Shoulder audit user guide

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Q: Who should be involved in the audit?

The hospital data manager and any clinician with involvement in the care of patients with shoulder pathology can be the named collaborator for selected hospitals and help submit the data for that trust.

Q: Why should I work on this audit?

Contributors will be acknowledged in the shoulder section of the 2023 NJR annual report and once your trust’s audit submissions are complete you will receive a letter of acknowledgement to show that you have demonstrated the skills necessary in this audit, including the understanding of the importance of routine data collection and understanding of the principles of research governance. This audit also presents a good opportunity to complete a requirement for doctors Annual Review of Competency Progression (ARCP). The collected data will be used to improve the NJR’s shoulder procedure volumes and to inform future analysis and research studies.

Q: How do I become a named collaborator for my trust?

Register your interest by email at shoulderauditnjr.gmail.com. You will receive a reply to confirm no other trainee is leading data collection in your trust. If there is a current audit lead in your trust, then we will advise you to contact them directly to collaborate on the work.

Q: How many people can be involved from one trust?

There is no limit on how many people can be involved from each trust but there can only be only one audit lead. It is recommended that contributors from the same trust work closely together to avoid unnecessary duplication of work.

Q: Do I need permission from my hospital?

Yes, you will need to register the audit with your hospital’s audit department and approach one consultant to be the supervising consultant for the project. It is advisable to download your local trust audit registration form and populate it using information available from the online resource page.

Q: When is the data collection happening?

Retrospective data is already collected and can therefore be completed at any time during the audit period. The audit data submission deadline is the 5 April 2024.

Q: What data are we collecting?

We are collecting data on all shoulder joint replacement procedures which are believed to be missing from the current NJR dataset between the years 2012 to 2020. These potentially missing shoulder procedures have been identified from Hospital Episode Statistic (HES) data that has been cross-referenced against the existing NJR shoulder joint replacement dataset, covering hospital trusts across England and Wales.

Q: How do I collect and record the necessary data?

Following confirmation of your registration with the NJR audit team you will then be supplied with a data collection spreadsheet, providing details of patient shoulder procedures performed within your trust to be reviewed as part of the audit. Start by entering your details including which hospital you are reviewing data for and identifying your co-contributors (including their email addresses). This spreadsheet will then need to be completed confirming whether each identified patient and procedure is eligible for inclusion in the registry. Please complete every column for each patient and avoid leaving gaps in the data.

For those episodes confirmed as eligible for registry inclusion and whose details have not previously been submitted to the registry, you will need to collect the required details to complete the S1/S2 MDSv8 form (add link to NJR website MDSv8 page). Data will need to be obtained from clinical notes and this includes implant stickers for ALL components used in a procedure (including for example, screws, liners and cement, where applicable). Usually, the stickers are obtained from theatre implant books, copies of the operation notes or theatre pathway documents. The catalogue number (also known as the reference number) and the lot number (also known as the batch number) are also required to input a component into the registry:

For those episodes confirmed as eligible for registry inclusion, and whose details have not previously been submitted to the registry, you will then need to collect the required details to complete S1/S2 MDSv8 form. Data will need to be obtained from clinical notes, and this includes implant stickers for ALL components used in a procedure (including for example screws, liners and cement where applicable). Usually, the stickers are obtained from theatre implant books, copies of the operation notes or theatre pathway documents. The catalogue number (also known as the reference number) and the lot number (also known as the batch number) are required to input a component into the registry:

The completed MDS dataset can then be submitted from these forms into the registry with assistance from your NJR hospital data manager within your trust. Further information can be accessed via the training video available here.

Q: What if I cannot obtain the component labels?

It is imperative that the component labels are obtained. This is because a key objective of the NJR is to track the components that have been implanted into patients. Without any component information, the procedure cannot be submitted to the registry. If some components used are no longer available to be selected from the lists within the data entry portal, please use the component request form, to request that this component be added.
If the details of only some of the components are available, please input these known components. If the procedure cannot be submitted because of missing components, then it should remain in the edit stack. At a later stage, we can examine these procedures and decide what course of action to take. Ideally, the ultimate aim is to submit fully completed procedures, because any procedures that remain in the edit stack cannot be fully analysed and tracked.

Q: What if I am missing data?

Please try to return as complete a record as possible. You might have to use several sources to obtain the data including case notes, electronic records and radiology records. If there is uncertainty, we recommend that you speak directly to the clinician for clarification. You should not contact the patient to obtain missing data.

Q: Can I use operation notes and/ or electronic clinic letters?

Most of the information can be collected from the relevant operation note(s). Any missing data may need to be collected from the electronic patient record/patient case notes.

We encourage using a combination of case notes, electronic records and radiology records.

If unsure about any data, please discuss with your supervisor as it is important that the data we obtain is as accurate as possible.

Q: What if my trust has more than one site?

We encourage you to register to complete the audit for all hospitals within your trust. Depending on local infrastructure, it may be preferable for you to recruit additional help and co-ordinate these colleagues across different sites to ensure all sites within your trust are covered.

Q: What happens if I sign up but don’t submit data?

The deadline for submission is 5 April 2024. If there are any difficulties hindering your ability to submit data, please contact us as early as possible and we will try help you. If the data is not submitted before the deadline, you will not be recognised as a contributor.

Q: How will any subsequent authorship acknowledgement work?

All contributors who have completed the audit by the deadline will be acknowledged in the 2023 NJR annual report, which will be published following completion of the audit.

Q: The patient is deceased. Do I still need to go through this process?

Yes. The patient’s procedure still needs to be entered onto the registry. The reason for this is that much analysis is conducted on the procedures and the implants (for those living and for deceased patients). The analysis results in valuable information being available to enable greater future patient safety and improved surgery outcomes.

Q: The surgeon who performed the surgery is no longer at the unit, so I cannot enter the procedure.

Please let the NJR know that the surgeon no longer works at the hospital so that they can be temporarily added back onto the system to allow you to submit the procedure. When you have completed the data submissions, please let the NJR know so that the surgeon can then be removed. You can let the NJR know by getting in touch with the NJR Service Desk at: enquiries@njrcentre.org.uk

Q: What about patient consent?

Patient consent cannot be obtained historically. In this case, select ‘Unknown’ in the data entry system. If a patient has specifically denied consent, then the procedure is still entered onto the registry, but the patient-identifying data is omitted. On the spreadsheet, please provide the procedure details, but do not provide the patient’s name, NHS number or local patient ID. Simply put “Consent denied” in these cells. (It is a requirement for the NJR to collect all joint replacement procedure details. ‘No consent’ simply means that the process to be followed is to omit the patient’s personal details).

Q: The surgery was performed many years ago, using an older MDS version. How should I manage this?

Please enter the procedure onto the current MDSv8 form (version 8), here even if it pertained to an older version.

Q: What do I need to consider in terms of data protection and accessing files which contain patient-identifiable data?

If you are emailing from and to an NHS.net email address, then the email and its attachments are automatically encrypted, so there is no need to worry about anything regarding data protection further. If you are emailing to or from a non-NHS.net email address, then the email needs to be manually encrypted. If you receive an encrypted email and need help to open it, please refer to the email encryption guide document in the resources section of the shoulder audit webpage here.

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