Introduction
Clinical Audit is a very important process that helps us to enhance the quality of treatment and patient care with the help of a systematic audit which includes an assessment to find out any shortcomings and ensures that the entire clinical process is improved regularly, is effective and is executed step-by-step.
If we discuss the goals and objectives of a clinical audit, it is obvious that patient safety and quality of care is the priority however few other important areas that we concentrate on, include reduction in variation of clinical outcome, assessment of risk in clinical procedures and making recommendations based on the clinical audit findings.
In this audit we have basically conducted a study on the ‘Respiratory Rate’, as this is an early sign of deterioration and if not handled effectively may lead to an unexpected attack and emergency situation.
The audit preparation basically involves the management of the team and the relevant structure of audit that takes place, in this scenario we will look at the respiratory audit where individual contribution will take place and all the details and data will me recorded, monitored and analyzed by me.
Audit Topic
The audit topic will be the data management and audit of respiratory functions of the patients admitted for surgery and the same will be done in order to check any issues related to respiration as this also an early sign of deterioration and at times results in attacks that end up in an emergency admission to the ICU. The selection of this topic is done on the basis of studies related to the respiratory functions and direct observation of care. Though there are no national policies and initiatives related to this topic, it definitely is an evidence of a forthcoming issue and must be managed to check the complication rates.
Audit Tool
In order to ensure that the clinical audit performed reveals positive and sustainable results it is important to create an audit tool and use it in order to perform the audit. The audit is performed on 6 different patients who are admitted at least five days before a surgery. Based on recommendations From the Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995 (2001), it is very important to ensure good communication with patients, maintain coherence in observations and maintain local monitoring of stress and respiration; using these guidelines I have developed my audit tool which will basically audit the charts for the information and readings related to respiration in order to avoid any deterioration or emergency before or after operation.
The clinical audit tool will primarily concentrate on respiratory readings twice during the admission period and will ensure that the monitoring is done along with the data which is maintained both before and after the surgery during the entire period of admission. This too will enable a very proactive method of avoiding any deterioration at the time of operation or emergency admission to ICU.
Measure of Level of Performance
The measure of sampling will not be a criterion impacting the study and therefore it has been kept out of scope, though normal data for fitness level is checked through the general monitoring of physical activities. The data collection will be done on the basis of the normal readings captured everyday for all the participants and the readings are saved for five days in a row. The nursing documentation will capture the respiratory readings of all the participants at two specific times during the day to understand the change that has been brought though any medication that is being taken. A qualitative analysis of the data for all the 6 participants is done and the details are analysed to reveal the reason for the admission and the tool as we discussed above is used to capture the details (please see Appendix I)
AC & AF have shown an emergency admission to ICU due to problem in respiratory functions leading to deterioration and a further study of the data reveals that the respiratory rate for both of these participants we 18 on an average during all the data collection cycles and therefore it is important to asses the rest of the participants as well in terms of the data that has been received. If we look at the data we will realize that the reading taken during the second attempt each day has been 16 for most of the participants and in case if the reading has been 18 on a specific day there has been an emergency situation which was faced in a couple of cases.
Making Improvement and analysis of the risks
In order to ensure that there is no such observation as seen for the participants AC and AF (see appendix I) we need to ensure that there is a relevant check in place as soon as the respiratory rate is found to be above 16. There must be an immediate consultation in place with the prescribed doctors or use of an appropriate medicine to control the respiratory rate so that this condition is not faced again. Following factors are critical from the monitoring point of view and may have serious effects if not taken care:-
Communication – There must be a robust system of communication between the doctors and the patient and nursing staff must ensure that they keep this communication active by ensuring that all the readings taken are effectively communicated and maintained.
Lack of Knowledge – There may be times when newly appointed nurses are taking care of the type of patients discussed above, in such cases it is very important for them to be taught, how to take the respiratory readings and maintain the data. They should be thoroughly advised about the communication that they have to make, in case if the readings are not normal.
Emergency Medication – If the audit reveals a result which indicated that there is a possibility of an emergency, the nursing staff must be ready to immediately use medication to control such issues and pre-preparation and procedure planning is required in order to be ready for this.
Sustaining Improvement
There are various clinical indicators that will have to be in place in order to ensure that this improvement is a sustained one, there has to be a dual approach in order to ensure that this issue is not faced. In the first attempt, the monitoring of respiration has to take place at least twice and the patients must be able to immediately contact the nursing staff as soon as they face any issue with respiration.
The high risk patients who have a history of respiratory issues and have been admitted in emergency due to these circumstances must be handled with great care and should be monitored for respiration using automatic monitors to take an idea of the readings continuously. Secondly, in case of a previous history or any other signs of risk, there must be a regular medication in place apart from the monitoring to eradicate any chances of deterioration taking effect.
Conclusion
We have audited the respiration related issues for a set of participants who have been hospitalized and are being regularly monitored for respiration rates. It is important to mention here that the entire process of clinical audit involved the various steps of nursing practice however in order to assess the cases as exceptions we have seen that the readings taken during the data collection have helped to deduce the improvement in the procedure.
Clinical audit has not only helped to place a check in order to decrease the number of cases but have also helped to ensure a sustained impact in this area so that any future issues in this area can be proactively handled and this will end up becoming a regular practice hence decreasing the cases of respiratory issues by a great number.
Patient Profile
1. Patient ID #
2. Age
3. Gender ~ Male ~ Female
4. Primary Diagnosis
5. Factors Predisposing Patient to Complications (Check all that apply):
~ a. Immunosuppressed
~ b. Circulatory Impairment
~ c. Diabetes
~ d. Obesity
~ f. Other documented. Describe:
6. Nature of Therapy:
~ a. Antibiotics
~ b. Chemotherapy
~ c. TPN
~ d. Other
7. Name of agent
9. Expected duration of therapy (in days)
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