Does medical audit lead to explicit standards? Experience with thrombolysis in four UK hospitals

The setting of explicit standards against specific criteria is a recognized part of the medical audit cycle, but often in practice it has been neglected, implicit judgements being used instead. The conduct of a study to evaluate audit among physicians in four UK district general hospitals provided an opportunity to encourage the setting of explicit standards and observe the results. The subject chosen for audit by the participating physicians was the extent of use of intravenous thrombolysis in patients with suspected acute myocardial infarction (AMI). Standard setting was requested at initial peer review meetings held to review baseline results. This was followed up by a written request to lead consultants and subsequent telephone calls. Two out of the four participating hospitals set technical standards, which excluded patients with contra-indications from the denominator. The other two hospitals set population standards as requested, one with considerable reluctance and scepticism. Each hospital set separate standards for definite AMIs and for probable AMIs. Six out of the eight standards set were achieved in at least one of four audits conducted in each hospital. Time trends were difficult to interpret because of small numbers. The amount of discussion between the lead consultant and colleagues about standards was highly variable, but there was no clear relationship between the process for agreeing standards in a particular hospital and subsequent attainment.