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					                         Executive Summary of Clinical Audit Activity

North West Regional Urology Audit

April 2009 – March 2010

The regional audit covers all Lancashire and South Cumbria and Greater Manchester

   Notable events or activities during the year

We undertook two audit presentations during the year – both audits were presented at the De
Vere Daresbury Park Hotel, Day Case Surgery on 6 May and the Management of Renal
Tumours on the 17 November 2009.

The Regional Urology audit is one of 6 projects to be supported by the Healthcare Quality
Improvement Partnership.

BAUS Poster, Glasgow June 09
         – Have the NICE guidelines on management of female urinary incontinence led to
              a change in practise? – A region wide audit.

ICS Presentation, San Francisco October 09
          – Procedure specific consent forms improve the process of informed consent in
               patients undergoing surgery for stress incontinence by urologists.

   Level of participation by clinicians covered by this audit (e.g.          giving the % who
    submitted data and/or who attended presentation meetings)

100% of the regions consultant urologists submitted data for both audit topics
Attendance at the meetings 76% of consultants attended the Day Case Surgery meeting and
80% attended the Renal Cancer audit.
Attendance is compulsory for all urology trainees.
The meetings were also well attended by the urology specialist nurses and representatives from
oncology, radiology and pathology.
Members of the audit departments of participating Trusts also attended the meetings.

   Main topics covered during year

Topics included:-

Day Case Surgery –

Unnecessary ‘in-patient’ operations are a major source of potential cost savings for trusts and
hence a major concern for both providers and commissioners of urological care.
There are guidelines relating to pre operative assessment and care published by The British
Association of Day Case Surgery that were the starting point for the audit data collection.
The audit into day case surgery looked at a selection of standard cases deemed by the department
of health to be suitable for day case surgery in the majority of patients. Pre operative assessment
of these patients was audited but crucially patients having the same surgery as an in patient was
also audited to see why they were not considered for day case procedures. Complication rates,
conversion to overnight stay and rates of re-attendance were all looked at. There are published
acceptable rates for all these occurrences.
In addition the pre operative care of diabetic patients was looked at, as this is believed to be a
common but unnecessary reason for deeming the patient to be unsuitable for day case surgery.

Renal Tumours and their management –

The renal cancer audit is an important audit as it is the last major urological cancer to be audited
since the Improving Outcomes Guidance initiative in urology. The IOG document defined which
renal cancers were suitable for treatment locally and which required referral to a specialist team.
Compliance with the IOG guidance was an important part of the audit.
There has been a significant increase in possible available surgical treatments including partial
nephrectomy and laparoscopic nephrectomy since the last renal cancer audit. Ensuring equality of
access and outcomes across the region was also a key component of the audit.
This is particularly relevant as some centres are continuing to do low volumes of certain renal
cancer operations (in keeping with the IOG publication) and there is a need to ensure the
outcomes, lengths of stay and treatment delays are equivalent to similar cases performed in the
specialist centres where more complex cases are also undertaken.
Requirements of defining the complexity of renal cancers and assessing various treatment options
have made imaging techniques more important than ever, this was examined by the audit.
There are now international guidelines (European Assoc. of Urology) on the follow up regimes of
renal cancers which were also scrutinized.

   Main standards used

There are national guidelines from NICE as to which procedures are suitable for day case
surgeries which were used to identify the cases for audit.
There are guidelines relating to which patients are suitable for day case surgery published by The
British Association of Day Case Surgery, (BADS) which also include guidance on pre op

Improving Outcomes Guidance (IOG) for urological cancers document as been published by
NICE in 2004. This defines certain criteria for the management of patients and also defines which
patients should be managed locally and which should be referred to specialist units.
There are further guidelines on patient management published by the European association of

The groups own North West Regional Urology guidelines were also used for both projects.

   Evidence that performance is changing (e.g. trends of improvement or comparative
    data between trusts)

Day Case Surgery

For the region as a whole, the audit showed improvement from the previous audit in the selection
of patients for procedures suitable for day case surgery (as suggested by BADS) i.e. more of the
following procedures had been performed as day cases:- Botox injection, TURBT procedures,
Ureteroscopies, and laser TURPS.

It also showed improvement in the documentation of pre-operative assessment.

Re-admission rates for day case surgery had also improved.

The audit also identified areas where further improvement needs to be implemented e.g. the peri-
operative management of patients with diabetes

Renal Tumours

Waiting times had improved since the 2003 audit i.e. median time in days from direct urology
referral to the first urology out patient appointment, excluding emergency admissions and in
patient referrals, had improved from 14 days to 9 days.

Median time from the first consultation to the first radiology investigation, excluding patients where
the diagnosis was prior to referral showed a considerable improvement from 11 days to 7 days.
This improvement was considered to be due to rapid access clinics; where ‘on the spot’ diagnostic
imaging was available.

Individual Trusts compliance with IOG guidelines was presented relating to:-
Assessment of vascular involvement and referral to specialist Uro-Oncologist, the selection of
patients for nephron-sparing surgery, and the increased use of new drugs e.g. Tyrosine Kinase

    Actions taken to improve standards

Data was analysed to provide comparative figures comparing urology units with one another,
appraising compliance with the agreed guidelines and sharing good practice as to how to achieve
compliance where some units may be finding difficulties.

    Actions taken to publicise findings

The data collected and subsequent conclusions and guidelines produced are disseminated to all
consultant urologists within the region so that they benefit even if they have not been able to
attend the meeting.
The renal cancer minutes have also been sent to the two cancer networks of Greater Manchester
& Cheshire and Lancashire & Cumbria.

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