Wolverhampton Eye Infirmary
The National Institute for Health and Clinical Excellence (NICE) Guidance TA155 for the treatment of wet age-related macular degeneration was issued in August 2008. In this work we describe our experience in the application of an audit tool provided on the NICE website for auditing the implementation of this guidance in our hospital setting and report on the specific and wider aspects of auditing guidance implementation.
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Aims and objectives
The aim of the work was to initially describe our experience in the application of an audit tool for auditing the implementation of this guidance in our hospital setting and to report on the specific and wider aspects of auditing guidance implementation.
Reasons for implementing your project
TA155 introduced a new treatment into the NHS for treatment of wet Age-Related Macular Degeneration, which allowed inclusion of a much broader range of patients to be treated than previously possible. We felt it was important to ensure that this new intervention which is also very labour intensive and costly, was being correctly implemented and thus the audit tool was very useful.
How did you implement the project
Case notes of patients were retrospectively reviewed for compliance to the NICE Guidance TA155, using the audit tool provided, which investigated five domains. A full audit cycle was completed. Our initial audit failed to reach a satisfactory level of compliance with NICE Guidance TA155 in one domain, which related to dissemination of patient information and documentation of treatment eligibility. To address this issue, we introduced specific changes to our processes, and on reaudit, were able to achieve a satisfactory level of compliance in all criteria.The reconfigured wet Age-Related Macular Degeneration treatment service was funded by a new business case after TA155 was released.
Our initial audit failed to reach a satisfactory level of compliance with NICE Guidance TA155. The specific criteria that were substandard related to dissemination of patient information (only 0%-10% compliant in Criteria 1.1-1.4) and documentation of disease and disease progression (only 0%-70% compliant in criteria 2.2-2.4). We were compliant with TA155 to a high standard (76.7%-100%) in all other domains and criteria.
Following the initial audit, we implemented changes in the areas that were deficient. Firstly, standard patient information leaflets were produced by the senior nurses and doctors involved in the diagnosis and management of patients with AMD. Once hospital trust approval of the information leaflets was granted, these were distributed to all new patients. Secondly, preprinted sticky labels were developed, to be used in patient notes at the commencement of therapy. These labels would indicate that (1) information leaflets had been given to patients; (2) the eligibility criteria had been checked and found to be fulfilled; and (3) there was documentation of disease and disease progression. The costs for these were borne by the directorate budget, and all doctors seeing new patients were informed of the changes, which were welcomed as a further improvement to patient care. By educating all staff to use the eligibility stickers and providing another level of check at the secretarial level, we were able to effectively achieve and maintain compliance in previously deficient areas.
After implementation of these measures, a reaudit was performed on a different subset of new patients entering the treatment program over a 3-month period between July and September 2011. The same process of random selection of audit cases was used, but for this shorter audit period, a smaller sample of 24 patients was selected by external staff from the hospital's clinical governance department. Following this, we were able to show satisfactory compliance with all criteria in the audit tool and were able to close the audit loop.
NICE guidance has allowed treatment of a much larger group of patients with wet Age-Related Macular Degeneration than previously possible and affords far superior visual outcome compared to the other options available at the time as evidenced by large scale multicentre clinical trials.
Key learning points
Our experience has demonstrated not only the usefulness of the audit tool in ensuring that our service was in adherence with NICE guidance but also, that as a result of introducing changes to ensure compliance, the quality of service provided to patients was further improved. Implementation of NICE guidance is an intrinsic part of the clinical governance process, and audits on the implementation of NICE guidance are requirements of all service providers, to ensure that there is uniform and systematic uptake of evidence-based medicine throughout the National Health Service.
All ophthalmic units will be using the new treatment recommended by NICE in TA 155.The advantage of the NICE audit tool is that it allows clinicians and commissioners to ensure that the guidance is being correctly implemented.
Wolverhampton Eye Infirmary
Is the example industry-sponsored in any way?