterinary medicine

Abstract

BackgroundClinical audit is a quality improvement process with the goal of continuously improving quality of patient care as assessed by explicit criteria. In human medicine clinical audit has become an integral and required component of the standard of care. In contrast, in veterinary medicine there appear to have been a limited number of clinical audits published, indicating that while clinical audit is recognised, its adoption in veterinary medicine is still in its infancy. A systematic review was designed to report and evaluate the veterinary literature on clinical audit in companion animal species (dog, cat, horse). A systematic search of English and French articles using Proquest Dissertations and Theses database (February 6, 2014), CAB Abstracts (March 21, 2014 and April 4, 2014), Scopus (March 21, 2014), Web of Science Citation index (March 21, 2014) and OVID Medline (March 21, 2014) was performed. Included articles were those either discussing clinical audit (such as review articles and editorials) or reporting parts of, or complete, audit cycles.ResultsThe majority of articles describing clinical audit were reviews. From 89 articles identified, twenty-one articles were included and available for review. Twelve articles were reviews of clinical audit in veterinary medicine, five articles included at least one veterinary clinical audit, one thesis was identified, one report was of a veterinary clinical audit website and two articles reported incomplete clinical audits. There was no indication of an increase in the number of published clinical audits since the first report in 1998. However, there was evidence of article misclassification, with studies fulfilling the criteria of clinical audit not appropriately recognised. Quality of study design and reporting of findings varied considerably, with information missing on key components, including duration of study, changes in practice implemented between audits, development of explicit criteria and appropriate statistical analyses.ConclusionsAvailable evidence suggests the application and reporting of clinical audit in veterinary medicine is sporadic despite the potential to improve patient care, though the true incidence of clinical audit reporting is likely to be underestimated due to incorrect indexing. Reporting standards of clinical audits are highly variable, limiting evaluation, application and repeatability of published work.Electronic supplementary materialThe online version of this article (doi:10.1186/s12917-016-0661-4) contains supplementary material, which is available to authorized users.

A clinical audit cycle of post-operative hypothermia in dogs

“…The,clinical,audit,was,performed,according,to,the,"Plan",,"Do",,"Study",,"Act",model, (Burgess,2011;,Rose, et,al.,2016).,"Plan",was,based,on,the,ini=al,percep=on,that,post;opera=ve,hypothermia,was,prolonged, and,sub;op=mally,managed.,A,strategy,to,collect,data,was,agreed,upon,with,the,prac=ce,manager.,Audit, 1,was,the,period,of,data,collec=on,("Do"),during,which,standard,clinic,prac=ce,for,post;opera=ve, temperature,management,was,followed :,each,dog,had,a,temperature,recorded,at,extuba=on,and,then, sporadically,thereaher,,varying,with,the,preference,of,the,technician,and,surgeon,responsible,for,each, case.,A,FAW,was,placed,on,all,dogs,in,the,recovery,ward,if,their,rectal,temperature,<,37˚C.,However,,the, dura=on,of,placement,and,frequency,of,subsequent,temperature,readings,was,at,the,discre=on,of,the, technician,and,supervising,veterinarian.,Data,on,FAW,use,in,the,recovery,ward,was,not,recorded,on,the, treatment,sheet.,Post;opera=ve,temperatures,recorded,on,each,dog's,treatment,sheet,were,collected, un=l,normothermia,was,achieved.,Data,collec=on,took,place,from,September,23,,2013,to,October,22,, 2013 health,technicians.,A,discussion,followed,,facilitated,by,the,authors, ("Study",,early,December,,2013) with,the,goal,of,discussing,peri;opera=ve,temperature,and,reaching,a,consensus,on,feasible,changes,in, prac=ce,to,try,and,reduce,its,incidence.,Once,a,consensus,was,reached,,staff,were,given,approximately, one,month,to,implement,the,agreed,changes,("Act").,A,poster,was,displayed,in,the,recovery,area, summarising,the,main,recommenda=ons,to,serve,as,a,visual,reminder.…”

“…Despite,clear,evidence,of,nega=ve,outcomes,associated,with,hypothermia,in,humans,,the,reported, incidence,of,post;opera=ve,hypothermia,is,high,,ranging,between,53%;85%.,However,,the,recent, development,and,implementa=on,of,hypothermia,management,guidelines,has,created,a,mechanism,for, improvement, (Sessler,2009;,Torossian,2007;,Alexander,et,al.,2008;,Slotman,et,al.,1985;,Vaughan,et,al., 1981;,Stewart,et,al.,1987)., In,veterinary,medicine,,two,large,scale,studies,(n=,275,cats,and,1525,dogs), reported,an,incidence,of,post;opera=ve,hypothermia,(defined,as,an,oesophageal,temperature,less,than, 38.5°C),of,83.6%,of,dogs,and,96.7%,of,cats, (Redondo,et,al.,2012a;,Redondo,et,al.,2012b)., There,are, currently,no,management,guidelines,or,standards,of,care,for,peri;opera=ve,hypothermia. Clinical,audit,is,a,quality,improvement,tool,for,evalua=ng,and,improving,pa=ent,care, (Rose,et,al.,2016;, Burgess,2011;,Mosedale,1998)., As,a,standard,of,care,in,human,medicine,,clinical,audit,has,been, successful,in,genera=ng,con=nued,improvements,in,pa=ent,care,though,its,applica=on,in,veterinary, medicine,is,currently,limited, (Patel,et,al.,2013;,Shonfeld,et,al.,2011;,;,Rose,et,al.,2016). In,light,of,the,evidence,of,adverse,effects,associated,with,post;opera=ve,hypothermia,,and,the, suspected,incidence,of,prolonged,hypothermia,in,our,clinic,,we,sought,to,quan=fy,and,reduce,the, incidence,of,post;opera=ve,hypothermia,by,performing,a,clinical,audit., ,prospec=ve,clinical,audit,was,conducted,at,a,small,animal,veterinary,referral,hospital.,Client,consent,…”

Clinical audit in equine practice, and the International Colic Surgery Audit

“…However, there remains a dearth of published veterinary examples and those that do exist commonly suffer poor design and reporting (Rose et al . ).…”

“…The intervening years have seen a steadily growing interest in veterinary clinical audit, reflected in the many review articles on the topic (Rayment 2002;Viner 2005Viner , 2009Mair 2009;Dunn 2012;Waine and Brennan 2015;Wylie 2015;Waine et al 2018a,b). However, there remains a dearth of published veterinary examples and those that do exist commonly suffer poor design and reporting (Rose et al 2016a).…”

“PDSA” – but not as you know it?!

“…Where indicated, changes are implemented at an individual, team or service level and further monitoring used to confirm improvement in healthcare delivery” (NICE ). Although this seems a very weighty definition, and has probably been the reason behind the poor adoption of clinical audit by veterinary practitioners (Rose et al ,), put more simply, clinical audit is just asking, “Are we adhering to current agreed best practice (evidence‐based standards or guidelines, where such exist) and, if not, can we do anything to improve?” Research is required to ask and answer the question, “What is best practice?” or even, “What is the right song?” and therefore has different goals to that of clinical audit, which is more about “Are we singing the song right?”…”