Carpal Tunnel Surgery Audits


Dear Colleague,

As we are all aware, those of us who are engaged in primary care surgery are under increasing scrutiny from commissioning organisations. The governance requirements are becoming ever more comprehensive. Also within the next 12-18 months we will all be required to be registered for CQC whether or not surgical services are carried out at our GP premises. Without this you will not be allowed to hold a contract.

One of the criteria for being CQC registered is to produce high quality audits of your work. ASPC is very supportive of this measure.

As well as being a CQC requirement, good audits will help us provide evidence of high quality primary care surgery as well as refute criticism about the quality and safety of the services we are providing in primary care.

In order to facilitate the audit process for ASPC members, council has produced some recommendations for audit of carpal tunnel surgery. We hope that all members who provide CTS will be agreeable to taking part. We anticipate beginning this process for all members early this year.  If we all use a standard form of audit then we will rapidly develop a substantial database of primary care managed carpal tunnel syndrome.  This will have the additional benefit of providing CPD points for those participating.

The suggestion for audit is, firstly, to compile a register of all referrals and then to look at patient reported outcomes, (PROMs). This data can then be compared to patient satisfaction surveys. Additionally, we should record any cases of iatrogenic nerve damage, vascular damage, post-operative infections requiring admission to secondary care and any revision procedures for failure to relieve symptoms. Patient complaints should also be recorded. All of this information should be recorded at the pre-operative and three month follow up consultation. (Follow up does not necessarily have to be face to face).

In order to standardise the PROMs, we are recommending the use of the Boston Levine symptom scoring tool. Several of our members are already using this tool. It has been validated and has been used worldwide for many years. It measures both symptoms (eleven questions) and functionality (eight questions). The average symptom and function scores are recorded.  We are advising that it should be completed pre-operatively and repeated at 3 months post op for each hand. The change in both scores is recorded for each hand.  Copies of the tool can be obtained by e-mailing Laura at ASPC.  Anonymised data can be submitted to ASPC for inclusion in the database at your convenience. Again, Laura will have a sample database for you.  Dr Jeremy Bland, consultant neurophysiologist has offered to help analyse our data. He already has a database of 37,000 CT procedures in East Kent going back about ten years. The scoring system can also be applied to steroid injections.

For audit purposes we hope to set some criteria and standards in order to measure our performance. The following have been suggested.

  1. All patients should have pre-treatment Levine scores. Standard 100%
  2. All patients should have a three month post-treatment score. Standard 85%
  3. All treated patients’ Levine scores should improve. Standard 100%
  4. The average change in scores should be; symptoms, -1.5; function -0.7
  5. No patient should sustain iatrogenic nerve damage. Standard 100%
  6. No patient should need hospital admission as a result of infection. Standard 100%
  7. No patient should require revision surgery for failure to relieve symptoms. Standard 100%

Justification for choosing these standards

It is reasonable that all patients should have their symptoms accurately assessed pre-operatively and that recorded post-operative scores should improve for all patients, so 100%is the gold standard. However diligent the surgeon some patients may not return post-op questionnaires so a post-op standard of 80% seems reasonable.in addition it should be expected that nerves should be undamaged by surgery, there should be no serious  post-op infections  or need for revision therefore again 100% remains the aim.

Patient satisfaction can be recorded simply as follows.

  1. Cured (all symptoms gone).
  2. Greatly improved (i.e.  much better).
  3. Slightly improved.
  4. Unchanged.
  5. Worse.

We should be aiming to get about 85% of patient responses to be in groups 1-3.
All of the data obtained can be entered onto an excel spread sheet for ease of analysis. Don,t forget we need to record the adverse events too.

Anyone who wishes to discuss CT audit further can contact John Tisdale or Matt Wordsworth by e-mail.

Regards,

Dr John Tisdale