Monday, 3 November 2014

Maintaining Clinical Standards in Practice

“Sometimes wrong but never in doubt” is an aphorism that could be ascribed to many senior equine practitioners in the 1960s and 70s.  George Bernard Shaw’s comment that information imparted confidently by a “grey beard” readily becomes received wisdom rang true. Clinical standards in the sixties and seventies were not only basic but more importantly they were not questioned.  It was perceived that in private practice we were too busy and it was too expensive either to achieve a high standard of clinical protocols or to evaluate the outcomes of our cases. This is manifestly not the case.

We all know what clinical standards involve: they are in the RCVS Guide to Professional Conduct. But at the coal face of clinical practice, with all its pressures, they are not always easy to achieve.  This article is not intended to describe the details of “best practice” for specific procedures, such as the correct way to deploy an intravenous catheter, but to discuss ways in which the daily routine can be the vehicle for maintaining standards.

Use of personal protocols for all clinical tasks. These are based on what is understood to be “best practice” but they should be adjusted in response to complications. Certain questions are good incentives for developing an acceptable routine. Should there be a complication, is there anything we would regret having done or that we failed to do during the procedure? If we had to defend our actions in a court of law could we proudly and confidently stand behind what we did? How publicly humiliating to be asked why we failed to perform an arthrocentesis aseptically on a joint that subsequently became septic. Mistakes are less likely to be made if we stick as much as we can to a routine for everything we do, from examination of the horse to any veterinary procedure we might have to perform. 

Imaging protocols are driven by the quality of the images. Recorded images are a permanent record that reflects how we performed the imaging procedure and they have the potential to haunt us for years.  Do we always properly prepare the horse for ultrasonography and do we take trouble to maximise image quality? Have we taken enough care with positioning for each radiographic projection? Inattention to detail in all imaging procedures can be the cause of a missed critical lesion. A proper routine that covers all the vital nuances should at least avoid regrets.  It may take longer but we have fulfilled our responsibility to the horse and its owner.

Monitoring clinical outcomes.  We know from the literature what “best practice” should be for many treatments and procedures we use, but have we checked that our results reach the accepted standard?  And how many of us can advise an owner that for a procedure we are recommending, a known percentage of our cases have returned to work?  Analysing the data does take time, but an organised follow up system that uses our secretariat will at least collect the outcome data.   The clients have to be proactively contacted; it’s no good waiting for them to call us and most owners really appreciate the interest.  Hard data will often overturn our expectations and guessing is no substitute.  Compared with the medical profession our poor knowledge of outcomes is one of our profession’s major weaknesses.  Evaluating outcomes depends on a real desire to do it, a robust system and good staff.  Even then the disheartening entry on the case notes “lost to follow up”, as well as the extra time required to process the data can be demoralising.  It is our responsibility to try and good or bad it should improve our clinical service to the horse.

Record keeping and paper work. There are no short cuts. Clinical standards can’t be maintained with inadequate records. Whether we are the “write up your notes straight away” type or the “leave them until later” type, the record must contain enough relevant information. This is stating the obvious but poor clinical notes are a major limitation to the evaluation of outcomes and again they have a humiliating side effect if we have to produce them in court.   

This rather sanctimonious article is born of a career in first opinion practice, hospital practice and university clinical practice. In the Liphook practice our main ethic was to perform the clinical work to the highest standard we could, despite the cost, and the standard we have reached was achieved with systems and discipline. But despite evaluating outcomes in a number of large case studies my main regret is that we didn’t do more of this, especially in the early days. That is my regret. What will yours be?

John Walmsley MA VetMB CertEO DipECVS HonFRCVS