Update on the RCVS Knowledge Canine Cruciate Registry – One year on

RCVS Knowledge:
This podcast was recorded for the first anniversary of the RCVS Knowledge Canine Cruciate Registry, a database of information about cruciate surgery in dogs across the UK.

Pam Mosedale:
Hi everyone. This morning, I’m going to talk to Mark Morton. If you remember, last year I talked to Mark about the very exciting Canine Cruciate Registry, and I promised I’d get back to him and see how it was going. Morning, Mark.

Mark Morton:
Morning, Pam. Thanks for having me back. I wasn’t sure whether it was a real invitation that you would want me back, but I’m very glad to be here.

Pam Mosedale:
Good. So how is it going with the cruciate registry?

Mark Morton:
Well, really good I think, but I’m of course slightly biased. We’ve been live for nearly a year now. So we started end the July, beginning of August last year, allowing vets to enrol and put cases on. And it’s
been a really promising start. Vets and owners both seem quite enthusiastic about it. So yeah, we’re  pleased with the progress so far.

Pam Mosedale:
And how many vets have actually registered onto the registry or are submitting data?

Mark Morton:
So we’ve had a bit of a look at early data from the registry as a whole. We’ve not done any stats on any of this that we might talk about yet, that’ll come in our annual report. But, for interest more than
anything, to last week, we’ve had about 270 vets sign up for the registry, which was more than we anticipated in the first wave. The interesting thing is that whilst we’ve had that many sign up to get
involved, only about a third of vets that have registered are regularly putting cases on.

Mark Morton:
So that’s our next area of focus is engaging with those vets who were interested enough to sign up, but maybe haven’t taken that next step and started using it with their clients. We’ve got a similar number of
what we call delegates, so they might be varied nurses, administration staff in the practice who can access your accounts and help manage putting surgical reports on, help with owner engagement,
checking they filled out the right things and so on. So yeah, from a numbers of people getting involved, we’re pleased.

Pam Mosedale:
Excellent. And are they all … I mean, you yourself, I forgot to introduce you, Mark, but I’m sure everybody knows you’re an orthopedic surgeon. A referral orthopedic surgeon. Are most of those vets
referral orthopedic surgeons?

Mark Morton:
So this was something that we were asked about when we were launching this project, was this just a project for specialists who were doing cruciates?

And it’s certainly not that at all. The cruciate registry’s open to any vet in the UK performing any procedure. And my thoughts were really that it would interest vets across the profession. What the early data shows is about two thirds of the vets who are putting cases on are advanced practitioners. And that’s not really surprising, because you’d imagine that lots of vets who are doing cruciates would have an interest in orthopedics and might have taken that next step along the training pathway. About 20% of people don’t have any additional qualification and only about 15% of specialists. And I think that’s the one area where we need to focus, is on getting more specialists
involved because they will be performing a large number of cruciate surgeries. And that data is important.

Pam Mosedale:
Excellent. Well, that’s great that you’ve got such a wide spectrum of people though, I think. So nobody should worry about joining in this if they’re not a specialist, orthopedic surgeon. It is for everybody who
does cruciate repair. But why do you think some of them have registered, but haven’t taken the next step?

Mark Morton:
I ask this question every time I talk about it. So I tend to ask people for a show of hands or we do a vote on who thinks the cruciate registry is a good idea. And almost universally people say they think it’s a
good idea.

And by the end of a talk about the registry, almost everybody says, “Yes, I’m going to get involved. This is really good.” So we then ask, “Well, what are the barriers that you haven’t? Or the reasons why you haven’t got involved yet?” Sometimes people worry about anonymity. So what’s going to happen to my data? Who’s going to be able to see it? And again, I’d want to emphasize that this is completely anonymous. You can see your cases, nobody else can, if that makes sense. So an owner can’t go on and look up your results.

Mark Morton:
You can join with colleagues in your practice and share data through what we call a common delegate, but it is anonymous once all the data’s submitted. So nobody’s going to publish your results elsewhere.
And the other perceived barrier is time, really. And I suppose time along every step of our workflow, so how long does it take to talk to owners about this? Now, I do appreciate when I say this, that I am in a
slightly privileged position being a referral surgeon and that I get 45 minutes for my consults, not 10 or 15.

But this adds probably a minute and a minute and a half to the end of my conversations with owners. So once they’ve decided that they’d like to proceed with surgery for treatment of a cruciate rupture, and we’ve done all the consent and everything, I’ll just say to people, “Just one other thing that I’d like to ask you, we’re involved with this project, the Canine Cruciate Registry.”

Mark Morton:
Tell them briefly about its aims to collect data that will help not only their dog and let us track its progress, but all dogs having cruciate surgery in the future. I let them know that all I need for them to
sign up is agreement to submit their email and they’ll be sent more information by email. I let them know that, at that point, if they decide they don’t want to take part, they can not proceed any further.

And I haven’t had a single client say no. There’s a little frequently asked questions information sheet available on the cruciate registry website, which you can print off as a PDF, and I give that to owners so
they’ve got something to take away that reminds them about it when they get the email. And as I say, everyone’s agreed to take part. The vast majority fill out the email when they get it. I can think of one or
two, maybe, that haven’t wished to proceed further.

Mark Morton:
When you ask them about it, it’s normally they forgot rather than they don’t want to. And then the second part of that is vet’s feeling, how long is it going to take me to put cases on? Well, actually, that’s
really easy as well. So once the owner’s completed their initial baseline assessment and registered, all you need to do is log into your portal on the registry, complete your initial vet assessment, but it’s all
click boxes. So, how lame was the dog? You don’t need to type anything in, you just select things, all its clinical signs. And then the most important thing is complete your surgical request form. Now that
changes for every procedure you do, but if you’re a creature of habit, like me, and you only do really one procedure, you can set up a default. So we really, here, only use one type of implant.

Mark Morton:
So all I have to do is say I want my default TPLO template. It brings up the plate that I normally use, all I have to do is select size, briefly select what you did, did it have a meniscal tear? But it’s all one box to
select things and off you go. And with that surgical report form, you can put in or complete as much or as little as you want. So if you want to record the length of every single screw you put in, that’s absolutely fine. You can do that. If you just want to say I did a TPLO or I did a TTA or did a lateral suture, the dog had a meniscal tear, that’s it. You can be as in depth or not as you like. But that’s where the delegates come in as well, that you can get your nurses to help you fill that out when you’re suturing or whatever it may be. Yeah, so it’s really not as time consuming as people think. And once you get into it, it’s really easy to do.

Pam Mosedale:
That’s interesting. I was going to ask you whether, that you could use the delegates to fill in some of that information. Because I think probably nurses would be a heck of a lot more efficient at doing that
routinely in some practices than some of the vets might be.

Mark Morton:
100%. Yeah, absolutely. And what we have found is, as well, engaging in the members of your team. So members of the administration staff, nursing staff with this project, they’re almost as enthusiastic as the
vets are about wanting to get involved and collect this data.

Pam Mosedale:
That’s really interesting about reception team, because presumably they could be talking to owners about it when they’re sitting, waiting in the waiting room. And so, including them. I mean I think for all
quality improvement activities, it’s so important to include the whole team, but this is another example where involving reception will be so powerful, I think.

Mark Morton:
Yeah, absolutely. And I think the more projects I’ve done around outcome assessment and things, you realize that engaging the whole team has such value to the projects but also to people’s enjoyment of
their job.

Pam Mosedale:
Absolutely, yeah.

Mark Morton:
It’s not just about answering the phone or booking an appointment, it’s getting the whole team involved with the care of that patient. And the more they know about what goes on out of reception and things,
the more they can advise clients who … We’ve had our, I’m going off topic here, but we’ve had our admin teams spending time with us in theater. And it makes such a difference because they know when
an owner phone’s up and says, “Oh, how is my dog doing with its procedure today?” They can say, “Don’t worry. Everything will be going absolutely fine. They’ll call you when they’re done.” But they have
that knowledge of being there and knowing what’s going on, they’re not making it up it.

Pam Mosedale:
No. And taking, still off topic, have you done it the other way around and put the orthopedic referral surgeons on the reception desk?

Mark Morton:
Can you imagine what would happen if I spent a day on the reception desk?

Pam Mosedale:
But yes, I think knowing how other people’s jobs work is important. And as you say, it makes the whole practice into a whole team, doesn’t it?

Mark Morton:
Absolutely. I mean, that was one of the good things about, if there was any good things, but COVID and the changes that we had to work in that early phase. It meant a lot to people who were doing lots of
different things that they wouldn’t normally do. And I certainly learned a lot about how our appointments were booked, how we engaged with clients, how our insurance process worked, because
we had to.

Pam Mosedale:
Yeah. And that’s right, vet’s having to work blood machines and things like that, nightmare. But I was also really interested in what you said about the clients, and I talked to Ross last year as well, up in Scotland, and he said he hadn’t had any clients not want to join in. I think doing it for the good of all other dogs is a powerful force, isn’t it?

Mark Morton:
Yeah, absolutely. We’ve got nearly 350 patients on the registry now. So that’s a really good number and that equates to about 3000 forms being filled out by owners, which is vast number, really, when you
think about it. But we chat to a lot of our human colleagues before we got this up and running, because they’re a bit ahead of us on the outcome assessment front. And one of the things that they said was,
that they quite often say to people, “Well, look, surgeons can’t phone you every day and ask how you’re doing. But if you are filling out these follow up outcome measures, assessing your current condition, or
in this case, assessing your dog’s current condition, they’ll see those scores as they come in.

And if something looks out of sync with where it should be, it’s a way that they can monitor the progress of your dog and get in touch if they need to.” So the cruciate registry certainly doesn’t replace owners
needing to phone up their vets and say, “Look, my dog’s got a problem.” It’s not the only means you can report an issue, or the way you should, it’s just an extra level on there, really, to be able to track
progress and spot something that might be not as it should be.

Pam Mosedale:
And another thing that occurred to me is this is a really powerful way for vets to be able to fulfill their clinical audit responsibilities. Or general practices. Veterinary hospitals and practice standards now all
have to participate in clinical audits, so this is one way to get involved.

Mark Morton:
Yeah, definitely. And one of the most powerful things about the portal, which, it’s run by a company called Amplitude Clinical Outcomes, you’ve got loads of experience with this on the human side. But
their reporting functionality that’s built into the registry is so powerful, there’s a dashboard report that we’ve written so everybody can easily see what we think they want to see. So number of procedures you’re doing, complications, outcomes, et cetera, et cetera.

Mark Morton:
But you can report on anything that you want. Of the data that’s in there, you can write your own reports and if anybody’s like me, tried to do clinical audit by using a antiquated PMS system that’s not
really up for the job, that’s one of the barriers, isn’t it, that that stops you doing it. It’s actually not very easy to get the information out. So I imagine loads of people are keen to do audits, but start and think,
oh, I just haven’t got time to delve through all these cases.

Pam Mosedale:
Anything that makes it simple for people and makes it, because it’s not … And collecting the data is the important thing, but then what they do with it is the next important thing with audit, obviously, and
whether they need to make any changes. But if they’ve got their data collected in a very user friendly, easy way, then that’s going to be really helpful to them, I would have thought.

Mark Morton:
Yeah, I agree, 100%. And that’s what we’ve tried to do, is build something that people can use in whatever way they want. So certainly we’ll analyze the data centrally and we’ll produce reports on that.
But one of the most interesting things that might come out of the cruciate registry is what people find out themselves. So somebody might run a report, I don’t know, looking at a type of procedure with a
type of breed in their cases. And actually, we might all learn something from that, that one particular procedure is better with a particular breed. I don’t know, that’s an example off the top of my head, but it opens up the door to so much opportunity for audit.

Pam Mosedale:
Absolutely. And was there any data, I know you said there’s going to be a report later, but do you know, predominantly, which breeds have had their procedures reported through the registry?

Mark Morton:
Yeah, so it’s as you’d expect, really. So the most common breed on there so far is a Labrador. There’s some Spaniels on there. Interestingly, breeds that we associate with cruciate ruptures, so for example, Rottweilers and Newfoundlands, they’re actually quite low down on the list. And it’ll be interesting to try and work out that because there’s less of those really large breed dogs around, compared to Labradors and French Bulldogs, Pugs, that are becoming more popular. Or is that a change in the prevalence of cruciate disease in those breeds? And it’s probably the former, that there’s the breeds that we commonly see a shifting, as we know.

Pam Mosedale:
But eventually you’ll be able to know that, rather than us just assuming that that’s the case.

Mark Morton:
Yeah, absolutely, we’ll be able to pull all that data out.

Pam Mosedale:
So what would be your message, then, to anyone who hasn’t registered or hasn’t submitted any cases yet. Who’s interested or does cruciate repair?

Mark Morton:
If you haven’t signed up already, sign up now. This is really good for your patients and for your clients. The only other thing that’s on there that we haven’t talked about is, there’s a built in owner survey. So
an owner satisfaction survey, similar to a friends and family test. If you want to do that yourself and run that survey out of your clinic, for all your patients when they’ve gone home, it’s really, really expensive
to do that. Or time consuming, if you’re contacting owners individually. The Cruciate Registry does that for you. And we ask them, would you recommend the hospital?

At four weeks we asked, would you recommend the surgeon and what your experience with the surgeon is. And the same with the procedure. And overwhelmingly, across the registry, it’s positive. So when you look at the figures about recommending hospitals, surgeons, and the procedures, it’s all really good. Ross Alan, who you chatted to, I know he did a really good project called, I think it’s called TPLO To Go, where he did this himself.

And I think he was highly commended in the RCVS Knowledge Awards for that project. But it’s really good because you can use that as a marketing thing. It’s fine for you to say, look, 97%, 99% of my
patients, their owners are satisfied with the procedure they had.

They’d recommend it. So there’s so much in there to do that. And the second part is, if you’ve signed up but you haven’t put any cases on
yet, join one of our online training sessions. So we run these quite regularly. It’ll take half an hour of your time. We alternate between afternoons and evenings, but we keep them to about 10, 15 people.
I’ll just show you, look, this is how you put a case on, this is how you fill out this form, this is how you do this. Just on a Zoom call. The mics are open so you can ask questions whenever you want. It’s pretty relaxed. But if that’s the barrier, just don’t quite know what you need to do, we run those sessions really regularly and I’d encourage you to join.

Pam Mosedale:
That’s a great idea. How can they find out about those? Are they advertised on our Knowledge website?

Mark Morton:
Yeah. So they’re on the website and everybody who’s registered … So the registry will receive an email when those sessions are scheduled. So every one we’ve done has been full, so we try and do them as
regular as we can, but when you see one advertised, sign up because they do fill up quickly. And it’s not something that we want to have 50, 60 people at. It’s really informal so you can ask a question if you
need to, and the approach is there’s no stupid questions.

Pam Mosedale:
Okay. And are they for delegates as well? Not just for the surgeons?

Mark Morton:
Yeah. Anyone can join those, that’s absolutely fine. It’s important that everybody sees how it works. And I’m sure there’ll be lots of admin staff and nursing staff who are the ones that drive this for the more
stubborn vets in our profession who won’t get involved unless they’re dragged along. So we encourage everyone to get involved.

Pam Mosedale:
Excellent. Yeah, I mean to me, I can’t see why you wouldn’t. I mean, if you were performing cruciate surgery, why wouldn’t you want to know about all this and how your results fit in? And I think it’s even
been looked at in human healthcare, hasn’t it? Didn’t you have a presentation at a conference recently? A human healthcare conference?

Mark Morton:
Yeah, so we submitted an abstract to the National Patient Reported Outcome Measures conference, which is a annual human thing. And there was a poster that was an online event for a couple of days,
but they’re really interested in what we do because one of the … They’re further down the line with assessing outcomes in this way, but one of the things where we can share knowledge with them is the
proxy completion of outcome measures. So for children who can’t complete these things themselves or people with mental health issues, for example. We only have a proxy model for completing these forms
because dogs aren’t very reliable in completing these questionnaires, in my experience. So there’s lots of sharing of knowledge there both ways that, I think going forwards, will help both human healthcare an
veterinary healthcare.

And although we’re behind with the numbers of these initiatives we have, we’re certainly catching up.

Pam Mosedale:
Absolutely. And we can learn, sometimes, from things of theirs that don’t work, can’t we? But that’s really one health, isn’t it? That’s fantastic. So, yeah, I mean, I can’t see why somebody wouldn’t want to,
because it’s there and it’s free, isn’t it? That’s the other thing?

Mark Morton:
100% free for vets and owners. I’m not going to say it doesn’t take any time, but it really doesn’t take long at all. It doesn’t add a lot to what you’re doing. And I think that the only hurdle is signing up and
putting your first case on. And once you’re up and running, it’s really intuitive as to how you use. It’s designed to fit into everybody’s workflow in that, it’s very flexible in how you use it day to day. So you
just need to work at how it fits into the way you can consult and operate and so on. But there’s loads of people using it who work in very different ways to how I work, for example, from a timing of consults and surgeries. So get involved, give it a chance. If there’s something on there that you don’t like, or you think we should have, just let us know because we welcome feedback to improve the experience for all our users and owners.

Pam Mosedale:
And there it is, quality improvement working. Because it’s improvement, it’s learning for the team, and it’s improvement in outcomes and in patient care, isn’t it?

Mark Morton:
Absolutely. And I hope that as we get more cases on there we can demonstrate, with the data, that we are improving outcomes and reducing complications for our patients with cruciate ruptures.

Pam Mosedale:
Thanks, Mark, that’s been amazing.

Mark Morton:
Thanks for having me back, Pam, and I look forward to seeing you this time next year for our next update.

Pam Mosedale:
Absolutely.

RCVS Knowledge:
For more information, and to sign up for the Registry, visit caninecruciateregistry.org.