Purpose and Background: The introduction of clinical governance made NHS organisations accountable for the monitoring and continuous improvement of the quality of patient care at all levels, across all services. Implementation of evidence-based practice and provision of an adequate infrastructure to support it is a major component and at local level, clinicians in all NHS organisations are required to participate fully in audit. The following describes the second phase. *. of a study investigating the dissemination and utilisation of an audit toolkit for the UK acute low back pain guideline through clinical governance routes. *. Phase I Results Were Previously Reported At SBPR. Methods: structured telephone interviews were conducted with 50 clinical governance leads and 22 clinical audit leads in 72 primary care trusts (pcts). the qualitative data were analysed using a framework approach involving identification of issues, concepts and themes and the construction of a theoretical perspective for the main categories. these were cross-validated by the original interviewer checking for dissonance. Results: Six categories were identified: priorities; capacity and resources; loss of quality support groups; organisational issues; local environment and lack of audit strategies. the results suggest that low back pain is still a considerable problem but has lost its priority status at both government and local levels, largely due to the introduction of national service frameworks (nsfs) and to inadequate resourcing. primary care has a huge agenda that is seen as being grossly under-resourced with respondents reporting difficulty in meeting nsf requirements. many localities had not generated or finalised audit strategies while gp autonomy and poor communication between the gps and pcts were identified as barriers to the implementation of audit processes in primary care. Conclusion: Presently, implementation of evidence-based healthcare for non-priority areas seems not to be feasible through clinical governance routes. without nsf status, the likelihood of seeing clinical audit used to assure evidence-based primary care for low back pain seems remote

The Thompson hemiarthroplasty is a common treatment option for acute neck of femur fractures in the elderly population. Our department noted a significant number of patients returning with thigh pain, radiographic loosening and femoral osteolysis following cemented implantation of the titanium alloy version of the Thompson hemiarthroplasty. We are not aware of any previous reports documenting complications specific to the titanium Thompson implant and a retrospective cohort study was therefore initiated following clinical governance approval. 366 titanium alloy Thompson prostheses were implanted for hip fracture treatment between 2017 and 2020. As of February 2023, 6 of these have been revised at our hospital. 5 were revised for symptomatic femoral osteolysis and 1 presented with an acute periprosthetic fracture. All revised cases were determined to be aseptic. 32 living patients were excluded from recall on compassionate grounds due to permanent nursing home residence. 47 living patients were identified of which 33 attended for xray. 28 deceased and/or nursing home resident patients who had pelvis x-rays in the previous 12 months were also included in the analysis. Including the 6 index hips already revised, a total of 61 hip xrays were analysed, of which 19 hips (31.1%) showed radiographic evidence of femoral osteolysis or loosening. We conclude that there is a concerning incidence of femoral osteolysis and implant loosening associated with the titanium Thompson implant. We have discontinued use of the implant and reported our experience to the MHRA. We encourage other Scottish Health-Boards who use this implant to consider enhanced follow-up

Healthcare organisations are accountable for improving the quality of their services, safeguarding high standards of care and meeting shorter waiting time targets. This presents a challenge of how to achieve such targets with limited resources. This paper looks at the hypothesis that adequate and appropriate clinical governance can be undertaken while increasing orthopaedic spinal clinic throughput in order to decrease outpatient waiting times. A spinal outpatient clinic was used as the test bed for the hypothesis of the project. The theoretical number of patients an individual consultant can see per session was calculated from recommended British Orthopaedic Association consultation times for new and follow-up cases. Patients were asked to complete the MODEMS (Musculoskeletal Outcomes Data Evaluation and Management System) questionnaire. A prospective randomised trial utilising a touch-screen computerised version of the questionnaire was also used. Time taken for outcome data management is included in the analysis. The time taken to see new and follow up patients was 31–42 and 24–35 minutes respectively. These times have implications in terms of waiting times and Director of Performance Management targets. The shortfall is calculated in terms of additional support necessary to reach these targets. Salary costs and infrastructural support costs are projected. The figure is likely to represent that required by any specialist clinic to realise the ideals of clinical governance and conservatively estimated to be £35, 000 per year. Total clinical governance and patient outcomes are inextricably linked. This is true of orthopaedic spinal surgery in that important information about clinical practice can be obtained. The organizational infrastructure and methods to implement data collection is technically feasible however is not without cost. In terms of economic evaluation the correct price for a resource is its opportunity cost. ‘Don’t just buy more healthcare, invent new healthcare’ is as incongruous as total clinical governance and increased capacity without support

Purpose of study: With the increasing demand for arthroplasty surgery, it is important to maintain a high quality of care. We describe a clinical governance framework for a simple, easy to implement method of assessing and monitoring radiological outcome following total knee arthroplasty. Methods: We completed a two-year prospective study (January 2006 to December 2007 inclusive) of all total knee arthroplasty operations. This included 1,295 procedures, the majority of which were undertaken by two Consultant Surgeons and up to eight independent middle grade surgeons. The two Consultant Knee Surgeons assessed component position on standard post-operative weight-bearing antero-posterior and lateral knee radiographs on a weekly basis. They were blinded to both the patient and surgeon details, and used our own simple grading system, whose weighted Kappa variance showed ‘moderate’ interobserver (K = 0.41) and intraobserver reliability (K = 0.51). Our system comprised of only three ordinal scores, which were good (score of 1), acceptable (score of 2) and poor (score of 3). Results: We provided individual surgeons with their results on a six-monthly basis. The average score for all the surgeons was good. The scores of the independent middle-grade surgeons were analysed by the Consultants, and feedback was provided in the form of formal advice and supervised surgery sessions. Repeat proportional analysis of their radiological scores showed significant improvements for all the individual surgeons (Pearson-Chi Square p value < 0.05). Conclusions: Clinical governance is an important facet of excellence in medical practice. Our system allows continued prospective assessment of radiological outcome following total knee arthroplasty. By utilising such systems and ensuring an atmosphere of clinical excellence, we are able to employ more surgeons and undertake an increased workload, whilst maintaining high standards. This assessment tool can also be used to assess and appraise trainees during their progression

Purpose of study: With the increasing demand for arthroplasty surgery, it is important to maintain a high quality of care. We describe a clinical governance framework for monitoring radiological outcome following total hip arthroplasty. Methods: We completed a two-year prospective study (January 2006 to December 2007 inclusive) of all total hip arthroplasty operations. This included 1,143 procedures, the majority of which were undertaken by three Consultant Surgeons and four independent middle grade surgeons. The three Consultant Hip Surgeons assessed component position on post-operative weight-bearing anteroposterior pelvic/hip radiographs on a weekly basis. They were blinded to both the patient and surgeon details, and used our own simple grading system. Weighted Kappa variance showed substantial interobserver (kappa = 0.60) and intraobserver reliability (kappa = 0.92). Our system comprised of only three ordinal scores, which were ‘good’ (score of 1), ‘acceptable’ (score of 2) and ‘poor’ (score of 3). Results: We provided individual surgeons with their results on a six-monthly basis. The average score for all the surgeons was ‘good’. The scores of the independent middle-grade surgeons were analysed by the Consultants, and feedback was provided in the form of formal advice and supervised surgery sessions. Repeat analysis of their radiological scores showed significant improvements for certain individual surgeons (Pearson-Chi Square p value 0.006). Conclusions: Clinical governance is an important facet of excellence in medical practice. Our system allows continued prospective assessment of radiological outcome following total hip arthroplasty. By utilising such systems and ensuring an atmosphere of clinical excellence, we are able to employ more surgeons and undertake an increased workload, whilst maintaining high standards. This assessment tool can also be used to appraise trainees during their progression

To promote cultural awareness and acceptance of clinical governance by developing a simple, reproducible model for reporting critical incidents and near misses within our department. An A4 sized departmental proforma was developed to parallel the Trust’s official adverse incident register. Prospective reporting of adverse events using the proforma was encouraged between August 2000 and June 2001. Incidents were discussed in an anonymised and a blame-free setting, at the monthly multidisciplinary clinical governance meeting and appropriate action taken. In the 6 months prior to commencing this study only 4 adverse events were reported with no discernible action taken. Following the introduction of the proforma 61 critical incidents and near misses were reported in the period August 2000 to June 2001. As a result of effective reporting of adverse events we have developed a number of protocols to improve patient care. A simple model for reporting critical incidents and near misses has been established. This has fostered a cultural change within the department and all members of staff feel more comfortable with reporting such incidents. The process is seen as educational and an important part of continuing professional and departmental development. Protocols and changes in organisational practice have been developed to reduce and prevent the occurrence of adverse events and offer our patients continuous improvement in care

Purpose of study: With the increasing demand for arthroplasty surgery, it is important to maintain a high quality of care. We describe a clinical governance framework for a simple, easy to implement method of assessing and monitoring radiological outcome following total knee arthroplasty. Methods: We completed a two-year prospective study (January 2006 to December 2007 inclusive) of all total knee arthroplasty operations. This included 1,295 procedures, the majority of which were undertaken by two Consultant Surgeons and up to eight independent middle grade surgeons. The two Consultant Knee Surgeons assessed component position on standard post-operative weight-bearing antero-posterior and lateral knee radiographs on a weekly basis. They were blinded to both the patient and surgeon details, and used our own simple grading system, whose weighted Kappa variance showed ‘moderate’ interobserver (K = 0.41) and intraobserver reliability (K = 0.51). Our system comprised of only three ordinal scores, which were good (score of 1), acceptable (score of 2) and poor (score of 3). Results: We provided individual surgeons with their results on a six-monthly basis. The average score for all the surgeons was good. The scores of the independent middle-grade surgeons were analysed by the Consultants, and feedback was provided in the form of formal advice and supervised surgical sessions. Repeat proportional analysis of their radiological scores showed significant improvements for all the individual surgeons (Pearson-Chi Square p value < 0.05). Conclusions: Clinical governance is an important facet of excellence in medical practice. Our system allows continued prospective assessment of radiological outcome following total knee arthroplasty. By utilising such systems and ensuring an atmosphere of clinical excellence, we are able to employ more surgeons and undertake an increased workload, whilst maintaining high standards. This assessment tool can also be used to assess and appraise trainees during their progression

London's Air Ambulance (LAA) was first set-up in 1989 as a direct result of a Royal College of Surgeons of England Report highlighting poor trauma care provision. Since its inception, the service's mission is to be an innovative and effective provider of advanced pre-hospital care. The service provides a senior Doctor and senior Paramedic to the scene of any incident within the M25 by helicopter, during the day, and by fast-response car at night. The vast majority of doctors are usually Emergency Medicine Physicians or Anaesthetists. During a 6-month tenure, doctors will usually have completed a number of procedures, which include rapid sequence induction of anaesthesia, pre-hospital blood transfusion, and, procedural sedation. In terms of innovations, the organisation was the first in the UK to provide a 24/7 service. It was also the first to start pre-hospital Rapid Sequence Induction of Anaesthesia for the severely injured; Resuscitative Thoracotomy for the victims of penetrating trauma; and pre-hospital Blood Transfusion for shocked polytrauma patients. The service also has a very thorough induction programme, for new Doctors and Paramedics, and a highly structured Clinical Governance process. The post offers a unique and privileged opportunity to treat the most severely injured at the roadside

Much has been written about ESP (Extended Scope Practitioners) lead clinical services, the vast majority of which have been developed in secondary care. Little evidence is available on the efficacy of ESP. clinics either for both the patient and weather they stream line back pain treatment. We present an interim audit of an assessment pathway for community management and MDT practice for lower back pain. 56 patients were reviewed with a revised ESP assessment tool and then presented to an MDT meeting. Each, assessment was 45 minutes long and outcome measures used included ODI and STaRT scores. Patients were telephoned at 12 weeks following their appointment and then at 18 weeks, to ascertain the progress they were making and to see if the 18-week target had been met. 56 patients were reviewed from September 2009. The average ODI, was 63%, and 56% at 12 weeks; most patients had a STaRT score of 6, and 3 on the psychological component it the beginning of the study. The EQ-5D scores were observed to show an improvement. MRI rates were 3.8% and the DNA rate was 7%. A total of 11 MRI requests; the results of 7 of these were available for analysis. The scans that were requested all showed a disc lesion that was amenable to surgical decompression or stabilization. Overall patients were very satisfied. Our formatted methodology allowed clinical governance at source to measure the efficacy of patient treatment. Early results suggest an efficient in delivering an acceptable standard of care as long as they are properly supported

Introduction. The outcomes programme of our institution has been developed from a system first used at Epsom and St Helier NHS Trust 15 years ago. The system was implemented at our institution when it opened in 2004, and has been used to collect data on over 17,000 joint replacement operations so far. A bespoke database is used to collect, analyse and report outcome data. Methods. An integrated system allows the collection of patient-reported outcome measures (PROMS), patient satisfaction scores, radiological assessment, and medical or surgical complications. Functionality allows the transfer of data from existing clinical management programmes, and the generation of customised letters and questionnaires to send to patients. Analysis of data and report production is fully automated. Data is collected pre-operatively, during the inpatient stay, and post-operatively at 6 weeks, 6, 12 and 24 months. Results are disseminated to the surgeons, the senior management team and the Clinical Governance Committee. Results. Response rates exceed 95% pre-operatively, 90% at 6 weeks and 6 months post-operatively and exceed 80% at 1 year and 2 year follow up. Data on over 17,000 joint replacement surgery have been compared to published literature. The results demonstrate high patient satisfaction and low complication rates. Discussion. This is an established outcome programme, effectively providing feedback to all involved in the care of our patients. Surgeons are thus able to identify where to invest efforts to improve their performance and management to assess the standard of service, monitor quality and promote the institution to healthcare purchasers as a cost-effective treatment centre. Patients can review the performance and the outcome of the health service at this centre prior to deciding where they have their treatment

Achilles tendinopathy is chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. It involves a triad of pain, swelling and impaired function. Primary treatment is rest, analgesia, corticosteroid injections and physiotherapy (eccentric training and heel pads to correct gait). Some patients remain symptomatic and further treatment options need considering. NICE produced a document from the Interventional Procedures Advisory Committee in 2009 which reviewed the literature and evidence for extracorporeal shockwave treatment (ESWT). Low energy shock wave treatment (SWT) is thought to stimulate soft tissue healing, inhibit pain receptors and promote angiogenesis. NICE guidance was that ESWT could be used in refractory Achilles tendinopathy if used for clinical governance, audit or research. Patients with refractory Achilles tendinopathy were enrolled between October 2010 and 2011. They received three sessions of ESWT over three week. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale (six points, high is worsening) were reassessed at 6 and 16 weeks post treatment. 51 patients completed follow up. The mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. There was a significant improvement (p<0.05) in VAS scores observed from baseline and 16 weeks post treatment. This was also the case in the VISA-A scores. The mean Likert score was 3 (somewhat improved) at 16 weeks but there was no statistical significance. This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy. Patients over 60 possibly have a worse outcome along with patient who had symptoms for over 25 months. Follow up scores at one year are due to be collected and the data will be submitted to NICE

Introduction: Outcome data is essential for clinical governance and research purposes, and will inform decisions on resource re-distribution. The Spinal Assessment Clinic (SAC) treats patients with low back pain referred by their GPs. Method: Low Back Outcome Score (LBOS) data was collected at presentation (Q1) for 691 patients and on review (Q2) for 98 patients. At presentation further administrative information is also collected. At review Q2 patient satisfaction is recorded as well as the patient’s perception of the status of their LBP. Results were compared between three clinic locations; inner city (CIT), urban (URB) and semi-rural (RUR). Results: Significantly more patients at the inner city clinic cancelled and re-appointed, and significantly fewer could be discharged after the first consultation. Equal numbers were employed in the three locations. Despite failure of improvement of perceived LBP, many patients reported an improvement of LBOS. Conclusion: Social and environmental factors influence behaviour within a treatment program. Patients can appreciate the difference between a satisfactory treatment experience and an actual change in their low back pain. Function can increase even when reported pain does not

Internal fixation of ankle fractures should be undertaken either before or after the period of critical soft tissue swelling. As part of the clinical governance in our unit, an audit was undertaken to examine the interval between admission and surgery and net inpatient stay of patients with ankle fractures over a 6 month period. Thirty four patients fulfilled the inclusion criteria of having an acute closed fracture of the ankle requiring open reduction and internal fixation (ORIF). There were 16 unimalleolar, 10 bimalleolar and 8 trimalleolar fractures. 10 Patients underwent surgery on the day of admission, 9 patients had surgery within 24 hours, 15 patients had surgery after 24 hours of admission. The average in patient stay was 9 days (1–61 days). If surgery was undertaken within 24 hours the average inpatient stay was 9 days (1–14). If surgery was delayed beyond 24 hours the average inpatient stay was 15 days (3–61 days). Delayed surgery of closed ankle fractures increases the risk of soft tissue complications and prolongs hospital stay with profound cost implications. Long-term disability resulting from ankle fractures can be reduced by optimal early management procedures

To evaluate the performance of this institution in its delivery of care to elderly patients with a hip fracture over an 11-year period and to establish recommendations to improve practice. Regular prospective audits of a cohort of 50 patients have been undertaken between 1990 and 2000. A larger and more comprehensive retrospective audit of 100 patients was performed in 2001. Goals were set regarding time to admission, time to surgery and to discharge in close accordance with the best practice guidelines devised by the Royal College of Physicians in 1989. There has been an alarming decline in standards in key areas. Time from A& E to admission: at best 78% of patients within 3 hours, 4% in 2001. Time from admission to surgery: at best 89% within 24 hours, 31% in 2001. Persistence of significant morbidity for patients delayed to surgery for non-medical reasons: 65% of these patients developed a post operative complication and 20% died within 30 days of admission. Delay to discharge: at best 13 acute bed days, now 18 (2001). Current practice is less than ideal. Clinical governance involves a dual responsibility – of the clinician to maintain high standards and of the management to provide adequate resources. Both need addressing to reverse the current trend

Aim: To reduce the amount of blood wastage in our unit. Method: In 72 patients, the number of blood units cross-matched and the haemoglobin/haematocrit fall were audited for primary total shoulder replacement (n=44), primary hemiarthroplasty (n=21), and revision shoulder replacement (n=7) over twelve months (January 2008 to December 2008). The amount of crossmatched blood was compared to the amount of blood transfused, pre-operative haemoglobin and fall in haemoglobin/haematocrit. Results: 23 of 44 primary total shoulder replacements and 5 of 21 hemiarthroplasties were crossmatched 55 units preoperatively. 4 of the 7 revision arthroplasties were crossmatched 7 units preoperatively. No units were transfused. 4 patients were later transfused 2 units each for symptomatic low haemoglobin at day 3–5 postoperatively from postoperatively crossmatched blood. No correlation existed between preoperative haemoglobin and number of units blood ordered. A haemoglobin reduction of ~2.5 g/dl was seen for both primary and revision surgery. There was significant correlation between low preoperative haemoglobin and need for transfusion (p< 0.05). Nearly all patients in whom blood was crossmatched rather than group and saved, belonged to one consultant. No patients had an adverse outcome due to a lack of immediately available cross-matched blood. Conclusion: A large amount of blood was crossmatched and no units used in primary and revision shoulder replacement surgery. We recommend group and save only in primary shoulder arthroplasty and crossmatch of 2 units for revision shoulder surgery. Providing pre-operative haemoglobin is > 11.5 g/dl, group and save is safe even for revision shoulder arthroplasty. Wastage of blood could be reduced to zero in our unit. We recommend regular audit as a tool to ensure compliance with guidelines, and for clinical governance purposes ensuring guidelines remain best practice

Clinical governance encompasses audit. Audit is a requirement of our professional bodies and our hospital trusts. It is not usually resourced adequately and the ability to audit spinal surgical outcomes is haphazard nationally. This presentation describes the results that can be achieved in the absence of formal audit support. A surgical database was started in 1993; its evolution involved the use of standard outcome measures in 1995. Between 1995 and 1999, four hundred and one major spine procedures were undertaken by a single surgeon. The outcome measures were the Oswestry disability index, the low back outcome, MSP MZD and a visual analogue pain scale. Pre-operative data was collected on all 233 elective cases. Follow up was 59% at 6 months, 51% at one year and 57% at 2 years. At two years a Macnab score was available in 106 cases and the results were excellent/ good 81%, fair/poor 19%. There were 56 recorded perioperative complications. 21 occurred in the 77 instrumented procedures and 35 in the 156 non instrumented procedures. The results of this type of audit can only be cautiously compared to published data because of poor follow up. Quality outcome measures and audit probably require a funded resource to be of value

Audit is an important part of surgical practice. Commissioners may use it as evidence of quality assurance. No comprehensive audit exists in spinal surgery. Usage of existing databases is disappointing. We developed an audit database which was comprehensive and gathered patient outcomes. The underlying principles were:. All patients having surgery should enter,. Duplicate data entry should be avoided. No effort should be required of the participating surgeons. Demographic data, OPCS codes, length of stay and other data were downloaded directly from the hospital information systems. A monthly printout of patients enrolled was provided to the audit coordinator. She was responsible for the collection of clinical outcomes at 6 months, 12 months, and 2 years after surgery. The initial audit involved the Northwest and Mersey Regions. Data from the hospital information systems (HIS) for two years were available for comparison. Unfortunately only two centres gathered clinical outcomes. We have continued to gather data. 380 patients have been enrolled. HIS data are available for all. With varying lengths of follow up, there are 1045 potential clinical outcomes available. Only 8 patients (2%; 8 outcomes, 0.76%) have been lost to follow up. Using this data we are able to compare outcomes between surgeons, between surgical procedures, and see changes over time. As far as we know we are the only centre in the UK able to do this. It is a valuable Clinical Governance tool. We believe that the principles underlying this audit are the only means to obtain comprehensive outcome audit in surgery

The Scottish Hip Fracture Audit (. 1. ) was founded on Rikshoft, the Swedish hip fracture register (. 2. ), and since 1993 has documented case-mix, process and outcomes of hip fracture care in Scotland. Evidence-based national guidelines on hip fracture care were updated by a multidisciplinary group in 2002(. 3. ). And hip fracture serves as a tracer condition by the health quality assurance authority for its work on older people, which reported in 2004 (. 4. ). Audit data are used locally to document care and support and monitor service developments. Synergy between the guidelines and the audit provides a means of improving care locally and monitoring care nationally. External review by the quality assurance body shows to what extent guideline-based standards relating to A& E care, pre-operative delay, multidisciplinary care and audit participation are met. Three national-level initiatives on hip fracture care have delivered: reliable and largescale comparative information on case-mix, care and outcomes; evidence-based recommendations on care; and nationally accountable standards inspected and reported by the national health quality assurance authority. These developments are linked and synergistic, and enjoy both clinical and managerial support. They provide an evolving framework for clinical governance and quality assurance, with methods for casemix-adjusted outcome assessment for hip fracture care also now developed

Background: The British Orthopaedic Association (BOA) guidelines regarding consultation time were published in 1990. There has been a change in the expectation of the patient and the responsibilty of the clinician to provide more information to the patients and more detailed investigation and consent forms to fill with a greater emphasis on clinical governance and increasing awareness of the patients over the years. The decrease in doctor working hours and increase in sub specialisation can not be ignored. Methods: 55 Orthopaedic clinics were observed and time mapped to the nearest second. 5 clinics observed for each of 11 clinicians (5 Consultants and 6 Registrars). From the time the clinician entered the consultation room to start the clinic till the time he left after finishing the clinic the entire span of time was mapped with a stop watch by an independent observer. The patient factors viz age, sex, mobility, BMI, site of disease were recorded. The clinician factors viz. seniority, sub-specialisation were also recorded. Results: Of total Clinic time, 45% spent for consulting follow up cases, 26% for new cases and 29% lost in in-between patient transit time. Of the total clinic time, patient time (time spent by clinician with the patient) was 75%, 4% spent on procedures, 3% on investigations, 4% on consent, 13% on dictation, only 1% on teaching. The mean time for consultation was 13 minutes 6 seconds for New patients and 8 minutes 43 seconds for Follow up patients which was significantly less than that recommended by BOA guidelines (15 – 20 minutes for new and 10 –15 minutes for follow up pateints in Orthopaedic clinics). Conclusion: Despite the clinics over running in time the BOA guidelines are not being adhered to potentially compromising quality consultation and training at the cost of pressures to see the recommended 22 unit patients per clinic. There is a need to revise guidelines to provide for more time in clinics per patient to maintain quality of care and training