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Ella Lee

Seven years ago, 70 per cent of the patients who had heart surgery at Prince of Wales Hospital in Sha Tin later received blood transfusions.
Today, only 20 per cent of such patients get blood transfusions, and the use of blood products by volume has dropped by 30 per cent.
Why the efficiencies? Doctors say it's because the hospital introduced a monitoring system that carefully charts patients' progress and doctors' actions.
Dr Calvin Ng Sze-hang, an associate consultant in cardiac surgery at the hospital, said doctors were able to reduce use of blood products by 'simply being aware of the fact that we are being audited'.
'Each time blood products are ordered for a patient, we would be asking ourselves whether it is really necessary,' Ng said.
The Hospital Authority, which runs more than 40 public hospitals, is still at a very early stage in making comprehensive clinical audits. But doctors pioneering close monitoring of medical practices say the audits are improving the quality of care.
At Prince of Wales, the cardiothoracic team of Chinese University has been collecting data since November 2005 about patients' post-operative mortality and complications such as severe blood loss, unexpected dialysis and strokes. It has also been monitoring intensive care unit stays, blood transfusions and other use of blood products. 
The audit went to 'real time' monitoring last year, meaning the team examines three months of data instead of that amassed over a year. Now it can react more quickly to changes.
'The audit here provides motivation and also pride to our staff,' said Professor Malcolm Underwood,  head of cardiothoracic surgery at Chinese University, one of the first departments in the city to make public its doctors' performance and benchmark them in an international database. 'They have set themselves a high standard,' Underwood continued. 'If we know if there is any deviation, we can go and fix it. If we don't know, we can't fix it.'
The clinical data are recorded at each stage of a patient's journey. The patient's medical history is recorded. After an operation, complications are noted. When the patient is discharged, data on any intensive care unit stay, post-operative course and recovery go into the record. The datasheets are then collected by an experienced auditing assistant for adding to an electronic database. 
Underwood said the audit wasn't intended to produce a 'league table' of hospitals and surgeons. Instead, it measured actual surgical results against the 'expected' results based on international standards.
 The Hospital Authority has completed a second year of clinical audits of its 17 surgical departments, but as the South China Morning Post previously reported, most of the information is being withheld from the public. The authority has disclosed that the results for last year were worse than for 2009, with a rise in mortality rates and complications, but details were sketchy.
The disclosures represented progress, Underwood said. 'Hong Kong is moving in the right direction. What we are doing here is really sophisticated in line with the UK, so to expect everybody to hit this level immediately is quite a challenge.'
The audits have helped Hong Kong position itself on the global map. Since 2008, the Prince of Wales team has submitted data to Britain's national audit programme. Last year, Prince of Wales became one of the 366 hospitals in 29 countries contributing to the European Association for Cardio-Thoracic Surgery database.  
The team's performance has been in line with the international standard. 
The British audit system is very stringent, making public the results of individual surgeons' performance. Underwood said it would not be smart for Hong Kong to single out individual doctors in the same way.
Underwood, who helped put the audit in place as a former consultant cardiac surgeon, said that degree of transparency is not necessarily beneficial because doctors may tend to practise defensive medicine. For example, they might avoid some difficult and high-risk cases to steer clear of bad results. 
'There is a real danger that a group of patients who might benefit the most from the operations may be turned down,' he said.
Ng said surgical outcomes were not based solely on doctors' surgical skills. Other specialties such as intensive care, anaesthetics and rehabilitation also come into play.
Keeping watch
The Hospital Authority has completed  a second year of clinical audits of  this many of its surgical departments: 17



Audits spark boost in hospital care