Pediatric Urology

Surgical Complications and Management

Prasad P. Godbole, Martin A. Koyle, Duncan T. Wilcox

• Publisher: Wiley-Blackwell
• Year: 2015
• ISBN:
  9781118473368
• Edition: 2
• Topic: Medicine
• Subtopic: Urology

Pediatric Urology: Surgical Complications and Management, 2nd edition focuses 100% on the most common problems that can occur during pediatric urologic surgery, and how best to resolve them, ensuring the best possible outcome for the patient.

As well as being thoroughly revised with the latest in management guidelines, brand new to this edition are a host of clinical case studies highlighting real-life problems during urologic surgery and the tips and tricks used by the surgeon to resolve issues faced. These will be invaluable for urology trainees learning their trade as well as for those preparing for Board or other specialty exams. Chapters will include problem solving sections as well as key take-home points.

In addition, high-quality teaching videos showing urologic surgery in action will be included via the companion website - again proving an invaluable tool for all those seeking to improve their surgical skills.

Edited by an experienced and international trio of urologists, they will recruit the world's leading experts, resulting in a uniform, high-quality and evidence-based approach to the topic.

Pediatric Urology: Surgical Complications and Management, 2nd edition is essential reading for all urologists, especially those specialising in pediatric urology and urologic surgery, as well as general surgeons.

PART I
Principles of Surgical Audit

CHAPTER 1
How to set up prospective surgical audit

Andrew Sinclair¹ and Ben Bridgewater²

¹Stepping Hill Hospital, Stockport, UK

²University Hospital of South Manchester NHS Foundation Trust, Manchester, UK

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KEY POINTS

• Clinical audit is one of the keystones of clinical governance
• Audit can be conducted prospectively or retrospectively and robust data collected for patient benefit
• A well-performed audit can inform patients about surgical results and drive continuous quality improvement
• Data can be derived from local hospital statistics to nationally reported outcomes
• Paper based audit is time consuming and is being replaced by IT-based support to clinical care pathways

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Introduction

Clinical audit is one of the “keystones” of clinical governance. A surgical department that subjects itself to regular and comprehensive audit should be able to provide data to current and prospective patients about the quality of the services it provides, as well as reassurance to those who pay for and regulate health care. Well-organized audit should also enable the clinicians providing services to continually improve the quality of care they deliver.

There are many similarities between audit and research but, historically, audit has often been seen as the poor relation. For audit to be meaningful and useful it must, like research, be methodologically robust and have sufficient “power” to make useful observations; it would be easy to gain false reassurance about the quality of care by looking at outcomes in a small or “cherry-picked” group of straightforward cases. Audit can be conducted retrospectively or prospectively and, again like research, prospective audit has the potential to provide the most useful data, and routine prospective audit provides excellent opportunities for patient benefit [1, 2, 3, 4].

Much of the experience we draw on comes from cardiac surgery, where there is a long history of structured data collection, both in the USA and the UK. This was initially driven by clinicians [1, 2, 3, 4, 5, 6, 7], but more recently has been influenced by politicians and the media [7, 8]. Cardiac surgery is regarded as an easy specialty to audit in view of the high volume and proportion of a single operation (coronary artery bypass graft) in most surgeons’ practice set against a small but significant hard measurement endpoint of mortality (which is typically around 2%).

In the UK recently, increasing focus has been placed on national clinical audit. A Public Inquiry into the events at Mid Staffordshire NHS Trust found unsatisfactory care that had gone on for some time, despite the existence of data in the “system” that identified potential problems [9]. The UK Government’s response to these events has been to drive public reporting of outcomes down to the level of individual surgeons for 10 specialties, including gastrointestinal surgery, interventional cardiology and urology. These data were published in 2013, and the process has led to marked improvements in engagement with national clinical audit in the UK and has dramatically increased data quality and the utility of the audits [10, 11].

Why conduct prospective audit?

There are a number of reasons why clinicians might decide to conduct a clinical audit (Box 1.1).

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Box 1.1 Possible reasons for conducting clinical audit.

• As a result of local clinical interests
• As a result of clinical incident reporting
• To comply with regional or national initiatives
• To inform patients about surgical results and support choice
• To drive continuous quality improvement
• To comply with health care regulation
• To engage patients in decisions about their health care
• To provide public reassurance

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As a result of local clinical interests

Historically, many audit projects have been undertaken as a result of local clinical interests. This may reflect interest in a particular procedure by an individual or a group, or may reflect concern about specific outcomes for a particular operation.

As a result of clinical incident reporting

The major disciplines that ensure high quality care and patient safety are clinical risk management and audit. Most health care organizations should have sophisticated systems in place to report and learn from adverse incidents and near misses [8]. Reporting is usually voluntary and investigated according to a “fair and just culture” but it is unlikely that all incidents that occur are reported. If an adverse incident is recorded, the record identifies that it has occurred but gives no indication of how often it has happened previously, and only limited indication of the likelihood of recurrence. A mature organization should have clear links between risk reporting and audit, and choose topics for the latter based on data from the former.

To comply with regional or national initiatives

Increasingly audits are been driven by organizations that exist outside a hospital. These may include audit led by professional societies, regulatory bodies or regional/national quality improvement and transparency initiatives.

To inform patients

Across the world health care is becoming more patient-focused. The modern health care consumer will sometimes want to choose their health care provider on the basis of that hospital or surgeon’s outcomes. Even if patients are not choosing between different hospitals, recent data from the UK suggest that patients are interested in outcomes of surgery by their doctors [13]. Patients’ views should inform decisions about what to audit, and they may be interested in many areas which will be dependent on the planned operation but may include data on mortality, success rates, length of stay, the incidence of postoperative infection and other complications, and patients’ experience data.

To drive continuous quality improvement

It has been shown quite clearly from cardiac surgery that structured data collection, analysis and feedback to clinicians improves the quality of outcomes. This has been detected both when data are anonymous and where named surgeon and hospital outcomes have been published [1, 2, 3, 4]. The magnitude of this effect is large; in the UK, a system of national reporting for surgical outcomes was introduced in 2001 and has led to a 40% reduction in risk adjusted mortality [4]. The introduction of any drug showing a similar benefit would be heralded as a major breakthrough, but routine national audit has not been embraced by most surgical specialties. Simply collecting and reviewing data seems to drive improveme...