Knowledge Natter: Dystocia Dilemmas

Louise Northway Clinical Lead RVN
Lucy Leicester MRCVS Vets Now Ltd
Sophie Gilbert MRCVS Vets Now Ltd

RCVS Knowledge:
Welcome to this Knowledge Natter by RCVS Knowledge. Here we have friendly and informal discussions with our knowledge award champions and those who are empowered by Quality Improvement in their work. Whether you are a veterinary surgeon, veterinary nurse, receptionist, or member of management, Quality Improvement will and can positively impact your everyday life. Listen and be inspired.

Lou Northway
Hello everyone and welcome to this RCVS Knowledge Natter. My name is Lou Northway. I’m Clinical Lead RVN at RCVS Knowledge. Tonight I’m excited to talk with Lucy Leicester and Sophie Gilbert from
Vets Now. They are here to tell us all about their amazing award that they have won with their veterinary team this year. So without further ado, Sophie, Lucy, please introduce yourselves and tell us all about you.

Sophie Gilbert
Thanks, Lou. Thanks for having us. It is really lovely to be here. So I’m Sophie. I’m a small animal veterinary surgeon and I am now part of our sort of clinical standards and professional standards team at Vets Now. I’ve gone into that from doing frontline clinical shifts with Vets Now for the last few years and have been really, really heavily involved with quality improvement and things within the business. It’s been a really exciting couple of years.

Lucy Leicester
Hi Louise. I’m Lucy. I graduated from the RVC, spent about 10 years in small animal practice, a mixture of day practice and some ECC. Then spent a few years as a university teacher at Nottingham Vet School. Got a GP certificate in forensics and law in 2016. And I’ve been working for Vets Now since then as an internal auditor. So the knowledge that we gained from the audits, we kind of use it
to identify ways that we can support our clinical teams, streamline processes, provide clinical and pastoral support, and add information resources to our intranet and digital learning platform.

Lou Northway
Amazing. So, I mean, you’ve already started saying sort of how you’ve navigated your way to QI, but what was it that made you come down this avenue?

Sophie Gilbert
Go for it, Lucy. <laugh>.

Lucy Leicester
Hmm. Well, I suppose that’s a really quite a difficult question to answer. I suppose it’s that feeling of always wanting to do better than you’re doing and being aware that, you know, continuous improvement is a good thing. And then realizing it was actually a thing. I think when I interviewed for this role, I researched clinical audit and then realized that that was just one part of QI and then
found out about what was going on in the human field and how the veterinary field was playing catch up. And there’s a lot of QI going on at Vets Now, isn’t there, Sophie? It’s kind of embedded in our culture.

Sophie Gilbert
Yeah, definitely. I’d really agree with Lucy. I guess probably, I didn’t really know what kind of QI or quality improvement actually was until recently, but I probably realized that we’re all doing it, or I’ve
definitely been doing it for years just as a vet in practice and you just don’t really know that you’re doing it until you sort of learn a little bit more about it. So even when you’re thinking about your
cases you go home at the end of the day and you think or have that case, or you talk to your practice team about something and you think, oh, how could we have done things differently? Or, you know,
things that went really well or, or whatever it is that you talked about. That’s all sort of quality improvement. And then I joined Vets Now about seven years ago.

As Lucy said, they’re really, I guess forward thinking, I think in terms of Quality Improvement and things that they’ve been putting in place for the teams on the frontline to support with their cases.
So, you know, ever since I joined Vets Now we’ve had things like clinical benchmarking, we’ve had guidelines, all sorts of things that are really there to help us as, as teams, do the best we can for the
pets that are in our care, I guess. And then when I moved through the company, I got a more senior leadership position. I was able to start putting some of that into practice with my own team and that
was really, really exciting. I was sort of able to actually make changes and see them happening within the clinic and that was really, really cool.

So I guess it’s really then that I’ve started learning about it. I did some research and I went through all the stuff on the RCVS Knowledge website as well. So that was probably one of the places I actually
started learning sort of what is audit, you know, what is Quality Improvement, sort of all these buzzwords that we have that talk about all of this stuff. And, and I started to realize we were all just
doing it anyway. So yeah, I think that’s probably where I first started really understanding what it was and maybe getting some more sort of experience in putting it into practice as well, rather than
just sort of accidentally doing it as it were.

Lou Northway
Yeah. So it sounds to me like you both really sort of had a bit of a light bulb moment. It’s like, oh, this is amazing. This makes so much sense. We’ve already been doing it. And then also it being really motivating and empowering for you and your team once you started making those improvements and achievements and seeing good things happen.

Sophie Gilbert
Yeah, definitely. I think that’s the biggest thing, isn’t it, is that it’s about learning things that you can actually put into real life practice. I think sometimes when you’re, as a vet or a nurse or whatever, whoever you are and you’re reading papers and you’re reading studies and things, it’s really hard to apply that knowledge to the cases that you’ve got in front of you, I think, isn’t it? And I think for me personally, starting to do my own sort of audits, my own M and M rounds or whatever parts of it has been in practice has been what made me realize that actually that’s what makes the difference for our patients. And that’s how that next dog or that next cat or whatever it is that walks through the
door, you can say, oh, well, okay, yeah, we’ve seen this and now we’re going to do this. I think that’s the best bit about it for me.

Lou Northway
Yeah, absolutely. Fantastic. And I can hear the enthusiasm in your voice and I can imagine the impact that you both have when you speak to your teams, because we all need to champion it and promote
it as much as we can. Because when I first started learning about Quality Improvement, I think I was a little bit like you to start with. I thought, oh, this is going to be a tick box exercise, it sounds a bit
boring, and oh, it’s something that management do, it doesn’t apply to me. But then as I started learning more and I think, oh gosh, no, this is me every day, every week, every month. Yeah, absolutely. Game changing. So, we’ve already sort of covered where you started to sort of hear and learn about QI.

So let’s start talking about your actual projects. So this was a huge, huge project that you guys did, which is phenomenal. Probably the one of the biggest QI projects I’ve come across so far, <laugh>, full on. But where did the inspiration for this specific topic come from? How did it all start?

Sophie Gilbert
So, I’ll let Lucy go with that because I sort of came in halfway through it as well, didn’t I, Lucy? And joined it.

Lucy Leicester
Yeah, well I did as well. Really, it’s been going on… We’ve been looking at canine dystocia cases at Vets Now for a whole decade. And the initial work was done by Aoife Reid. Well she was Aoife O’Sullivan then and Dan O’Neil and Amanda Bogue and some other people at the RVC. And there were a couple of papers published as a result of that. And then we followed up with two more phases of data collection. But the real turning point was when we formed a working party in 2021-
Sophie and I and Rachel Marshall, head of Clinical Nursing and Aoife, who’s head of our edge program, and we wanted to work out how we could disseminate all the knowledge that we’d gained, which was like a really big challenge because we had so much data, but getting the knowledge to where it was needed was a real challenge. And so that our biggest job. But in doing that, we all bought sort of different perspectives and different knowledge and the collaboration kind of just made it better with each new person that we collaborated with. And we got input from kind of other experts in the business, our National Clinical Lead, Dan Lewis at the time, and Laura Playforth, who was at Vets Now and then our Professional Standards Director. Lots of help from Dan O’Neill all the way through. And he helped us to publish the paper. It would, you know, it would’ve been really
difficult without him, wouldn’t it, Sophie? A very long journey. Very exciting and all about the people that helped us really.

Lou Northway
So many, so many people didn’t as well.

Lucy Leicester
Not to mention the volunteer auditors. As soon as we knew we wanted to do another large audit, we asked everyone in the business if they’d like to join in. And we had so many volunteers and those
people made it possible with all their hard work.

Lou Northway
I saw also in the sort of overview of the projects that in each sort of practice team, there was somebody that was in charge as well of collecting data collection and monitoring things as well. So that must have been quite empowering for teams on a sort of more local level too.

Sophie Gilbert
Yeah, I think that’s the thing, isn’t it? Its getting involved sort of from the start and really understanding how that can make a difference to your cases in practice. I think one of the biggest things for us as well is we had actually at the time that the working party was created, as Lucy said, we actually had lots and lots of sort of, I guess not requests, but um, we were, we were listening to people who were saying, these are the kind of cases that we are seeing a lot of and we knew we’d
had a big increase in caseload around that time as well of these sorts of cases. So actually it was it was the right timing for us to be able to go out with that sort of information as well, because that’s
what people were asking for.

That’s what they, you know, that’s what everybody was saying, these
are the cases we’re seeing and these are the cases that actually we’re perhaps finding a little bit challenging. So I think that really helped in terms of knowing that we were, um, sort of listening to, to people and, and doing what they were asking for, I guess in that perspective.

Lou Northway
Yeah, I’m sure most people listening to this as well will relate to sort of the stress around managing dystocia cases, because a lot of people have different approaches and sometimes it goes really well,
sometimes it goes not so well, and it can really knock your confidence when it doesn’t go so well. Your outcomes from your audit, since you’ve been doing all of this training, updating guidelines, and
looking at the finer details of how cases have managed, you’ve massively increased, sort of improved outcomes as well, haven’t you? Could you tell me a little bit about that?

Sophie Gilbert
Yeah, certainly. So, I think dystopia cases, like you said, they can be really challenging and I think it’s like a lot of other cases that we see in veterinary practice, there’s not a wide evidence base out there and with lots of cases they’re not, they’re not sort of clear cut. There’s not always an answer one way or the other. And I think often these are the ones that come in in the middle of the night, obviously, as Vets Now we’re an out-of-hours company only, so they’re the cases that we deal with.

But I think as a, you know, as a new graduate vet or as a vet in practice, often you might be on your own in the practice or it might just be you and a small team, one nurse or a skeleton team, so they can be really challenging cases to deal with from a communication and a clinical aspect, making those decisions in the middle of the night on your own.

And like I say, it’s not always sort of that clearcut, I think, where you are also dealing with lots of lives. I think that can add a little bit of pressure on, you know, you’re not just dealing with life of that
one pet, you’ve got all the puppies and things as well that, that you are trying to make sure that everything’s o okay and that it, you know, the outcomes are as best that you can at the end of that.

So I think the work we did showed that just simple things, you know, having the checklists and having the guidelines. We’re all doing the right things, but it can be hard to make those decisions in the middle of the night when you’re in practice dealing with those cases. So just having that checklist by your side sort of thinking, right, okay… it decreases that cognitive load, I guess.

And you can just think right, okay and go through things really, really logically. So I think that was probably one of the, sort of the biggest outcomes of that whole project really was being able to create those checklists and support people just in moving through that thought process when dealing with a case, I guess.

Lou Northway
Yeah. I love your checklist. We, I have them printed at work, actually. And they are, they are so helpful because like you say, they always happen in the middle of the night pretty much, don’t they?

Yeah. You’ve already worked a day most of the time unless you have the luxury of being an overnight care provider, just having almost like a friend, I always view chat list like a friend really just to check in with and make sure you’re on the right path. But they are super easy to follow and all of them are available to download on the RCVS Knowledge website, just for those of you listening. So check those out because that’s definitely something that’s discussed in forums a lot as well. How would you, you know, how do you manage them? What do you do? What drugs do you use? What drugs don’t you use? So your QI project had loads of different elements and one of the big focuses was team training. So how did you deliver that training to so many people?

Sophie Gilbert
Yeah, so as Lucy touched on earlier, we were very aware, you know, our Vets Now, we are in quite a unique situation where we’ve got 58 sites across the, the company and all our sites work as their
own teams, which is fantastic. It means, you know, they can work, and they can make decisions for their teams. Sometimes it can be challenging to distribute information across the whole company
and I think the biggest thing that we learned was to do it in lots of different ways because people learn in different ways, don’t they? So I think for us, our, one of our big learns throughout the project was not only to keep sort of going out with lots of different ways of doing things, but to do it on different forums as well. So, one of the things that we did was we held a discussion forum for all staff.

It wasn’t just for the clinical staff, it was for, for anybody who wanted to attend. So that included all members of the teams, the receptionists and animal care assistants as well. The idea behind that was really to look at how the whole team is impacted by these cases because we are really, really aware that it’s not just vets and nurses that deal with these, it is from the moment that the only steps through the door with their pets. it’s the whole team that’s managing these cases. So we really felt it was really important to get the whole team involved, with not only the data and the, and the research that we’d been doing, but to chat about these cases and to come and have a chat with people who perhaps had been managing cases like this in practice for a number of years.

And really just to talk about things and as an open discussion forum. So on that we had some specialists who came and gave us a hand to talk through some of the more specialist clinical information, but also we just had representatives from different members of the teams essentially. And it was free for everybody to attend and just come and have a chat with us, ask questions. We covered clinical aspects, but we also did cover some of the sort of more communication aspects
around these kind of cases as well. So we’ve tried really hard to address the things that people found challenging with these types of cases and, and really just have an open forum that all our teams
could come and talk to us about, that was recorded. So then obviously we were able to disseminate that across the whole company as well for those that couldn’t attend the live session, which worked quite well and that’s available to them all still on our learning, our internal learning management system as well.

Lou Northway
Amazing.

Sophie Gilbert
Which is really good. And then, like I said, yeah, we had different sort of… we had lots of different…we developed a couple of infographics, we had the checklists, we’ve got our learning management system, so we were able to put them up on there. We were able to put things out, in
the newsletters and things. So it was just about going on lots of different channels and trying to get people aware of, of what had been, what was out there and what was out there to help with these
cases essentially. So, yeah.

Lou Northway
Yeah, I think that the points about giving information to people and how you do it is so important. So it can be really hard, can’t it just being sent like pages of text to read all the time. And like you say,
some people like visual infographics and things like that, so that’s amazing. And the feedback you had, which was included in your Knowledge submission is phenomenal as well. Your teams really
enjoyed the training that was provided.

Sophie Gilbert
Yeah, absolutely. We’ve been… do you know what? We were so lucky. I guess that, that everybody… I guess it is a subject that everybody felt passionate about as well. That’s the thing. So lots of people
were invested from the beginning and the information that was coming out was hopefully helping people with their cases, which is, which is what they need, isn’t it? So, I think from that aspect, it was
really positive and we’ve definitely, you know, we had lots of just unsolicited feedback saying thanks, and our teams have taken the time to write in and say, oh, wouldn’t it be fantastic if we could do
this?

Lou Northway
Yeah, I bet <laugh>

Sophie Gilbert
To see the enthusiasm out there, it’s absolutely fantastic, you know, like people asking and saying, oh, there’s not much information on this. We must have so much data, let’s do something about this. Which is just, you know, it’s super exciting and it’s really the best outcome possible, isn’t it?

Lou Northway
It’s quite addictive, isn’t it? Once you start, you think, oh, what else can we improve? And I, when I look at you submission and I think that, cause you’re like, well, you did this and then you’ve done
this. Yeah. And then, oh, you’re looking at this now too. <laugh>

So I hope people listening feel inspired and be at home thinking, or at work, oh, you know, what could we improve? What areas are important to the team? What are the things that people worry about? Or perhaps, you know, you’ve been on a webinar and you think, oh, that was a good idea, but I’m not sure how we are doing. Let’s start measuring it. So yeah, inspirational. So let’s have a little chat about your achievements.

So through doing all of this amazing work, what things did we improve? What were the, what were your sort of top five achievements?

Sophie Gilbert
So I guess for me, one of our biggest achievements was actually just getting people involved in QI. I guess, I know that sounds a bit corny, perhaps..

Lou Northway
I love it. No, I love it. <laugh>.

Sophie Gilbert
Thinking about it, you’d love it to be sort of something really clinical or something like that. But actually no, for me it was just really seeing the enthusiasm of people wanting to get involved, telling us how they were using the information in their cases, using the information myself in my cases, learning.

Yeah, I think that was one of the biggest things that I took away from it and learned from, from the whole project, I guess. And would like to take that forwards into future projects to try and replicate that, for sure.

Lou Northway
Yeah, I know, I think that’s really special. And, yeah, something perhaps you don’t initially jump to, you always think of like the actual outcomes with the patient from the patient focus, but when you
reflect on how much this would’ve improved your team culture, communication, and bringing the different teams together too. Yeah. Amazing. I love it.

Lucy Leicester
Yeah. I think the connections that were created between colleagues have just been amazing throughout the project and afterwards. That’s been really rewarding and really kind of unexpected, I didn’t realize that that would be that would be quite such a prominent feature. And obviously the checklist and the guidelines and we’ve added to the literature. Yeah. So yeah. Really pleasing.

Lou Northway
Yeah, so are Vets Now going to release their own book now. <laugh>

Lucy Leicester
<laugh>.

Sophie Gilbert
No, I think one…I think picking up on what Lucy just said, I think that’s a really important point to make. I think, I think we picked up on that earlier about, you know, in the, in the veterinary industry, we do often really have a lack of sort of evidence-based about a lot of things…

Lou Northway
Or it’s very outdated, isn’t it? It’s, um, yeah,

Sophie Gilbert
Exactly. And I think practice-based research and things like this is really the way to go, isn’t it? Because it’s how cases are, are being seen in practice now. It’s not sort of a theoretical study or something that, you know, this is absolutely what you might do, but it’s, it’s not replicable because of operational things or whatever else. It’s, it’s something that actually worked for people within our company. And what would be really lovely is obviously, and one of the reasons we published this study was that hopefully, you know, across the profession that information can be used for others as well.

So that’s a really lovely thing to think about. But also, yeah, just contributing to the evidence based. So one of the things we’re doing more within Vets Now is using app Apgar scores a little bit more for puppies and kittens when they first come out, and actually there’s not a huge, again, not a huge amount of evidence behind that, but wouldn’t it be lovely if we can start creating that data and then start looking back at that new data that we are building and, and putting into our practice management system and start thinking, okay, well, you know, this is the next step and this is where we need to go now. So that’s, I think that’s really exciting.

Lou Northway
Yeah, no, it is. It’s like, yeah, where could you go from here? You know, it’s like you’ve just started building a big, amazing pyramid of goodness for those listening that may not know what Apgar scoring is. Could you tell us a little bit about that?

Sophie Gilbert
Yeah, sure. So, Apgar scoring actually comes from sort of human medicine and it’s been used in neonatal babies and in human medicine for a number of years. And essentially it’s a scoring system
when a baby is first born and it’s an early indicator, I guess, of where interventional help might be needed. Um, so if a baby comes out and it’s struggling a little bit, it’s a, you know, it’s an early indicator for the clinicians, that it gives them a clear idea of where that neonate might be struggling and what they might need to do to support it.

So it’s something that has only been used a little bit in the veterinary world, I guess, for, for a few years. And there’s been a few studies that have come out and we’ve got a slightly updated system, I guess that’s more applicable to puppies than human babies.

But it essentially looks at a few different things like breathing and how much the babies, the puppies are moving, and then it can guide our clinicians in saying, right, okay, well this puppy needs a little bit of additional support and, you know, this might need a bit of oxygen, or we might need to do something a little bit additional or just keep a bit of a closer eye on this one. So it’s a really useful system that can just really help identify and improve outcomes because we are able to pick those things up earlier.

Lou Northway
I think that’s something I’m definitely going to take back into practice with me, because when you have like a big litter in front of you… my litter record… I’m just going to tell everyone this because I’m
really proud <laugh> was 15 Labrador puppies. (Wow.) On my own C-section. Yeah. When I was a student nurse about, I don’t know, how long was that ago? 18 years ago. It was absolutely “Oh my gosh”… but you know, day to day, you are faced with so many lives in front of you, prioritizing who needs, you know, more attention than someone else, having something just to rationalize and focus on is really helpful.

Sophie Gilbert
Yeah, definitely. Definitely.

Lou Northway
Do you girls have a record? Like, what’s the biggest litter you’ve done <laugh>?

Sophie Gilbert
I don’t think I’ve had one as, as many as 15. 15 <laugh> 11, yeah. Is probably my record to be honest. Fifteen’s really impressive

Lou Northway
<laugh>. They were, honestly, they were crawling off everywhere. <laugh>, I was so unprepared, you know, really sort of rabbit in a headlight student nurse. I was with my boss at the time I remember
putting them in a line on the floor and rubbing them like this with my arm all at the same time. And then obviously they were, they were doing great and then they started crawling off trying to find the
milk cart because you know, me at the time hadn’t got my box ready to put them in had I? Honestly, you live and learn. But a checklist back then would’ve been very helpful. <laugh> really.

Sophie Gilbert
I think that’s when us vets have an easy job if I’m really quite honest because especially if it’s a cesarean section because we get them out and then hand them over to the nurse or whoever’s
helping us and then, you know…

Lou Northway
“You like another one?” “No, not yet!” <laugh>. Yeah. Honestly. Yeah. Crazy. Where I live, we have mainly Labrador and Spaniels. So the Labradors can have large litters, but it’s not crazy – crazy, but in
your Vets Now cases you have quite a lot of brachycephalic’s don’t you? So they were quite highly represented in your audits. I wonder if we could just talk a little bit about those as well, because I’m sure this will be significant to a lot of people listening because they are very, very popular now, but often need help.

Sophie Gilbert
Yeah, definitely. So I think brachyephalics generally are overrepresented, like you say, in terms of breeds that need additional support when, when giving birth. French Bulldogs and Chihuahuas and those sort of breeds we’re the ones that definitely we tend to see the most commonly, that need assistance. Not necessarily always that need a cesarean section, but, you know, need support of some kind, whether it be medical or surgical. And generally the reasoning is that conformation. So it’s, you know, the bigger heads and the smaller pelvis essentially can often cause trouble when giving birth. I mean, I guess the important thing for us is that owners at home are able to recognize when support is needed and that’s what we are there for. So, you know, being able to call up and have a chat with us and we have got for our staff, telephone triage checklists and things that they
can go through that can help to decide when an owner needs to come down with their pet and when they need a little bit more support.

And it’s really important for us obviously, that the welfare of all of the animals is the most important. But yeah, it’s really that bit of, of getting owners to recognize when support is needed and being able to get them down to the clinic, to see us and, and get that support essentially.

Lou Northway
Yeah, and what you’re saying earlier as well about having sort of like the whole team on board, so getting the client care team in as well to know to ask the right questions, um, because sometimes there might not be a nurse available to speak to the client themselves, things like that. Super important. So I’m sure they were very grateful to be involved in the, the discussion and the troubleshooting around everything too.

Sophie Gilbert
Yeah, definitely. I think it’s, it’s really important that anybody front of house dealing with people calling in, asking questions about pets and able to understand the process, I guess from start to finish, not from a clinical perspective, but just understanding what the concerns are and what the worries might be. And of course, if anybody is ever worried, then it’s always best just to go down and, and see your vet and get an appointment and get things checked out as well.

I think involving the whole team, as you said was, was really important, to get everybody understanding how…I guess sometimes tricky, but yeah. Important these cases are from a welfare perspective.

Lou Northway
Yeah, no, absolutely. Um, I digressed then, getting excited about reminiscing on the old times <laugh>. But I wondered, can we go over a few of the other things that you audited more specifically where outcomes were in were improved as well? Maybe if we touch on the neonatal heart rate monitoring, because that’s very interesting.

Sophie Gilbert
Yeah, sure. So that for me was something from, on a personal level that I really enjoyed learning about during the audit because I think, again, like we said earlier, there’s not been a huge amount of evidence out there. So again, neonatal heart monitoring is something that’s done a lot in human medicine, and, you know, monitoring heart rate can indicate whether the baby is stressed essentially. Stress of the baby is one of the things that we use to tell us whether or not we need to get that baby out sooner rather than later essentially. And it’s the same with puppies and kittens.

Um, if we have a patient that presents to us, we as the veterinary team are the ones that are trying to make the decision as to whether this is something, you know, is the patient just in normal labor, are things progressing normally?

Or actually are the puppies stressed? Do we need to start talking about whether or not medical or surgical intervention is required? Um, so heart rate monitoring is something that we can use to help guide us on that. But I think the really difficult thing is, is there’s no, I guess no set guidance. One always heard that if the puppy’s heart rates were sort of less than twice out of the mother’s, then that was an indicator of stress. But I never really had any sort of firm idea. So I was able to put an ultrasound scanner on and think, okay, well I’ve got this number, I can count the heart rates, but I don’t really know what that means.

Um, so part of what we did was look at some of the literature
and create some guidelines for our teams around trying to give them some more objective areas that they could count those heart rates and say, right, okay, well if it’s in this area, we’re comfortable as long as, you know, all other things are going okay, it’s probably okay for now.
But if it’s less than this number, then maybe we want to intervene a little bit sooner.

One of the things we wanted to do was just to be able to give everybody the confidence to pick up the scanner, look for heart rates and puppies and kittens, count them, think about what that might mean for the patient, and use that with all the other information that they’ve got about the patient and the situation and the history and everything and be able to sort of come up with a slightly more objective decision. And we were really, really pleased that the amount of people across Vets Now using ultrasound scanning and recording foetal heart rates really increased quite dramatically. I don’t know the numbers off the top of my head.

Lou Northway
I’ve got them right in front of me here, <laugh> and a big part of your improvements was not just on your actual physical outcomes with your patients, but your record keeping teams got really, really
good at recording everything and making sure that everything got attached and put in the right place, which is another important part of QI. So, yeah, that was really good. Right. Let me just see if I can find it.

Uh, where are we? I highlighted so much this afternoon <laugh> because I was like, there’s so much I want to talk about. Um, we could be here till midnight. Uh, where was it? Um, oh gosh, now I can’t see where it was on my, the paperwork.

But anyway, it was, it was a massive jump in improvement and really impressive. Yeah. Really, really good. Um, so that was amazing. I wonder sort of how many people that are listening to this are doing that already in practice or whether it’s something they will now consider hopefully.

Sophie Gilbert
It’s really easy actually, isn’t it? It’s just having the confidence to start doing it. I think it’s definitely something that’s helped me work through my dystocia cases, my trouble giving birth cases and it’s a,
it’s something that I always try and do now for sure. Yeah.

Lou Northway
Yeah. It’s, yeah. Amazing. I mean, I said there’s so many points in here and good things that we could chat about <laugh>. Are there any other things that you re would just love to shout about that?

Sophie Gilbert
Have you got anything Lucy?

Lucy Leicester
Um, I think we’ve shouted about it. <laugh>. <laugh>,

Sophie Gilbert
Yeah. I think for me it was just the amount of teams, like I said, picking up things that perhaps they hadn’t been so confident to do before. So that Apgar scoring, the ultrasound scanning, using imaging all together. So actually, although we talk about ultrasound, scanning to monitor foetal heart rates using radiography to look at positioning, foetal positioning and things like that as well, that was something that teams became a lot more confident doing as well. So, um, I think the use of imaging was probably one of the, the biggest things. And, and that’s, you know, in terms of welfare for our patients, that’s what helps make us with decision making. You know, it builds that picture because that’s what, I guess that’s what you’re trying to do with any case, isn’t it?

When you first see any patient that comes into a surgery, you’re building a picture from what the owner tells you of the history, you examine the animal and then you start building that picture with whatever diagnostics it is that you need to do. So I think that imaging for us was kind of one of the real key focuses that we wanted our teams to be able to get confident using. So yeah.

Lou Northway
Yeah, like you say, a radiograph in a Chihuahua when you, you know, it’s maybe if it’s just one puppy, which it sometimes is, yeah. And you see this tiny little pelvis and then this big round domed head
that’s expected to come through <laugh>. So Yeah, and also drug usage as well, it was quite varied wasn’t it, between teams. So sort of standardizing that a little bit and adapting drug protocols improved outcomes as well.

Lucy Leicester
Yeah, I think we were really struck, weren’t we, given the licensing limitations for analgesia in pregnancy have, just have the degree of amazing pain relief that’s been given and multimodal analgesia, and we were really proud of what a good job our staff were doing in that regard.

Lou Northway
Yeah. So I mean, for years it was definitely something, wasn’t it? That was sort of everyone worried about the risk to the puppies if we were giving particular drugs and timings as well. So giving your team support on when it would be appropriate, when it would not be appropriate, takes away the anxiety. Because I still think that’s something that everybody does worry about. Yeah. Fantastic. And
the other thing I wanted to mention as well is about technique of managing the puppy. So, no longer swinging the puppies because that’s now known to be an outdated technique, and that was certainly
something I did back in the day. I think, well if I had time with those 15, I’m not sure I had time to swing any of them, but <laugh>, um, yeah, certainly something that I have seen in previous years
too.

Sophie Gilbert
Yeah, absolutely. It was something I was definitely taught as well. And I think it’s just really fascinating the amount of new research that comes out about these sorts of things, but again, it’s getting it across and getting it into practice, and understanding what we can do instead. I think as well, that’s the thing. So, um, we went out with some support, some guidelines for neonatal resuscitation, and we’re sort of able to say, well, okay, this is something that’s sort of perhaps a little
bit outdated now, but these are the sorts of things that you can do. And again, sort of talking about the Apgar scoring was all part of that whole part of it as well. So yeah, when you said we went off on lots of tangents, we definitely did <laugh>, it started off just being sort of like the actual trouble giving birthing and then it’s developed into to all sorts of different things. Yes. Which has been really exciting. <laugh>,

Lou Northway
You know, it’s so, it’s just so comprehensive and yeah, like every single procedure we do in practice, you could build <laugh> a similar like web of QI around it, couldn’t you? So I hope everyone listening
gets inspired to start their own projects. Yeah. And get on board theQI bus, as I always say, <laugh> and I hope to receive your award nominations next year, <laugh>. And I can’t wait to see what you
guys are going to do next. Can we know a little bit about what you might be working on at the moment? Or was it top secret <laugh>?

Sophie Gilbert
Oh no. Top secret. I mean, you’ve already said it actually for me. So in my current job at Vets Now, I now mainly work from home, and like I said, I’m part of the team that we are responsible for clinical
and professional standards, but QI is an absolutely massive part of that. And for me, one of my biggest sort of goals I guess of the year would be to see our teams having the confidence to do their own kind of clinical audits and their own little QI projects and things like that.

Yeah. We’ve got amazing things going on across the company, and people come to us with their projects and things all the time, which is just so exciting to see and I’d love for more and more teams just to just have the confidence to do that.

So again, one of the things that, that actually came out of this sort of writing this paper accidentally, it wasn’t planned from the start, but one of the things that came out of it was us building like a little
infographic and a support thing for doing a clinical audit in practice. So what we’re really hoping is that our teams feel inspired and want to go and think, oh yeah, I want to go and look at the last 10 cases that I saw with this or whatever and start doing it themselves and sharing what they’re doing as well.

Um, so whilst that’s not, you know, a central thing, I think that would just be so exciting if we can inspire that in, in all of the individual clinics and teams across the company.

Lou Northway
Yeah. All the time I have little conversations with my team and they’ll be like, oh, well Lou, I think we should do this, or can we try and improve this? I’m like, well we need to measure it first, don’t we?
<laugh> <laugh>.

So, yeah, I think there’s a bit of a, it’s a movement, isn’t it? And I feel like everyone is going with it now and it’s really exciting because I do think it really revolutionizes how you view your everyday work, when things don’t go so well QI helps you process them, manage them together and work through them and you don’t feel like you’re on your own anymore. And that team chat is just absolutely invaluable.

Sophie Gilbert
Yeah. Yeah. And I think it also really helps you see where things have gone well as well because, I mean, I don’t know about others, but I’m definitely always quite critical. So I always remember the things that perhaps weren’t so positive, but actually 99% of things that you do in a day did go brilliantly and went perfectly fine. And, and it’s, I think, can really help you to process that as well and remind you that actually all of those things went really, really well, I think it’s really good for that
as well.

Lou Northway :
Yeah, I really celebrate things when they go well and you make improvements, even if it’s like 1% improvement, it’s still an improvement <laugh>. Yeah. Um, did you encounter any problems along the way, because it’s such a big project, like were there any bumps in the road that you had to navigate?

Sophie Gilbert
I think just the volume of data. What would you say?

Lucy Leicester
Just, yeah, getting the… we crafted an enormous Excel spreadsheet to collect data and fine tuning that and getting it to work was a challenge. There were several kind of cells that we put menus and dropdown menus and various conditional formatting which turned out to be not very helpful for the auditors. So we had to remove it, you know, technical details that we had to tweak, but generally speaking I think we just learned as we went along and I mean the main thing was we had people wanting to help and be engaged and that was just fantastic. So it kind of grew legs and gathered momentum.

Lou Northway
Now have you all got the same computer systems or do you have slightly different types? Or is it all like integrated? Can you collect data quite easily?

Lucy Leicester
Yes. We’ve got access to the practice management system so we can access that remotely. Yeah.

Sophie Gilbert
And I think we’re really, really lucky actually, one of the things…because we have a bespoke system for Vets Now, one of the positives about the system is that it is built around coding, so we’re, we’re
able to sort of collect that data a little bit easier, I guess. So that’s a benefit for us within Vets Now, we’ve got that volume of data there because we’ve got all of those practices that are automatically
putting that data in. I guess I wouldn’t say it’s easy, but it’s relatively easy to try and pull that data out. Yeah.

Lucy Leicester
Yeah, it’s good.

Lou Northway
I’m sure some people that were listening just then would be like, oh my gosh, coding is hard, I can’t do that <laugh> but my advice would be to talk to whoever it is that makes your computer software
and just see what it can do because the one that I use is quite easy, much easier than I thought it was going to be and you don’t even have to use computer software to collect data if your system isn’t set up. For example, some of the first audits that I did was just on pieces of paper on my prep room wall, literally probably not GDPR compliant now if I’m honest, things have improved there, but you know, it’s as simple as that, when you want to start collecting and have a new look.

So I don’t want anyone listening to be put off by thinking you have to use a computer, but it does help. And certainly, Excel is not my friend. I probably need to do some CPD on that this year. <laugh>.

Lucy Leicester
Yeah.

Sophie Gilbert
I think that would definitely be one of my biggest sort of, I guess, pieces of advice, like Lucy said, we learned so much as we went through the process, but also it grew massive arms and legs because of the fact that we did have to benefit that we were able to collect so much data, but actually, just keep things simple, you know, like an audit is still an audit if you do it on five cases, it’s, you know,
it’s what matters for you and your cases in practice. It’s not about collecting…, you know, if you want to write a paper and, and all of that sort of thing, I guess it is about collecting statistically significant
information and stuff.

But if you are doing it to see where you are at now and what you’re doing in practice and what things you can put in place to change what you’re doing in practice, if that’s what you need to do, then yeah, it doesn’t, like I said, it doesn’t need to be complicated. It doesn’t need to
be done on Excel. It doesn’t need to be done through the practice management system. So yeah, definitely I would agree with that.

Lucy Leicester
Yeah. Yeah, you could just use the next 10 cases that come through the door, couldn’t you? And that would be absolutely brilliant.

Lou Northway
Yeah, absolutely. I mean, don’t get me wrong, Lucy, I would like to have you in my life at work <laugh>. So that would be great <laugh>. It would make my life so much easier. Vets Now are very lucky to have you both, because, your whole team is amazing, but it’s such an influential project which is going to benefit dogs and teams for years and years to come. And the wide profession too, I think when they have a read. So your project is available to read in full on the link on the screen, which has been up the whole time. And the checklist we’ve discussed are available to download as well.

So I hope everybody thinks about doing that. And if you are also thinking about doing an audit and you don’t know where to start, on the RCVS Knowledge website, we have everything you could
need and more. My top recommendation, if you want to start auditing and you’re in primary care, is start with your neutering patients. We’ve got a walkthrough, we’ve got a spreadsheet you can
download, which works out all the crazy calculations for you and you just have to fill in the boxes. What more could you want? <laugh>,

And the team at RCVS Knowledge are also always here to help. So if you have any questions or you want some advice, please reach out to us. I just want to say thank you so much ladies for joining me tonight. I’ve thoroughly loved firstly reading your submission and also just chatting to you about it now. And I can’t wait to see what you and the team we’re going to do next.

Lucy Leicester
Thank you

Sophie Gilbert
Thanks. Really, really fun tonight. Thanks Lou.

Lucy Leicester
I think we’ll be auditing some more dystocia cases next.

Lou Northway
Yeah, well it’s an ongoing process, isn’t it? So it’s like, what, what are you going to improve next? <laugh>

Lucy Leicester
Watch this space.

Lou Northway
Yeah, it’ll be really interesting to see over the next couple of years how, sort of, favored breeds change and whether that will influence how many dogs are coming through the door for c-sections as well. Well thank you so much ladies, it’s been great speaking with you and we hope to see you again for our next Knowledge Natter soon. At RCVS Knowledge, we open our awards at the end of this year. So if you’ve already been doing QI in practice, no matter how big or small your project may be, please send them on in, we’d love to read them and good luck. But anyway, that’s all from us for now. Take care.

RCVS Knowledge
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