AUDIT ON USE OF ANITIBIOTICS FOR SURGICAL PROPHYLAXIS
INTRODUCTION
Surgical Antibiotic Prophylaxis reduces the likelihood of infection where:
Inoculum of infecting bacteria likely to be high.
Procedure may result in infection from small inoculum
The idea behind prophylaxis is not to protect against post operatively acquired infection.
In most cases single I.V dose at induction is adequate.
The audit is based on evidence obtained from national and local guidelines and evidence based literature prepared by our micro department
OBJECTIVES
To ascertain current practice in most surgical specialities.
To find whether we use appropriate antibiotic.
If so , appropriate dose or doses given at appropriate time.
To come to a consensus among specialities regarding this and re-audit in 2 months time.
METHODS
The audit was performed from 22nd of Feb – 15th of Mar.
All surgical patients both elective and emergency were included.
Totally 80 patients were followed up prospectively and data was obtained from anaesthetic and prescription charts.
The pharmacist was also involved in obtaining data.
DATA INTERPRETATION
PERCENTAGE OF CASES IN EACH SPECIALITY
FINDINGS
PROPHYLAXIS GIVEN
DOSES GIVEN
(within appropriate prophylaxis GROUP)
NUMBER OF DOSES GIVEN
(within appropriate prophylaxis GROUP)
GIVEN AT APPROPRIATE TIME
(within appropriate prophylaxis GROUP)
OVERALL “INAPPROPRIATE” ANTIBIOTICS
“INAPPROPRIATE” ANTIBIOTICS WITHIN SPECIALITIES
REASON WHY“INAPPROPRIATE”
Urology and General Surgery contributed the most towards the overall percentage of “inappropriate” use of antibiotics.
However vascular and General Surgery contributed the most individually.
Though the number of Orthopaedic cases that were followed up were high, 90% of cases received appropriate antibiotics.
Most of the cases in Urology and General Surgery were “inappropriate” because the patients received treatment rather than prophylaxis.
The patients who received “inappropriate” antibiotics underwent the following procedures:
We also observed that each surgical consultant had their own choice of antibiotics which at times were “inappropriate”.
This resulted in some of the anaesthetists giving “inappropriate” antibiotics as prophylaxis.
NO CURENT RECOMMENDATIONS
SUMMARY
Based on the findings we observed that almost 60% of patients received appropriate antibiotic prophylaxis.
Guidelines are not available for more than 20% of cases audited.
Potential implications for the patient and the trust are to provide high level prophylaxis while minimising production of resistant microbes.
We welcome evidence based suggestions from all the staff involved in use of antibiotics following which guidelines can be revised for better practice in future.
Monday, May 22, 2006
Lparoscopic Surgery
DR Raghvendra Kulkarni.
Introduction
In recent years, laparoscopic surgery has become common clinical practice. Initially, the use of laparoscopic procedures was confined to the obstetric and gynaecological department where it was used for laparoscopic sterilization and short diagnostic procedures. Thus, it was usually carried out on young and healthy females.
New intra-abdominal laparoscopic surgical techniques have been developed, performed and advocated for older patients when they may have coexisting cardiac and pulmonary disease. These laparoscopic procedures may involve changes in patient position and require a longer period of intra-abdominal carbon dioxide insufflation.
The major problems during laparoscopic surgery are related to the cardiopulmonary effect of pneumoperitoneum, systemic carbon dioxide absorption, extraperitoneal gas insufflation, venous gas embolism, unintentional injuries to intra-abdominal structures and patient positioning.
An appraisal of the potential problems is essential for optimal anaesthetic care of patients undergoing laparoscopic surgery. Appropriate anaesthetic techniques and monitoring facilitate surgery and allow early detection and reduction of complications. The need for rapid recovery and a short hospital stay impose additional demands on the anaesthetist for skilful practice.
Anaesthesia
Anaesthetic management
Anaesthetic management of patients undergoing laparoscopic surgery must accommodate surgical requirements and allow for physiological changes during surgery. Monitoring devices are available for the early detection of complications. Recovery from anaesthesia should be rapid with minimal residual effects. The possibility of the procedures being converted to open laparotomy needs to be considered.
Pre-anaesthetic assessment
Medical contraindications to laparoscopic surgery are relative. Successful laparoscopic surgery has been performed on anticoagulated, pregnant and morbidly obese patients.
Premedication is usually not necessary except in anxious patients for whom anxiolytics, such as the benzodiazepines, may be prescribed. Atropine can be used for premedication to prevent vagally mediated bradyarrhythmias but may cause undesirable mouth drying and increase the likelihood of tachyarrhythmias. It is, therefore, more appropriate to give the drug intravenously only when necessary.
Anaesthetic techniques
The choice of anaesthetic technique for upper abdominal laparoscopic surgery is mostly limited to general anaesthesia with muscle paralysis, tracheal intubation and intermittent positive pressure ventilation (IPPV) .
At induction of anaesthesia it is important to avoid stomach inflation during ventilation as this increases the risk of gastric injury during trocar insertion. Tracheal intubation and IPPV ensure airway protection and control of pulmonary ventilation to maintain normocarbia. Ventilation with a large tidal volume of 12-15 ml/kg prevents progressive alveolar atelectasis and hypoxaemia and allows for more effective alveolar ventilation and carbon dioxide elimination.
The use of nitrous oxide during laparoscopic surgery is controversial because of concerns about its ability to produce bowel distension during surgery and the increase in postoperative nausea. Nitrous oxide is about 30 times more soluble than nitrogen. Thus, a closed air-containing space may accumulate nitrous oxide more rapidly than it can eliminate nitrogen.
Eger and Saidman observed an increase of more than 200% in intestinal lumen size after 4 hours of breathing nitrous oxide. Lomie and Harper reported a reduction in postoperative vomiting from 49% to 17% when nitrous oxide was omitted in a prospective randomized study of 87 patients undergoing gynaecological laparoscopic surgery. In contrast, in an extensive randomized and blinded prospective study, Muir et al. Found no association between the use of nitrous oxide and the subsequent development of postoperative nausea and vomiting.
Halothane increases the incidence of arrhythmia during laparoscopic surgery, especially in the presence of hypercarbia. Isoflurane is the preferred volatile anaesthetic agent as it has less arrhythmogenic and myocardial depressant effects.
Regional anaesthesia
Epidural anaesthesia has been used for outpatient gynaecological laparoscopic procedures to reduce complications and shorten recovery time after anaesthesia. Local or regional anaesthetic techniques have not been reported for laparoscopic cholecystectomy or other upper abdominal surgical procedures except in patients with cystic fibrosis. A high epidural block (T2-T4 levels) is required to abolish the discomfort of surgical stimulation of the upper gastrointestinal structures. The high block produces myocardial depression and reduction in venous return, aggravating the haemodynamic effects of tension pneumoperitoneum.
Monitoring
The electrocardiogram, noninvasive arterial pressure monitor, airway pressure monitor, pulse oximeter, end-tidal carbon dioxide concentration monitor, peripheral nerve stimulation and body temperature probe are routinely used. A urinary catheter is usually placed to minimize the risk of bladder injury and improve surgical exposure. The urine output should be monitored in patients with compromised cardiopulmonary function.
End-tidal carbon dioxide is most commonly used as a noninvasive substitute for PaCO2 (tension of carbon dioxide in arterial blood) in evaluating the adequacy of ventilation during laparoscopic surgery because the gradient between PaCO2 and PECO2 (tension of CO2 in expired air) in healthy patients under general anaesthesia is between 2 mmHg and 9 mmHg. However, for patients with compromised cardiopulmonary function, the gradient between PaCO2 and PECO2 may become large and unpredictable so direct estimation of PaCO2 by arterial blood gas analysis may be necessary to detect hypercarbia. A PECO2 monitor is also valuable for early detection of venous gas embolism.
An airway pressure monitor is mandatory for anaesthetized patients receiving IPPV. A high airway pressure alarm can aid detection of excessive elevation in intra-abdominal pressure.
Nerve stimulation ensures adequate muscle paralysis which reduces the intra-abdominal pressure necessary for abdominal distension. This also prevents sudden patient movement during surgery that can lead to accidental injuries of intra-abdominal structures by laparoscopic instruments.
Postoperative course
Laparoscopic surgery is a relatively new surgical technique, with the advantages of shortening hospital stays, allowing a more rapid return to normal activities and lessening pain.
Nausea and vomiting are particularly troublesome after laparoscopic surgery; over 50% of patients require antiemetics, so prophylactic antiemetics may be given routinely. The use of non-steroidal anti-inflammatory drugs for postoperative analgesia has been described to minimize emesis after laparoscopic cholecystectomy . Pain following laparoscopic surgery consists of early transient vagal abdominal and shoulder discomfort due to peritoneal irritation by residual carbon dioxide. Patients can also experience deep-seated pain related to trauma at the surgical site.
Pain from the puncture wounds of the trocars is generally mild because the wounds are small and are produced without the cutting of muscle fibres. Pulmonary function is better presented following laparoscopic surgery; forced vital capacity is reduced by 27% after laparoscopic surgery and by 48% after operation.
DR Raghvendra Kulkarni.
Introduction
In recent years, laparoscopic surgery has become common clinical practice. Initially, the use of laparoscopic procedures was confined to the obstetric and gynaecological department where it was used for laparoscopic sterilization and short diagnostic procedures. Thus, it was usually carried out on young and healthy females.
New intra-abdominal laparoscopic surgical techniques have been developed, performed and advocated for older patients when they may have coexisting cardiac and pulmonary disease. These laparoscopic procedures may involve changes in patient position and require a longer period of intra-abdominal carbon dioxide insufflation.
The major problems during laparoscopic surgery are related to the cardiopulmonary effect of pneumoperitoneum, systemic carbon dioxide absorption, extraperitoneal gas insufflation, venous gas embolism, unintentional injuries to intra-abdominal structures and patient positioning.
An appraisal of the potential problems is essential for optimal anaesthetic care of patients undergoing laparoscopic surgery. Appropriate anaesthetic techniques and monitoring facilitate surgery and allow early detection and reduction of complications. The need for rapid recovery and a short hospital stay impose additional demands on the anaesthetist for skilful practice.
Anaesthesia
Anaesthetic management
Anaesthetic management of patients undergoing laparoscopic surgery must accommodate surgical requirements and allow for physiological changes during surgery. Monitoring devices are available for the early detection of complications. Recovery from anaesthesia should be rapid with minimal residual effects. The possibility of the procedures being converted to open laparotomy needs to be considered.
Pre-anaesthetic assessment
Medical contraindications to laparoscopic surgery are relative. Successful laparoscopic surgery has been performed on anticoagulated, pregnant and morbidly obese patients.
Premedication is usually not necessary except in anxious patients for whom anxiolytics, such as the benzodiazepines, may be prescribed. Atropine can be used for premedication to prevent vagally mediated bradyarrhythmias but may cause undesirable mouth drying and increase the likelihood of tachyarrhythmias. It is, therefore, more appropriate to give the drug intravenously only when necessary.
Anaesthetic techniques
The choice of anaesthetic technique for upper abdominal laparoscopic surgery is mostly limited to general anaesthesia with muscle paralysis, tracheal intubation and intermittent positive pressure ventilation (IPPV) .
At induction of anaesthesia it is important to avoid stomach inflation during ventilation as this increases the risk of gastric injury during trocar insertion. Tracheal intubation and IPPV ensure airway protection and control of pulmonary ventilation to maintain normocarbia. Ventilation with a large tidal volume of 12-15 ml/kg prevents progressive alveolar atelectasis and hypoxaemia and allows for more effective alveolar ventilation and carbon dioxide elimination.
The use of nitrous oxide during laparoscopic surgery is controversial because of concerns about its ability to produce bowel distension during surgery and the increase in postoperative nausea. Nitrous oxide is about 30 times more soluble than nitrogen. Thus, a closed air-containing space may accumulate nitrous oxide more rapidly than it can eliminate nitrogen.
Eger and Saidman observed an increase of more than 200% in intestinal lumen size after 4 hours of breathing nitrous oxide. Lomie and Harper reported a reduction in postoperative vomiting from 49% to 17% when nitrous oxide was omitted in a prospective randomized study of 87 patients undergoing gynaecological laparoscopic surgery. In contrast, in an extensive randomized and blinded prospective study, Muir et al. Found no association between the use of nitrous oxide and the subsequent development of postoperative nausea and vomiting.
Halothane increases the incidence of arrhythmia during laparoscopic surgery, especially in the presence of hypercarbia. Isoflurane is the preferred volatile anaesthetic agent as it has less arrhythmogenic and myocardial depressant effects.
Regional anaesthesia
Epidural anaesthesia has been used for outpatient gynaecological laparoscopic procedures to reduce complications and shorten recovery time after anaesthesia. Local or regional anaesthetic techniques have not been reported for laparoscopic cholecystectomy or other upper abdominal surgical procedures except in patients with cystic fibrosis. A high epidural block (T2-T4 levels) is required to abolish the discomfort of surgical stimulation of the upper gastrointestinal structures. The high block produces myocardial depression and reduction in venous return, aggravating the haemodynamic effects of tension pneumoperitoneum.
Monitoring
The electrocardiogram, noninvasive arterial pressure monitor, airway pressure monitor, pulse oximeter, end-tidal carbon dioxide concentration monitor, peripheral nerve stimulation and body temperature probe are routinely used. A urinary catheter is usually placed to minimize the risk of bladder injury and improve surgical exposure. The urine output should be monitored in patients with compromised cardiopulmonary function.
End-tidal carbon dioxide is most commonly used as a noninvasive substitute for PaCO2 (tension of carbon dioxide in arterial blood) in evaluating the adequacy of ventilation during laparoscopic surgery because the gradient between PaCO2 and PECO2 (tension of CO2 in expired air) in healthy patients under general anaesthesia is between 2 mmHg and 9 mmHg. However, for patients with compromised cardiopulmonary function, the gradient between PaCO2 and PECO2 may become large and unpredictable so direct estimation of PaCO2 by arterial blood gas analysis may be necessary to detect hypercarbia. A PECO2 monitor is also valuable for early detection of venous gas embolism.
An airway pressure monitor is mandatory for anaesthetized patients receiving IPPV. A high airway pressure alarm can aid detection of excessive elevation in intra-abdominal pressure.
Nerve stimulation ensures adequate muscle paralysis which reduces the intra-abdominal pressure necessary for abdominal distension. This also prevents sudden patient movement during surgery that can lead to accidental injuries of intra-abdominal structures by laparoscopic instruments.
Postoperative course
Laparoscopic surgery is a relatively new surgical technique, with the advantages of shortening hospital stays, allowing a more rapid return to normal activities and lessening pain.
Nausea and vomiting are particularly troublesome after laparoscopic surgery; over 50% of patients require antiemetics, so prophylactic antiemetics may be given routinely. The use of non-steroidal anti-inflammatory drugs for postoperative analgesia has been described to minimize emesis after laparoscopic cholecystectomy . Pain following laparoscopic surgery consists of early transient vagal abdominal and shoulder discomfort due to peritoneal irritation by residual carbon dioxide. Patients can also experience deep-seated pain related to trauma at the surgical site.
Pain from the puncture wounds of the trocars is generally mild because the wounds are small and are produced without the cutting of muscle fibres. Pulmonary function is better presented following laparoscopic surgery; forced vital capacity is reduced by 27% after laparoscopic surgery and by 48% after operation.
Do we waste drugs in theatres?
Aim of audit
Anaesthetic expenses, a small part of hospital expenses.
But, it definitely is an expense.
To find out whether we waste any drugs.
If yes, what are the things we waste?
Methods
A simple audit form, to be filled in by ODPs/ Anaesthetic nurses.
Duration- one month- April, 2005.
Data
Total 32 sessions reported.
Week days- 31, Week ends- 1.
Sessions- Morning 13, Noon 12, Evening 6, Night 1.
Scheduled 21, CEPOD 2, trauma 3, Emergency 6.
Main OT 26, Obstetrics 5.
Results…
Out of 32 sessions-
No wastage 10 sessions.
Wastage on 22 sessions.
The list of drugs opened but not used at all.
Atropine 11, Ephedrine 15.
Thiopentone 5, Propofol 5.
Lignocaine 4.
Antibiotics 1.
Suxamethonium 4, NMDR 3.
Morphine 3, Fentanyl 1.
Midazolam 1.
Phenylephrine 1.
Total…
Percentage…
Timing wise
Conclusion…
Difficult to draw conclusion.
But we definitely waste drugs.
It involves expensive drugs including propofol, NMDR, Morphine, fentanyl.
May be over reported positive finding.
May be just a tip of an iceberg.
Recommendations
Communication- in theatre, recovery?
Labelling
Drawing up of drugs- Morphine, Fentanyl- just before use.
Muscle relaxants, especially NMDRs just before use (more safe!).
Atropine/ ephedrine/ Suxamethonium- pre-filled syringes?
Have you got any solutions? - Discussion.
THANKS
Aim of audit
Anaesthetic expenses, a small part of hospital expenses.
But, it definitely is an expense.
To find out whether we waste any drugs.
If yes, what are the things we waste?
Methods
A simple audit form, to be filled in by ODPs/ Anaesthetic nurses.
Duration- one month- April, 2005.
Data
Total 32 sessions reported.
Week days- 31, Week ends- 1.
Sessions- Morning 13, Noon 12, Evening 6, Night 1.
Scheduled 21, CEPOD 2, trauma 3, Emergency 6.
Main OT 26, Obstetrics 5.
Results…
Out of 32 sessions-
No wastage 10 sessions.
Wastage on 22 sessions.
The list of drugs opened but not used at all.
Atropine 11, Ephedrine 15.
Thiopentone 5, Propofol 5.
Lignocaine 4.
Antibiotics 1.
Suxamethonium 4, NMDR 3.
Morphine 3, Fentanyl 1.
Midazolam 1.
Phenylephrine 1.
Total…
Percentage…
Timing wise
Conclusion…
Difficult to draw conclusion.
But we definitely waste drugs.
It involves expensive drugs including propofol, NMDR, Morphine, fentanyl.
May be over reported positive finding.
May be just a tip of an iceberg.
Recommendations
Communication- in theatre, recovery?
Labelling
Drawing up of drugs- Morphine, Fentanyl- just before use.
Muscle relaxants, especially NMDRs just before use (more safe!).
Atropine/ ephedrine/ Suxamethonium- pre-filled syringes?
Have you got any solutions? - Discussion.
THANKS
A study of use of Low Flow Anaesthesia in our department at NHH.
Some background-
Former reservations against low flow anaesthesia are not justified any longer.
Definitions-
Metabolic flow = 250 ml/minMinimal flow = 250-500 ml/minLow flow = 500-1000 ml/minMedium flow = 1-2 l/minHigh flow = 2-4 l/min, Very high flow = > 4 l/min
LFA- recommended by authorities.
Advantages
Apart from other advantages of LFA, there is definite reduction in cost with the use of low flows.
According to 1994 study at Northwick Park Hospital, there was a proportional decrease in cost of inhalational agents used with reduction in flow rates.
Method of audit
A simple questionnaire, 5 questions.
Definition
What flow rates?
Why?
Which inhalational agents?
Nitrous oxide?
Results
Definition-
What Flow rates?
Why these flows?
Which agents?
N2O
Definition of LFA
Individual flows
Reasons for not using LFA
Inhalational Agents
Inhalational agents.
Awareness & Usage.
Summary
Third of us do definitely know and use LFA.
In general, more than half of us are not very familiar with the concept.
Those who think they use LFA- 40% of them don’t use LFA actually.
Third of us don’t understand the concept, 25% are not comfortable with it.
Recommendations
Use low flow, its definitely better than higher flow.
More teaching.
More training, discussions.
? Trainees.
Re-audit.
ALFA website.
THANK YOU.
Some background-
Former reservations against low flow anaesthesia are not justified any longer.
Definitions-
Metabolic flow = 250 ml/minMinimal flow = 250-500 ml/minLow flow = 500-1000 ml/minMedium flow = 1-2 l/minHigh flow = 2-4 l/min, Very high flow = > 4 l/min
LFA- recommended by authorities.
Advantages
Apart from other advantages of LFA, there is definite reduction in cost with the use of low flows.
According to 1994 study at Northwick Park Hospital, there was a proportional decrease in cost of inhalational agents used with reduction in flow rates.
Method of audit
A simple questionnaire, 5 questions.
Definition
What flow rates?
Why?
Which inhalational agents?
Nitrous oxide?
Results
Definition-
What Flow rates?
Why these flows?
Which agents?
N2O
Definition of LFA
Individual flows
Reasons for not using LFA
Inhalational Agents
Inhalational agents.
Awareness & Usage.
Summary
Third of us do definitely know and use LFA.
In general, more than half of us are not very familiar with the concept.
Those who think they use LFA- 40% of them don’t use LFA actually.
Third of us don’t understand the concept, 25% are not comfortable with it.
Recommendations
Use low flow, its definitely better than higher flow.
More teaching.
More training, discussions.
? Trainees.
Re-audit.
ALFA website.
THANK YOU.
Control of blood sugar level on our unit
Why control blood glucose?
•Van Den Berghe study, Belgium, 2001, (110mg/dl).
•Van Den Berghe study, Belgium, 2003, high insulin therapy- mortality.
•BHF, Dr Finney, Oct. 2003, JAMA, for Insulin therapy.
•Laver et al, 2004, (Royal United Hosp, Bath), first paper in UK on protocols for BM control.
Methods
•Aim- To check how we were doing on our HDU/ ITU.
•Maximum and minimum blood sugar and insulin doses used over 24 hours.
•Mixed medical & surgical cases.
•Data collected over Sep-Oct. 2004.
Data
•152 audited*
•Diabetic-24
•Non diabetic-128
•145 fed/7 not fed
•Insulin- 112,
•DM- 21
Non DM- 89.
Maximum blood sugar levels
Minimum blood sugar levels
Percentage of patients, max. sugars.
Insulin therapy*
High dose Insulin therapy
High dose insulin*
Conclusions
•>10 BM- Not bad ( esp. for non DM).
•4-8 BM- Just under 50 % of total, all Non DM.
•Main bulk outside this range- BM 8-10, (50% DM, 23% Non DM).
•>10 BM- 50% DM lie above 10.
•We have a scope for improvement in BM 8-10 group.
•Further scope for control of even higher BM level groups, with insulin dose adjustments.
Recommendations
•For us- We can look at BM as if its a vital parameter, during daily ward rounds*.
•For nurses- Regular reinforcement of the protocols for BM control.
•Recheck the outcome after implementing these suggestions.
Why control blood glucose?
•Van Den Berghe study, Belgium, 2001, (110mg/dl).
•Van Den Berghe study, Belgium, 2003, high insulin therapy- mortality.
•BHF, Dr Finney, Oct. 2003, JAMA, for Insulin therapy.
•Laver et al, 2004, (Royal United Hosp, Bath), first paper in UK on protocols for BM control.
Methods
•Aim- To check how we were doing on our HDU/ ITU.
•Maximum and minimum blood sugar and insulin doses used over 24 hours.
•Mixed medical & surgical cases.
•Data collected over Sep-Oct. 2004.
Data
•152 audited*
•Diabetic-24
•Non diabetic-128
•145 fed/7 not fed
•Insulin- 112,
•DM- 21
Non DM- 89.
Maximum blood sugar levels
Minimum blood sugar levels
Percentage of patients, max. sugars.
Insulin therapy*
High dose Insulin therapy
High dose insulin*
Conclusions
•>10 BM- Not bad ( esp. for non DM).
•4-8 BM- Just under 50 % of total, all Non DM.
•Main bulk outside this range- BM 8-10, (50% DM, 23% Non DM).
•>10 BM- 50% DM lie above 10.
•We have a scope for improvement in BM 8-10 group.
•Further scope for control of even higher BM level groups, with insulin dose adjustments.
Recommendations
•For us- We can look at BM as if its a vital parameter, during daily ward rounds*.
•For nurses- Regular reinforcement of the protocols for BM control.
•Recheck the outcome after implementing these suggestions.
Audit of compliance with NICE guidelines for preoperative tests
What does NICE say?
Patients
ASA 1
ASA 2
ASA 3
ASA 4
Surgery
Grade 1
Grade 2
Grade 3
Grade 4
Who need what?
Grade 1 surgery
ASA 1 < 16 yrs; grade 1 surgery.
ASA 1 <80> 80 yrs will need ECG. Age 40- 80 consider if indicated.
ASA 2 will only need relevant tests for their condition.
ASA 3 will need FBC and other relevant tests.
Grade 2 surgery
ASA 1 <16 year- nil
ASA 2- FBC in above 60 and ECG in above 80 yrs.
ASA 3 >16 will need ECG and renal functions; other tests as indicated.
Grade 3 surgery
ASA 1; <16 yrs- consider FBC, renal functions, urine analysis.
ASA 1, >16 yrs- FBC for all ECG and renal functions in >60 yrs. Others.
ASA 2; > 16 yrs- ECG, FBC, renal functions.
ASA 3; > 16 yrs- ECG, FBC, renal functions.
Grade 4 surgery
ASA 1; < 16 yrs- consider FBC, Urine, renal functions.
ASA 1; > 16 yrs-FBC, renal functions, ECG for >60 yrs.
ASA 2; >16 yrs-ECG, FBC, renal functions.
ASA 3- ECG > 40, FBC, renal functions, others.
This audit
Simple
Forms
Elective cases
25 forms collected
Data
Appropriate investigations
ASA 1- 2/6
ASA 2- 4/10
ASA 3- 4/8
ASA 4- 1/1
Inappropriate investigations
ASA 1- 4/6
ASA 2- 6/10
ASA 3- 4/8
ASA 4- 0/1
Summary
Juniors in surgery
Pre-assessment nurses
Local guidelines for the trust
Inappropriate use of tests
Tip of iceberg
Recommendations
More teaching in this field
Induction of juniors at the start of job
Ward nurses
NICE guideline cards
Charts on the walls
Re-audit
Thank you
What does NICE say?
Patients
ASA 1
ASA 2
ASA 3
ASA 4
Surgery
Grade 1
Grade 2
Grade 3
Grade 4
Who need what?
Grade 1 surgery
ASA 1 < 16 yrs; grade 1 surgery.
ASA 1 <80> 80 yrs will need ECG. Age 40- 80 consider if indicated.
ASA 2 will only need relevant tests for their condition.
ASA 3 will need FBC and other relevant tests.
Grade 2 surgery
ASA 1 <16 year- nil
ASA 2- FBC in above 60 and ECG in above 80 yrs.
ASA 3 >16 will need ECG and renal functions; other tests as indicated.
Grade 3 surgery
ASA 1; <16 yrs- consider FBC, renal functions, urine analysis.
ASA 1, >16 yrs- FBC for all ECG and renal functions in >60 yrs. Others.
ASA 2; > 16 yrs- ECG, FBC, renal functions.
ASA 3; > 16 yrs- ECG, FBC, renal functions.
Grade 4 surgery
ASA 1; < 16 yrs- consider FBC, Urine, renal functions.
ASA 1; > 16 yrs-FBC, renal functions, ECG for >60 yrs.
ASA 2; >16 yrs-ECG, FBC, renal functions.
ASA 3- ECG > 40, FBC, renal functions, others.
This audit
Simple
Forms
Elective cases
25 forms collected
Data
Appropriate investigations
ASA 1- 2/6
ASA 2- 4/10
ASA 3- 4/8
ASA 4- 1/1
Inappropriate investigations
ASA 1- 4/6
ASA 2- 6/10
ASA 3- 4/8
ASA 4- 0/1
Summary
Juniors in surgery
Pre-assessment nurses
Local guidelines for the trust
Inappropriate use of tests
Tip of iceberg
Recommendations
More teaching in this field
Induction of juniors at the start of job
Ward nurses
NICE guideline cards
Charts on the walls
Re-audit
Thank you
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