Clinical Audit

Dr. Noureen Zawar MD, MPH

PG Trainee Family Medicine
Jan 2018
What is a Chart Audit…?
 Clinical audit is a way to find out if healthcare is
being provided in line with standards and lets
care providers and patients know where their
service is doing well, and where there could
be improvements.
Why do we do Chart Audit…?
 The aim is to allow quality improvement to
take place where it will be most helpful and will
improve outcomes for patients.
Who performed the first clinical audit
 Florence Nightingale
Steps of Chart Audits

 Too Many Patients Stress the Care System

Adversely!
First Step
Topic:

Pelvic Inflammatory Disease Treatment & Follow

up
Second Step
Measures:

 Prescribed the recommended regime

 Arrange the follow up (3 days)

 Treatment of the partner

Third Step
Patient Population:
 Females of reproductive age-18-49 years

 Seen in PHC Nov –Dec2017

 Prescribe using the standard patient card (those

with prescription slip were excluded)

 ICD code of vaginal discharge, PID

Fourth Step
Sample Size:

 Sample size calculation

 Convenient sampling
Fifth Step
Audit Tools:
 Audit tools created using WHO guidelines
regarding PID/STD syndromic based treatment

 Vaginal discharge, lower abdominal pain,

menomettroragia, dysuria, fever, nausea,
vomiting, dyspareunia

 Table of symptoms/signs created in Excel and

populated with patients charts
Sixth Step
Collect Data:

 Data was collected with the help of PHC staff

using ICD codes for vaginal discharge and PID
Seventh Step
Summarize Results:

The results will be summarized shortly

Eighth Step
Analyze & Apply Results

 The results have been analyzed and will be presented later

PID Treatment –Chart Audit
Justification:

 A gold standard for the accurate diagnosis of PID

is not available therefore a pragmatic approach to
diagnosis and treatment is applied in many
clinical trials (UK Guidelines, 2017)
PID-Chart Audit Contd.
AIM:

Appropriate short term audit outcomes include:

 proportion of women receiving treatment with a
recommended regimen – target 95%
 number of named male contacts screened for
infection and/or treated-target 90%
 Follow up suggested –target 90%
Risk factors of STI-WHO
 Being less than 21 years old and unmarried

 Having more than one sexual partner in the

previous three months

 Having a new partner in the previous three

months

 Having a current partner with STI

WHOM to Treat
 Gonorrhea and Chlamydial infections are
asymptomatic

 Screen based on having vaginal discharge and

having positive risk assessment (curtailed
according to the local prevalence)

 WHO has flow chart based on vaginal discharge

and lower abdominal pain
Criteria for drug selection
WHO Outpatient Therapy
Results
SPSS-tables were generated
 Recommended Rx Prescribed
 Recommended treatment given to 40 %
 Target 95%
 Difference 95-40=55%

Frequency Percent Valid Percent

Cumulative Percent
Valid N 6 60.0 60.0 60.0
Y 4 40.0 40.0 100.0
Follow up suggested
 Follow up suggested days-70%
 However the recommended follow up -3 days
(one)
 Target 90%
 Difference 90-70=20%
Frequency Percent Valid Percent
Cumulative Percent
Valid N 3 30.0 30.0 30.0
Y 7 70.0 70.0 100.0
Total 10 100.0 100.0
Partner treated
 Partner treated 30%
 Target 90%
 Difference 90-30=60%

Frequency Percent Valid Percent

Cumulative Percent
Valid N 7 70.0 70.0 70.0
Y 3 30.0 30.0 100.0
Total 10 100.0 100.0
Abdominal examination –performed
Bimanual exam-A tenderness
ACTION POINTS
 Identification of main risk factors of STI. To curtail
the management based on that (WHO)

 History taking regarding the sexual behaviors

 Inquire regarding IMB and PCB

 We should either offer contraceptive devices or

should know a resource in the community to connect
the patients
ACTION POINTS
 Print the WHO flow charts as visual reminders to
clinicians

 Prompt referrals

 Partner treatment should be included –eliminate

the payment
Take home messages
 Always do abdominal and vaginal examination
(P/S and P/V-bimanual)
 Vaginal discharge is not a good indicator of
cervicitis
 Cervical mucopus, erosion and friability is IMB
and PCB
 Vaginal discharge (TV, Candida, BV are common)
Rx for BV & TV
Thank you
Any questions
 References
 Oluwatosin Jaiyeoba and David E. Soper, “A Practical Approach to the Diagnosis of
Pelvic Inflammatory Disease,” Infectious Diseases in Obstetrics and Gynecology, vol.
2011, Article ID 753037, 6 pages, 2011.
doi:10.1155/2011/753037https://www.hindawi.com/journals/idog/2011/75303
7/cta/

 Ross JDC. Pelvic inflammatory disease. Systematic review 1606. BMJ Clinical
Evidence. http://clinicalevidence.bmj.com/x/systematic-
review/1606/overview.html. 2013 December. Accessed [Nov 25th, 2017]
http://clinicalevidence.bmj.com/x/systematic-review/1606/overview.html

 Savaris RF, Fuhrich DG, Duarte RV, Franik S, Ross J. Antibiotic therapy for pelvic
inflammatory disease. Cochrane Database of Systematic Reviews 2017, Issue 4. Art.
No.: CD010285. DOI: 10.1002/14651858.CD010285.pub2.
http://www.cochrane.org/CD010285/STI_treatment-pelvic-inflammatory-disease

 Guidelines for the management of Pelvic Inflammatory disease BASHH Guidelines

https://www.bashhguidelines.org/media/1144/pid-guidelines-2017-for-
consultation.pdf
 References
 Khan et all, 2012 http://www.jpma.org.pk/full_article_text.php?article_id=3678

 http://www.jpma.org.pk/full_article_text.php?article_id=2602

 syndromic approach for STD https://www.popline.org/node/213533

 https://r.search.yahoo.com/_ylt=A0LEV70VjBlaTSUA.9sPxQt.;_ylu=X3oDMTByOHZyb21tBGNvbG8DYmYxBHBvcwMx
BHZ0aWQDBHNlYwNzcg--
/RV=2/RE=1511652501/RO=10/RU=https%3a%2f%2fwww2a.cdc.gov%2fstdtraining%2fready-to-
use%2fManuals%2fPID%2fpid-notes-2014.docx/RK=2/RS=P9h67V7cobXvGTn7vTW41nNwdPk-

 Partner managementhttps://www.ok.gov/health2/documents/Pelvic%20Inflammatory%20%20Disease.pdf

 Antibiotic regimes –Cochrane reviewhttp://www.empr.com/news/pid-azithromycin-doxycycline-quinolone-cephalosporin-

nitroimidazole/article/652827/

 https://bpac.org.nz/bpj/2012/april/metronidazole.aspx

 Chart Audits Steps http://www.aafp.org/fpm/2008/0700/pa3.html

 https://www.england.nhs.uk/clinaudit/ Clinical audit definition