Carpal Tunnel Audit Dr Gareth James ASPC Audit

Carpal Tunnel Audit Dr Gareth James ASPC Audit lead free to email me Gtb. Vas@Yahoo. co. uk Or grab me in the Coffee breaks!!

Why Audit? • To improve you have to firstly see how you compare to others and their outcomes…don’t you want to be the best you can? • The collected audit data will allow us – the ASPC and it’s members to get comparison results on a yearly basis. • This you can compare with your peers and will be presented at the following ASPC conference. • So this data doesn’t just tell you “how am I driving” but also “how am I driving compared to the other road users”. • Taking part in the ASPC CTS Audit will also show evidence of ongoing CPD in field of Carpal Tunnel Operation, with a certificate for your PDP • CCG’s want your audit data!

A quick reminder…. The ASPC decided to use the PEM Hand Health Questions (this should NOT be routinely used for diagnostic purposes) And to use 3 patient questionnaires…

CTS QUESTIONNAIRE ONE - CTS PRE-OP • This is the 11 questions from just Part 2 of the PEM Hand Health Questions • This should be sent to the patient at the same time as their appointment details and/or information leaflet • Ask the Patients to bring it completed on the day of their operation. • If they arrive without, then ask them to complete in the waiting room this prior to their surgery • Score their PEM 1 (Pre-Op) by adding together the patients number answers for each of the 11 questions into one total (out of 77)

CTS PRE-OP The Hand Health Questions

CTS QUESTIONNAIRE 2 - CTS IMMEDIATE POST-OP • To be filled straight after the operation. • There are Just 5 questions:

CTS QUESTIONNAIRE 3 - CTS POST-OP • These should be sent out to the patient 3 months Post Operation • Or contact the patient another way – phone them up? • This one has the PEM Hand Health Questions (part 2) to fill out again • Score their PEM 2 (Post-Op) by adding together the patients number answers for each of the 11 questions into one total (out of 77)

CTS POST-OP PEM Part 2 again The Hand Health Questions

CTS POST-OP Questionnaire Page 2 Plus there another 5 questions, these will be THE MAIN BASIS OF YOUR KNOWLEDGE OF YOUR COMPLICATION RATES

How to Score #1 – PEM Post Op Difference The difference from the first Pre-op total (PEM 1) to the Post-op total (PEM 2) will be our VALIDATED total called the PEM Post Op Difference (PEM Po. D) • Patients name, or identity number needs to be on both Pre and Post questionnaires • GDPR issues…. • This Audit asks for your AVERAGE PEM Po. D Score for all your patients But you should be following up: • Patients with a minus or static PEM Po. D score (obviously have not done well) • Any patient with any severity still scoring 7. The commonest reason is either the Pre-Op CTS was very severe with irreversible nerve damage or the hand has collateral pathology which accounts for on going disability.

How to Score Q 2 – CTS IMMEDIATE POST-OP We then take the average score per question for: • 1. How good was the information leaflet sent to you prior to your appointment to prepare you for today’s operation? • 2. How did you rate the Doctor's manner and communication during the operation? • 3. What was your overall impression of having your Carpal Tunnel Operation undertaken here at this Clinic? But only percentage achieved for ‘Very Likely’ to • 4. How likely are you to recommend our clinic to friends or family if they needed similar care or treatment?

How to Score Q 3 – CTS POST-OP PEM as already mentioned, then We then take the average score per question: - : • 12. How good was the information in the Post-Op Advice leaflet in preparing you for any post operative issues? • 16. Overall please rate your overall satisfaction with our service The percentage and number for EACH of the 5 choices relating to • 13. How have your symptoms responded to surgery? The percentage of those who required antibiotics post-operation, and of those what percentage were given by the CTS surgeon in Q 14 Plus any replies you received from the question: • 15. Did you have to seek any medical advice (urgent or routine) for any reasons other than an infection?

Audit cycle time frame • The audit cycle runs for 12 months covering the periods 1 st Jan until 31 st Dec • Collection of that year’s data for the following years Conference presentation • The 2017 audit cycle started 1 st Jan 2017 until 31 st Dec 2017 and will be presented in the next slides • Data from 2018 should be now being collected and will be presented at the 2019 conference

2017 CTS Audit results I had data from 9 practices. This is an improvement on just 4 practices who submitted data for last year’s Audit This means we have data on some 2089 CTS operations This is a massive improvement from just 759 CTS Operations for last year’s Audit But there's more of you out there!!!

2017 CTS Audit results – Return Rates What percentage Returns rates are you getting? Pre-op: Average 64%. Previous year %: 81 Not sure why this isn’t 100%. You need this for you PEM Po. D score…get them to do it on the day otherwise if they don’t bring it before their operation On the Day: Average 80% Previous year %: 79 Again why not higher, they cant leave the building until its done! Post op: Average 49% Previous year %: 46 Not that bad actually! You can just get someone to phone them and do the form…. The average PEM Po. D score was 27 Previous year: 21

Audit results – On the day Questionnaire Average scores for the below questions: rated 1 (Excellent) to 7 (Very Poor) 1. How good was the information leaflet sent to you prior to your appointment to prepare you for today’s operation? Average Score 1. 1 Previous year Av score: 1. 1 2. How did you rate the Doctor's manner and communication during the operation? Average Score 1. 1 Previous year Av score: 1. 0 3. What was your overall impression of having your Carpal Tunnel Operation undertaken here at this Clinic? Average Score 1. 2 Previous year Av score: 1. 0 4. How many said VERY LIKELY to: How likely are you to recommend our clinic to friends or family if they needed similar care or treatment? Average percentage 91% Previous year %: 95

Audit results – Post-Op Questionnaire Average scores for the below questions: rated 1 (excellent) to 7 (poor) following the Hand symptom sheet 12. How good was the information in the Post-Op Advice leaflet in preparing you for any post operative issues? Average Score 1. 3 Previous year Av score: 1. 1 16. Overall please rate your overall satisfaction with our service Average Score 1. 2 Previous year Av score: 1. 1

Audit results – Post-Op Questionnaire #2 13. How have your symptoms responded to surgery? Cured 42% Previous year %: 50 Greatly Improved 42% Previous year %: 35 Slightly Improved 11% Previous year %: 11 No Change 4% Previous year %: 4 Worse 2% Previous year %: 0 14. Did you require any ANTIBIOTICS resulting from your Operation? Average of 2. 2% of patients needed antibiotics Previous year %: 3. 4 29% of antibiotics were given by the Surgeon Previous year %: 42

Audit results 15. Did you have to seek any medical advice (urgent or routine) for any reasons other than an infection? Minor: • Pain x 4 • Wound bleed • slight gaping of wound • Dressing came off • Needed reassurance x 2 • To ask about swollen fingers at wrist More serious • Bilateral haematoma's • Post op wound infection – hospitalised & IV Antibiotics required • Pain had Complex Regional Pain Syndrome requiring referral to secondary care • Referral to secondary care for pain in palm

2018 – CTS audit collection • It’s not too late to start using the Audit tool to start collecting for this years audit that runs from 1 st January 2018 until 31 st December 2018 • Email me and I’ll send you all the bumpf you need to set it up • Collect the data whilst you go along – as I have now set up an Excel sheet that will do all the work for you and even will fill out your return audit sheet for you – all you’ll need then is transpose your completed audit sheets figures into a Survey. Monkey weblink

2019 Audit suggestion #1 Raj Dhumale had some queries about the questions asked in the preoperative questionnaires He felt we should be asking the questions below: • Effects of tingling numbness • Sleepless nights • Dropping objects e. g. cups etc. . . Personally, I think these are really covered by the PEM The Hand Health Questions, which is a validated tool and cant really be mucked around with Or do members feel I should include these to the 11 asked questions?

2019 Audit suggestion #2 Raj also felt that we should delve deeper into post operation complications such as : • Numbers of total sensory or motor loss due to damage of median nerve This would need to be added and completed by the surgeon per individual cases and 2 new questions added to the Audit Return: Numbers (and percentage) of total SENSORY Loss Numbers (and percentage) of total MOTOR Loss Do we want these questions asked from 2019? YES/NO?

2019 Audit suggestion #3 Raj also felt we should have more information about referrals to secondary care such as IVABx; the need for re exploration by another surgeon etc. . Coincidently I was at a meeting with my CCG a few weeks later, about getting all their primary care surgeons to use the ASPC questionnaires for all procedures and they were asking for the same question to be included. They want to know how many and how often patients required secondary care input following their primary care surgery I feel this SHOULD be asked, and plan to add this to ALL the ASPC questionnaires

2019 Audit suggestion #3 cont We sort of ask this question already to the patient: 15. Did you have to seek any medical advice (urgent or routine) for any reasons other than an infection? I therefore recommend we expand this question in the 2019’s Questionnaires: Did you have to seek any medical advice from your Hand Surgeon team or GP (urgent or routine) for any reasons other than an infection? Did any complication following your hand surgery require you see a Consultant at a Hospital? If Yes to either of these questions please inform us why, and what treatment you received from them? Any dissenters? YES/NO?

2020 Audit? ? BUT……. After some chasing I finally heard back from Will Mason, the chap from the BSSH who came along last conference, and who was looking to try and align CTS secondary care questions with us…. Due to a change of software (amplitude) this been somewhat derailed. We still plan on collecting outcomes for carpal tunnel syndrome but people couldn’t quite agree on the best outcome measure for carpal tunnel syndrome. I will try and persuade our audit committee that we should use the same as you and I think this would be sensible. However they do tend to over think these things a little and I suspect may want to collect rather too much data than is practical.

2020 Audit? ? Will Mason: The committee also have a feeling that once our new system is up and running all the GPs who do carpal tunnel release will undoubtedly want to use it. It would be ideal if all carpal tunnel releases in the UK were audited using the same tool and could be recorded on the same database but we will have to see how our new system pans out. It probably won’t be working yet for another six months at least but you might look at the foot and ankle registry (BOFAS) or the spine registry which also use amplitude.

Vote/discussion please • 1) Adding the 3 pre-op questions or to the 11 PEM The Hand Health Questions? Effects of tingling numbness; Sleepless nights; Dropping objects e. g. cups etc. . . • 2) Whether to ask for numbers (& %’s) of SENSORY and MOTOR loss? • 3) Happy for me to change and expand Q 15 to include secondary care? • 4) Any other thoughts/comments on the Audit/Questions asked? • 5) Should we use this questionnaire for ALL hand surgery, such as Dupuytren's and trigger fingers? And finally • 6) Are people going to be more interested to use the BSSH one when up and running? ? ? Take it away Nanda!!