Audit of clinical activity

Introduction

This section of the web site posts an audit of my in patient clinical activity since August 1998 when I started to collect audit data on my patients. Before then I relied on the hospital information systems to provide me with feedback on my activity. This was unsatisfactory for a number of reasons. The data was not always accurate, it was incomplete and was more relevant to management than clinical practice. It is now no longer accessible at all even for retrospective audit purposes. I have always taken the view that a patient has the right to information on a surgeon’s activity. ‘Have you done this operation before?’ ‘How often?’ ‘What are your results?’ ‘What is your complication rate?’ All these are very valid questions and ones which I would ask (and have asked) if I or my own were having surgery. This information should now be available to patients and their carers but it must be accurate..

However if patients are going to have this information I would like it to be accurate. When I last compared the results of my own data collection with hospital generated data there was only a 30% correlation between the hospital information systems and my own data. Since it is the hospital data that is posted with organisations like Dr Foster and the GMC it is all the more important that somewhere there is access to what I regard is a more accurate reflection of my surgical activity.

The difference between the hospital generated data and my own personal data lies in the methods of data collection. Hospital data at Frenchay hospital is collected retrospectively by non medical audit clerks. In practice this means one or two key individuals going through notes after a patient’s discharge to code a patient’s admission. The data is then added to the hospital’s information systems. Our coders have become very good at the job and get some of the data exactly right e.g. overall numbers of admissions to hospital and the reason for hospital admission, but they cannot be expected to recognise surgical complications or if they do, apply the appropriate weighting to a particular complication. Since 1998 I have collected my data prospectively i.e. as I go along. I started by using a Toshiba palmtop which I carried with me at all times. I now carry all my data o a hardware encrypted memory stick. I collect data of direct clinical relevance on all my patients by adding data to Excel spreadsheets. By ‘clinical relevance’ I mean all complications that are the direct result of the surgery I do and all other complications that influence a patient’s stay in hospital. Minor complications or those not relevant to my practice are excluded and anomalies in the way hospital data is generated are corrected. My data therefore compliments the hospital generated data. In truth, both are needed. The hospital data is independent but is retrospective but not strictly relevant to surgery. My data is prospective but is biased towards my view of my practice. This does not constitute ‘cooking the books’, the convenient political view of a surgeon’s own audit but is simply a means of collecting data that is relevant to my day to day practice. I need to have accurate data to hand to monitor my practice. In 1998 and for the ensuing decade I was asked to do twice the amount of work that is recommended as safe by the profession and was doing so with resources that were often inadequate to the task. The issue of workload I have tackled in recent years but I am still having to tailor the work I do to the resources available to me. I therefore need to monitor my activity very closely. If my complication rates were to change then I would need to know about it as early as possible.

I am resigned to the fact that I will always work in an environment that is under-resourced with constant competition for available resources between emergency and elective work. I may wish to work in a ring fenced environment with proper opportunities for training, continuing professional development and service development but without the data to support my case I cannot approach the political battle that we all have to face. In the meantime I feel it is my duty to be honest about what I can achieve at present.

‘How do you compare with other surgeons?’ Finally I feel I should address this question. The best comparative data between surgeons probably comes from hospital generated databases, bearing in mind that the inaccuracies that I have described above apply to everyone in the department equally. At present there is no uniformity in the way different hospitals collect data so there is no way of comparing surgeons from different hospitals., although Dr Foster is trying to do so. Recent attempts to do so with regard to crude data such as death rates have been applied to specialties where there has been some collection of data nationally. Neurosurgery is now one of them. The political view that crude death rates can be corrected for external variables in order to make data comparable between surgeons. I am very sceptical of this – see below.

A word about the consent process. The latest rulings on consent have defined the need for surgeons to discuss all the available treatment options with their patient so that they can make their own informed choice about the management of their condition. If you feel that I have not done this then please let me know. Inevitably if you practice a 'do as you would be done to' style of medicine that I aspire to, I am likely to stress the management option that I feel is most appropriate but this shoudl not prevent me or any surgeon from outlining all treatment options

At the end of the day I believe one can try to make too much of a science out of this. ‘Do you like your surgeon?’ ‘Do you trust them?’ ‘Have they answered your questions and addressed you concerns thoroughly?’ ‘Do they object or facilitate your request for a second opinion if you so wish?’ ‘Are they confident they have the resources to take your case on?’ The final decision about whom you should let operate on you is often a subjective one.

A word more about mortality. Making sense of comparative mortality data is extremely difficult as it is always difficult to compare ‘like with like’. Nevertheless this has become the main criterium by which a surgeon’s competence is judged. A study in our department showed considerable variation of mortality between my colleagues on a year by year basis. So much depended on the severity of cases presenting to us while on call. All neurovascular deaths are recorded under the name of the admitting surgeon even if a patient was never treated surgically. Sometimes surgical philosophy and expertise influences mortality. Surgeons with the most experience in a discipline often take on the hardest cases, in which case a higher mortality can actually reflect greater competence not less!

My data tries to make my mortality data more transparentIf you have read this far it will because you want to find hard data on my activity so read on. The raw data is presented in the excel file (click here).

Audit Summary - (August 1998 to April 2008)

I used to admit in the region of 450 patients per year. 10% of those admissions were private but since November 2007, when I stopped operating in the private sector, all are now NHS. 14% of my activity was classified as routine. 47% of my admissions were emergencies and 34% were urgent admissions. 30% of admissions did not undergo surgery. 42% of all admissions were for cranial interventions, while 29% had spinal surgery. Then I operated on an average of three glioma patients and two meningioma patients a month. I did one cranial epilepsy operation and two VNS operations a month. On the spinal side I did an average of three cervical operations and four lumbar operations per month.

Audit Summary (April 2008 to March 2013)

During this period I admitted an average of 338 patients a year, all of them NHS. This figure is more in line with recommended safe neurosurgical practice. The percentage of emergency admissions remained unchanged at 47% but the percentage of urgent and routine admissions was reversed, reflecting better organisation of my elective practice. In particular the appointment of new colleagues to take on the management of neuro-oncology services and elective spinal services, allowed me to focus on the epilepsy surgery service. The ratio of non surgical admissions, cranial and spinal surgical admissions remained unchanged. I operated on an average 2 glioma patients and 1 meningioma case a month. I did 2 cranial epilepsy cases a month and 4 VNS cases a month. I did 2 cervical spine cases and 4 lumbar cases a month. The slight reduction in tumour and spinal activity reflects the input from my excellent new colleagues.

Audit Summary (April 2012 to March 2013)

During this period, due to pressure on beds, the trust allocated only one bed to each elective list, making the rest of the bed pool available to emergency admissions, in order that the ‘trolley wait’ target could be met. (The thrust for ‘foundation status’ seems to have been the driving force here). By July the cancellation rate on my elective lists was so high that I decided to comply with trust policy and only admit one case per list. As a result I gave up routine spinal surgery to focus on epilepsy surgery. This change has been reflected in my activity. I admitted a total of 322 cases, 48% of which were elective. The same number of cases were classified as urgent as routine. The total number of cranial operations remained the same but the total number of spinal operations was reduced by 30%

Audit Summary (April 2013 to March 2016)

This period covers the move to the new hospital at Southmead, where bed allocation was even more uncertain. I admitted and average of 358 patients per year. As always 50% of admissions were emergency cases and 1/3 were non surgical.I continued to operate on a tumour case a week and an epilepsy craniotomy a fortnight. I operated on an average of 60 spinal cases a year

Audit Summary (April 2016 to March 2017)

This  year saw a further change in my practice. Since October 2016, with the appointment of new colleagues and in recognition of my advancing years, my services on the on call rota were no longer  required. My revised job plan included regular week end sessions, in line with the current trend towards seven day working. The input to my practice cama from the epilepsy multidicsiplinary team meetings, from my general outpatients and from the generic spinal waiting list. Since all my lists were elective, they could be planned ahead, minimising the risk of cancellation. It may have taken over two years but the trust now recognised the need to use the medirooms as a 'hospital within the hospital' allowing day case and short stay patients to be treated without involvement of the limitied inpatient bed resource. Pressure on the trust from NHS England with regard to long waiter patients means that at long last, there has been some degree of 'ring fencing' of beds for epilepsy surgery which  meant a significant reduction in the number of my patients having their admissions cancelled on the day of surgery (NONE since May 2016 - quite an achievement!) At the end of the third quarter I had admitted 15 tumour cases, 30 epilepsy craniotomy cases 50 VNS cases and 50 spinal cases.

Audit Summary (April 2017 to December 2017)

This period has been a continuation of my practice focussing solely on elective work, using a resource base that included weekend working. My primary remit was to continue taking the lead on the adult epilepsy surgery service. In addition I had an unofficial role 'back filling' the pain surgery service that was lacking consultant input and taking trust long waiter patients that colleagues, for one reason or another had been unable to admit themselves. I anticipated that the pressure on input beds would increase as the year went on. 80% of my admission have been managed as day cases, using the medirooms as the bed base. Despite this short term cancellations have started to occur again despite my best attempts to avoid them. Four patients had their procedures cancelled at short notice. I admitted a total of 150 patients.These included 20 epilepsy craniotomies, 75 VNS procedures, (95 epilepsy operations) 27 spinal procedures (9 cervical, 14 lumbar, 4 intrinsic) and 16 pain procedures. 

Audit Summary (January 2018 to October 2018)

In January I was off having surgery myself. As I left to have my knee surgery, I wrote the following: In preparation for this I cleared my waiting list, in part by facilitating my paediatric colleague Mike Carter to take on more adult epilepsy cases, thereby enhancing the  interface between the paediatirc and adult services. I will come back to work in March with no waiting list, with my succession planned for the epilepsy surgery service, with weekend working established, with the long waiter problem eased by colleagues stimulated into organising to treat their own patients in a more timely fashion rather than have them handed on to me and the pain surgery service run efficiently by my new colleague Adam Williams. My 'time' could be up! The reality was that I came back to a servrice that had stagnated, with a waiting list built up again. I was informed that I could no longer continue on the elective contract I had before I left as the trust had decided that only consultants with a full time on call commitment could be employed full time - (all my efforts to create a useful and sustainable working environment for older consultants reduced to nothing!) 60% of my activity during this period related to the epilpesy surgery service. I continued to do urgent spinal cases referred by the spinal physiotherapists and I covered a colleague's adult spinal dysraphism practice, admitting 102 cases overall with 63 of them being epilepsy surgery and the rest mainly spinal.

Benchmark Audit statistics

Benchmarks statistics for surgical expertise include mortality data, data on patients made worse by surgery, second operation rates, readmission rates and complications. All these benchmarks have to be interpreted appropriately. Mortality varies dramatically with case mix.

 Death rates are very carefully monitored in our department with each case being audited individually and presented at our monthly clinical audit meeting. The overall death rate under my care is 1.9%. The overall death rate in patients undergoing surgery is 2.1%. Of these the majority were deemed at audit review to be inevitable in that they occurred in patients presenting in extremis. That leaves 24 patients (0.6%) where their deaths could have been avoided. Two had pulmonary emboli. three developed a postoperative haematoma with subsequent complications, three developed a major stroke after coiling of an aneurysm, five suffered a subarachnoid haemorrhage during coiling of their aneurysm, two developed postoperative status epilepticus from which they never recovered, three died from the complications of infection, three suffered multiorgan failure, one patient had an allergic reaction to an anaesthetic drug while one patient had a haemorrhage from his tracheostomy that led to his death. 22 of these cases were urgent or emergency admissions. Only one was a routine admission. Eight (the vascular cases) were treated by my neuroradiology colleagues and did not undergo open surgery. Patients made worse by surgery. I have recently published a 15 year longitudinal study of mortality in my practiice. Click here to access the preprint of this.

34 patients were made worse by their surgery (2%) 17 patients undergoing glioma surgery had a worse neurological deficit after their surgery (6%). Five patients had neurological complications after extrinsic tumour surgery (2%) Six patients were worse after cervical surgery (2%) Three patients were worse after spinal cord surgery (1%) One patient suffered a stroke after aneurysm surgery (6%) and two were worse after coiling. One patient developed worse pain after injection treatment for trigeminal neuralgia. One patient had a stroke after her shunt was removed

Other measures of surgical expertise include second operation rate and readmission rates within one month. The crude data on this is not relevant as approximately half the cases were planned. However the complication related second operation rate is 4% and the hospital readmission rate is 4%. I have no idea what should be considered benchmark figures for these statistics.

Surgical infection rates are an important benchmark for a number of reasons. Morbidity from infection is major, prolonging hospital stay and in some cases reversing the benefits of surgery completely. MRSA (hospital 'superbug' infection is life threatening. The established wisdom is that elective surgery done in dedicated facilities is subject to less infection than elective surgery done using the same resources (beds and theatres) as emergency surgery - the situation at Frenchay. My overall infection rate is 1.8%. At Frenchay it was 2.6%

Since the move to Southmead, where use of the medirooms as a bed base produces a degree of ring fencing of resources and the change of my practice to an elective one, my infection rate has dropped to >1%. I have only one documented case of MRSA infection in an elective procedure. This was cervical spine procedure done in the private sector (The patient was a carrier of MRSA organisms acquired in the community)

Infection in patients undergoing implant surgery is more frequent and more devastating when it occurs. This stable shows the number of implant procedures I have performed over the last two decades. While there is much that is wrong with the facility at Southmead there is a clear improvement in the rate of infection. In recent years the procedure most commonly associated with infection was cranioplasty / bone flap replacement. It is important to note this when the clinical indications for bone flap removal are increasing.