Medical audit is a process by which certain aspects of practice are assessed and compared with predefined standards. If those standards are not met, then the reasons for not meeting them are analysed and addressed; subsequent audits can be used to confirm that the situation has improved (thus completing the audit ‘loop’). Audit should be distinguished from research, which seeks to determine what the standards should be, resulting in ‘generalisable knowledge’. Research, for example, might suggest that drug A is best for uterine relaxation in premature labour, whereas audit might determine whether drug A is in fact being used appropriately in a particular unit, and show that the right intervention might improve this. In practice, many projects do not fit into either category precisely: for instance, the first step of an audit may produce ‘generalisable knowledge’ that might be applicable in other units.
Audit is widely supported as a means of encouraging evidence-based medicine and improving standards of care.
National audit
The best-known and oldest obstetric audit is the annual report of the Confidential Enquiries into Maternal Deaths, in which obstetric deaths are analysed, their causes determined and management compared against ‘best practice’, and recommendations made about standards of care in maternity units (see Chapter 89, Maternal bortality). Anaesthetic and critical care aspects are considered by specific anaesthetic and intensivist assessors, respectively. Other than this, there is no comprehensive national obstetric anaesthetic audit system, although most units have a system for collecting some measure of activity and outcomes. This causes problems with estimating true incidences of adverse outcomes, since the denominators are rarely known (e.g. the number of general anaesthetic caesarean sections in the UK), although there have been recent attempts by the Royal College of Obstetricians and Gynaecologists (and more recently by anaesthetic organisations, particularly the Obstetric Anaesthetists’ Association) to collect these basic data.
The National Audit Projects of the Royal College of Anaesthetists provided national data on complications related to neuraxial analgesic and anaesthetic techniques (NAP3), complications related to airway management (NAP4), awareness under general anaesthesia (NAP5) and perioperative anaphylaxis (NAP6); all these reports included information from obstetric cases.
Local audit
At unit level, rates of epidurals in labour, accidental dural punctures, anaesthesia for caesarean section and complications are commonly recorded. Whether this information is used for ‘true’ audit as defined above is uncertain. In addition, definitions of these various terms may not be uniform among units - for example, should ‘epidural rate’ include spinals and combined spinal-epidurals, and should the denominator be the number of women delivering, the number of women in labour, or the number of babies delivered? Finally, the real impact of sometimes expensive audit on actual outcome of care has been repeatedly questioned.
It is important to perform audit with specific aims, rather than simply to collect data for its own sake. Simple audit can easily be performed for particular aspects of care, such as to assess whether antacid prophylaxis is being given to all patients before elective caesarean section or to labouring mothers in high-risk groups, or whether appropriate investigations are being performed in pre-eclamptic patients before regional analgesia. Administrative aspects can also be audited, for example response times of anaesthetists on call or provision of adequate teaching on the labour ward. The value of an audit is increased by concentrating on objective data: for instance, satisfaction is commonly measured following obstetric anaesthesia, but data derived from vague satisfaction scales may be a poor reflection of quality of service.
In recent years, the concept of quality improvement (QI) has been proposed as a better means of monitoring and improving service delivery than audit, since the latter is a static process in which improvements are made in steps, after each audit cycle. In QI, a continuous cycle of monitoring and intervention allows a more dynamic process of improvement.
Finally, if the data are unreliable any project is worthless; thus each audit should be planned carefully to ensure that high-quality data are collected. During each cycle, the audit can itself be audited by sampling the data collected and checking them for accuracy and completeness.
Key points
• Audit comprises:
1. Assessment of practice
2. Comparison against ‘best practice’
3. Analysis of any shortcomings
4. Correction of deficient practice
5. Repeating the assessment
Further reading
Holdcroft A, Verma R, Chapple J, et al Towards effective obstetric anaesthetic audit in the UK. Int J Obstet Anesth 1999; 8: 37-42.
Knight M, Bunch K, Tuffnell D, etal.; MBRRACE-UK. Saving Lives, Improving Mothers’ Care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014-16. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2018.
National Institute of Academic Anaesthesia. National Audit Projects. https://www.nationalauditprojects.org.uk/National_Audit_Projects (accessed December 2018).
Paech M, Sinha A. Obstetric audit and its implications for obstetric anaesthesia. Best Pract Res Clin Obstet Gynaecol 2010; 24: 413-25.
Wagstaff DT, Bedford J, Moonesinghe SR. Improvement science in anaesthesia. Curr Anesthesiol Rep 2017; 7: 432-9.