Paediatric Day Case Tonsillectomy - Audit of a New Programme

Aims The primary objective of this audit was to assess 30-day unplanned admission or readmission rates following day case tonsillectomy. Secondary objectives included assessing demographic characteristics of patients and surgical and anaesthetic techniques employed. Methods Retrospective chart review was performed. Results 34 tonsillectomies or adenotonsillectomies were performed for children aged between 5 and 17 years. A total of six patients (17.6%) were either admitted from the day ward or readmitted within 30 days. This was not statistically significantly greater than the maximum acceptable rate of 15% as recommended by ENT UK and the Royal College of Surgeons (95% confidence intervals 4.8% - 30.5%, p = 0.33). Of these admissions, one (2.9%) was due to nausea and inadequate oral intake, one (2.9%) was due to clinical concerns regarding sleep apnoea and four readmissions (11.8%) were due to bleeding. Anaesthesia techniques used varied considerably. Conclusion Further multidisciplinary co-operation and standardisation of care may help to improve this programme and reduce unplanned admission and readmission rates.

Pharmacist-led therapeutic carbohydrate restriction as a treatment strategy for type 2 diabetes: the Pharm-TCR randomized controlled trial protocol

BACKGROUND

The current treatment paradigm for type 2 diabetes mellitus (T2D) typically involves use of multiple medications to lower glucose levels in hope of reducing long-term complications. However, such treatment does not necessarily address the underlying pathophysiology of the disease and very few patients achieve partial, complete, or prolonged remission of T2D after diagnosis. The therapeutic potential of nutrition has been highlighted recently based on results of clinical trials reporting remission of T2D with targeted dietary approaches. During the initial phase of such interventions that restrict carbohydrates and/or induce rapid weight loss, hypoglycemia presents a notable risk to patients. We therefore hypothesized that delivering very low-carbohydrate, low-calorie therapeutic nutrition through community pharmacies would be an innovative strategy to facilitate lowering of glycated hemoglobin (A1C) while safely reducing the use of glucose-lowering medications in T2D.

METHODS

A community-based randomized controlled trial that is pragmatic in nature, following a parallel-group design will be conducted (N = 200). Participants will have an equal chance of being randomized to either a pharmacist-led, therapeutic carbohydrate restricted (Pharm-TCR) diet or guideline-based treatment as usual (TAU). Pharm-TCR involves a 12-week very low carbohydrate, calorie-restricted commercial diet plan led by pharmacists and lifestyle coaches with pharmacists responsible for managing medications in collaboration with the participants' family physicians. Main inclusion criteria are diagnosis of T2D, currently treated with glucose-lowering medications, age 30-75 years, and body mass index ≥ 30. The primary outcome is a binary measure of use of glucose-lowering medication. Secondary outcomes include A1C, anthropometrics and clinical blood markers.

DISCUSSION

There are inherent risks involved if patients with T2D who take glucose-lowering medications follow very low carbohydrate diets. This randomized controlled trial aims to determine whether engaging community pharmacists is a safe and effective way to deliver therapeutic carbohydrate restriction and reduce/eliminate the need for glucose-lowering medications in people with T2D.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03181165. Registered on 8 June 2017.

Faculty Perceptions of Entrustable Professional Activities to Determine Pharmacy Student Readiness for Advanced Practice Experiences

Objective. To quantify pharmacy faculty members' perceptions of the importance of entrustable professional activities (EPAs) and the expected level of entrustment that should be achieved to determine APPE readiness. Methods. Entrustable professional activities define the core skills and tasks expected of new pharmacy graduates and may serve as a logical framework for determining pharmacy student readiness to begin advanced pharmacy practice experiences (APPEs). A five-question survey was distributed to all faculty members, staff members, and administrators at Ferris State University College of Pharmacy. Respondents were asked to rate 18 statements mapped to 12 EPAs on the perceived importance of each statement and the expected level of entrustment students should achieve to determine readiness for APPEs. Thresholds were used to determine consensus for importance and level of entrustment for each statement. Results. Of the 44 faculty members surveyed, 28 (63.6%) responded. A strong consensus was reached on the level of importance for 16 of 18 statements (89%), while two statements demonstrated moderate consensus (11%). No strong consensus was identified on levels of entrustment. Seven (39%) of 18 statements demonstrated moderate entrustment consensus and 11 (61%) statements demonstrated little consensus. Conclusion. Strong consensus was identified regarding which EPAs are important to determine students' APPE readiness; however, no strong consensus was found when evaluating levels of entrustment. Lack of consensus regarding entrustment raises several questions that require further study and clarification as the implementation of EPAs continues throughout the Academy.

Estimating the public health impact of a national guideline on cervical cancer screening: an audit study of a program in Campinas, Brazil

BACKGROUND

A Brazilian guideline on cervical cancer screening was released in 2011. The objective was to verify changes in screening indicators around this period.

METHODS

An audit study which sample was all screening tests performed by the public health system of Campinas city from 2010 to 2016. Variables were absolute tests numbers, excess tests, intervals and results, by age. For trend analysis was used Cochran-Armitage × 2 and linear regression.

RESULTS

Were carried out 62,925 tests in 2010 and 43,523 tests in 2016, a tendency at a reduction (P = 0.001). Excess tests were higher than 50% over the years, with a tendency at a reduction (P < 0.001). Tests performed on women under 25 ranged from 20.2 to 15.4% in the period (P < 0.001), while in the 25-64 years age-group, it ranged from 75.1 to 80.2% (P < 0.001). In 2010 the most frequent interval was annual (47.5%) and in 2016 biennial (34.7%). There was a tendency at a reduction in the proportion of tests performed at the first time and those with an annual interval (P < 0.001), and also a tendency at an increase in tests with intervals equal to or greater than biannual (P < 0.001). We observed a tendency at a reduction in LSIL and HSIL-CIN2 results (P = 0.04 and P = 0.001, respectively), and a tendency at an increase in HSIL-CIN3 result (P = 0.02).

CONCLUSION

The proportion of cervical cancer screening tests performed out of the recommendation showed a significant reduction in the period. This indicates a tendency to align cervical cancer screening in Campinas with the standards recommended.

The Effects of Environmental Factors on the Efficiency of Clinical Commissioning Groups in England: A Data Envelopment Analysis

Clinical Commissioning Groups (CCGs) were created in 2013 to make the NHS more responsive, efficient and accountable. A large number of different indicators can be used to measure the quality and outcomes of services provided by CCGs, however there is currently no single measure of overall efficiency available. The performance of CCGs may also be confounded by environmental factors such as deprivation, population size and burden of disease. Data Envelopment Analysis (DEA) is a linear programming technique that can be used to measure the relative efficiency of a given set of organisations. To use DEA to measure the efficiency of English CCGs and assess the impact of environmental factors. This study estimates the technical efficiency of 208 CCGs in England using DEA. The inputs and outputs used include budget allocation, number of general practitioners, mortality rates, patient satisfaction and Quality and Outcomes Framework achievement scores. Regression analysis is used to assess the effects of environmental factors on efficiency, such as population size, prevalence of disease, and socio-economic status. Twenty-three percent (47/208) of CCGs were efficient compared to the others. Three environmental factors were statistically significant predictors of efficiency: CCGs with smaller population sizes were more efficient than those with larger ones, while high unemployment rates and a high prevalence of chronic obstructive pulmonary disease led to a decrease in efficiency scores. Comparative deprivation was not a significant predictor of efficiency. The finding that the relationship between deprivation and efficiency is not statistically significant suggests that NHS England’s adjustment for environmental factors within the CCG-level budget allocation is broadly successful. This study shows the potential of DEA for assessing technical efficiency at CCG-level in the English NHS.

The development of entrustable professional activities for internal medicine residency training: a report from the Education Redesign Committee of the Alliance for Academic Internal Medicine

PURPOSE

The Alliance for Academic Internal Medicine charged its Education Redesign Committee with the task of assisting internal medicine residency program directors in meeting the challenges of competency-based assessment that were part of the Accreditation Council for Graduate Medical Education's (ACGME's) Next Accreditation System.

METHOD

Recognizing the limitations of the ACGME general competencies as an organizing framework for assessment and the inability of the milestones to provide the needed context for faculty to assess residents' competence, the Education Redesign Committee in 2011 adopted the work-based assessment framework of entrustable professional activities (EPAs). The committee selected the EPA framework after reviewing the literature on competency-based education and EPAs and consulting with experts in evaluation and assessment. The committee used an iterative approach with broad-based feedback from multiple sources, including program directors, training institutions, medical organizations, and specialty societies, to develop a set of EPAs that together define the core of the internal medicine profession.

RESULTS

The resulting 16 EPAs are those activities expected of a resident who is ready to enter unsupervised practice, and they provide a starting point from which training programs could develop assessments and curricula. The committee also provided a strategy for the use of these EPAs in competency-based evaluation.

CONCLUSIONS

These EPAs are intended to serve as a starting point or guide for program directors to begin developing meaningful, work-based assessments that inform the evaluation of residents' competence.

Admission and discharge practices: High Dependency Unit audit outcome

This paper presents the findings of a retrospective audit of admission and discharge practices of a nurse led High Dependency Unit (Nurse Specials Unit) in Perth, Western Australia. The aim of the study was: to review the effectiveness of the inclusion and exclusion guidelines for patients admitted to the Nurse Special Unit (NSU); to identify characteristics of admitted patients; and to determine the level of adherence to admission protocols for documentation of patient condition, plan of care, medical and Clinical Nurse Consultant review. The sample comprised all patients admitted to the NSU from September 2004 - March 2005, excluding those (50) in the pilot study (n = 154). This audit revealed patients were primarily elderly and admitted for close nursing supervision. Inclusion and exclusion criterion were adhered to, however documentation of patient data, in relation to current status and plan of care, was poorly completed and frequently absent during intra hospital transfer. This lack of clear documentation poses a significant risk to the patient. Further research is required to determine strategies that result in appropriate and useful transfer documentation. In addition, the content of transfer data that permits continuity of care needs to be determined.

Audit uncovers weak skill mix

More than a quarter of hospital wards in Wales do not have the nursing skill mix recommended by the chief nursing officer, according to an audit.

Associations between the organisation of stroke services, process of care, and mortality in England: prospective cohort study

OBJECTIVE

To estimate the relations between the organisation of stroke services, process measures of care quality, and 30 day mortality in patients admitted with acute ischaemic stroke.

DESIGN

Prospective cohort study.

SETTING

Hospitals (n=106) admitting patients with acute stroke in England and participating in the Stroke Improvement National Audit Programme and 2010 Sentinel Stroke Audit.

PARTICIPANTS

36,197 adults admitted with acute ischaemic stroke to a participating hospital from 1 April 2010 to 30 November 2011.

MAIN OUTCOME MEASURE

Associations between process of care (the assessments, interventions, and treatments that patients receive) and 30 day all cause mortality, adjusting for patient level characteristics. Process of care was measured using six individual measures of stroke care and summarised into an overall quality score.

RESULTS

Of 36,197 patients admitted with acute ischaemic stroke, 25,904 (71.6%) were eligible to receive all six care processes. Patients admitted to stroke services with high organisational scores were more likely to receive most (5 or 6) of the six care processes. Three of the individual processes were associated with reduced mortality, including two care bundles: review by a stroke consultant within 24 hours of admission (adjusted odds ratio 0.86, 95%confidence interval 0.78 to 0.96), nutrition screening and formal swallow assessment within 72 hours (0.83, 0.72 to 0.96), and antiplatelet therapy and adequate fluid and nutrition for first the 72 hours (0.55, 0.49 to 0.61). Receipt of five or six care processes was associated with lower mortality compared with receipt of 0-4 in both multilevel (0.74, 0.66 to 0.83) and instrumental variable analyses (0.62, 0.46 to 0.83).

CONCLUSIONS

Patients admitted to stroke services with higher levels of organisation are more likely to receive high quality care as measured by audited process measures of acute stroke care. Those patients receiving high quality care have a reduced risk of death in the 30 days after stroke, adjusting for patient characteristics and controlling for selection bias.

Health workers, health facilities and penile cutting in papua new guinea: implications for male circumcision as an HIV prevention strategy

There has been increasing interest in Papua New Guinea (PNG) in male circumcision (MC) for HIV (human immunodeficiency virus) prevention following compelling evidence from ecological studies and clinical trials in Africa, and the World Health Organization's recommendation in 2007 that MC be considered part of comprehensive HIV prevention programs in high-prevalence settings. Though no national policy has been established in PNG, East Sepik Province (ESP) commenced a formal program of MC in 2006, and there is evidence that PNG health workers are involved in other penile foreskin cutting activities in many areas. As part of a wider Male Circumcision Acceptability and Impact Study in PNG, we conducted an audit at a sample of PNG health facilities to assess their suitability for implementing a national MC program, and to identify issues that may arise in any future roll-out. The clinical audits demonstrated the difficulties with procurement and availability of equipment for general services around PNG, shortage of staff and capacity, and limitations of available clinical space. Results show that the ESP program has been successful; however, the success relies heavily on commitment from key workers to volunteer their time and services. A review of penile cutting activities by health care workers outside of the ESP program showed that the PNG health system is already involved in contemporary and traditional penile cutting practices via formal and informal arrangements: for example, by responding to complications from penile cuts performed by non-health workers, assisting community members to perform penile cutting through provision of equipment and advice, or providing regular penile foreskin cutting services for contemporary and traditional practices.

Reduction of severe acute maternal morbidity and maternal mortality in Thyolo District, Malawi: the impact of obstetric audit

BACKGROUND

Critical incident audit and feedback are recommended interventions to improve the quality of obstetric care. To evaluate the effect of audit at district level in Thyolo, Malawi, we assessed the incidence of facility-based severe maternal complications (severe acute maternal morbidity (SAMM) and maternal mortality) during two years of audit and feedback.

METHODOLOGY/PRINCIPAL FINDINGS

Between September 2007 and September 2009, we included all cases of maternal mortality and SAMM that occurred in Thyolo District Hospital, the main referral facility in the area, using validated disease-specific criteria. During two- to three-weekly audit sessions, health workers and managers identified substandard care factors. Resulting recommendations were implemented and followed up. Feedback was given during subsequent sessions. A linear regression analysis was performed on facility-based severe maternal complications. During the two-year study period, 386 women were included: 46 died and 340 sustained SAMM, giving a case fatality rate of 11.9%. Forty-five cases out of the 386 inclusions were audited in plenary with hospital staff. There was a reduction of 3.1 women with severe maternal complications per 1000 deliveries in the district health facilities, from 13.5 per 1000 deliveries in the beginning to 10.4 per 1000 deliveries at the end of the study period. The incidence of uterine rupture and major obstetric hemorrhage reduced considerably (from 3.5 to 0.2 and from 5.9 to 2.6 per 1000 facility deliveries respectively).

CONCLUSIONS

Our findings indicate that audit and feedback have the potential to reduce serious maternal complications including maternal mortality. Complications like major hemorrhage and uterine rupture that require relatively straightforward intrapartum emergency management are easier to reduce than those which require uptake of improved antenatal care (eclampsia) or timely intravenous medication or HIV-treatment (peripartum infections).

The Stroke Practice Improvement Network: a quasiexperimental trial of a multifaceted intervention to improve quality

OBJECTIVE

The aim of this project was to determine whether a tailored multifaceted intervention aimed at site-specific barriers is more effective than audit feedback alone for improving adherence to inhospital stroke performance measures (PMs): door to needle time of less than 1 hour for tissue plasminogen activator, dysphagia screening, deep venous thrombosis prophylaxis, and warfarin treatment for atrial fibrillation.

METHODS

Hospitals were paired on baseline adherence to dysphagia screening and quality improvement infrastructure and randomized to receive audit feedback alone (n=7) versus audit feedback plus site-specific interventions (n=6). Data were collected on all admitted patients with stroke seen in the neurology department before and after a 6-month implementation period. The primary end point was the difference in postintervention adherence rates for each PM, except tissue plasminogen activator because of low sample size.

RESULTS

Data were collected on 2071 preintervention patients and 1240 postintervention patients. Targeted site-specific interventions, such as standing orders and standardized dysphagia screens, were imperfectly implemented during the 6-month intervention period. For atrial fibrillation, the intervention group had an 11% higher postintervention adherence rate beyond that of the control group (98% v 87%, P < .005). No other statistically significant changes in PM adherence were observed.

CONCLUSION

Implementation of site-specific interventions for quality improvement of specific measures in stroke was difficult to achieve in a 6-month time frame and led to improved adherence for only one of 3 PMs. Studies with a longer intervention period and more sites are required to determine whether tailored interventions can enhance stroke improvement.

Crossing professional boundaries: nurse-led catheter insertion

The steady expansion of nursing roles is enabling staff to perform tasks traditionally undertaken by doctors. This change is perceived as being in the interests of patients, particularly because it can reduce waiting times, but it can also increase job satisfaction and enhance opportunities for the recruitment and retention of staff. This article describes the establishment of a nurse-led service for tunnelled central venous catheter insertion for renal dialysis. The result of a retrospective audit describes what impact this service has had.

Use of the bacteriology laboratory to decrease general practitioners’ antibiotic prescribing

OBJECTIVE

Use of the bacteriology laboratory to guide antibiotic prescribing in primary care is often considered inappropriate due to difficulties of access in a relevant time scale. The overnight analysis offered to general practitioners in the Grampian area of Scotland for the past 6 years (ABLE), and which had previously been shown to reduce antibiotic prescribing by two-thirds in a randomized controlled trial, was audited to see if it was being used correctly in general practice, that is to reduce unnecessary antibiotic prescribing.

METHODS

699 consultations were audited. Of these, 357 were ABLE patients. The other 342 were chosen because an antibiotic had been prescribed.

RESULTS

Only 36.7% (140) of the ABLE patients were prescribed an antibiotic, 65.7% being given a delayed action script. All but 10 were culture positive. ABLE patients had a greater proportion of urinary tract infections than the non-ABLE patients, but less lower-respiratory and skin or soft-tissue infection. The antibiotics prescribed reflected the differences in infection type. The repeat visit rate and repeat antibiotic prescription rate were almost identical between the two groups.

CONCLUSION

While the overall use of ABLE in Grampian is low, its use seems to be appropriate in that it is successfully being used to identify bacterial infection and reduce unnecessary antibiotic prescribing.

The Oncosurge strategy for the management of colorectal liver metastases – An external validation study

INTRODUCTION

Because most patients with colorectal liver metastases (CRLM) present to general surgeons and oncologists without a specialist interest in their management, a computer program (OncoSurge) has been created that identifies individual patient resectability and recommends optimal treatment strategies. The aim of this study was to validate the Oncosurge strategy by comparing its recommendations with the decisions made by a multidisciplinary (MDT) meeting, in a supra-regional hepatobiliary referral centre, using real cases with known outcomes.

METHODS

We reviewed the records and imaging of 98 consecutive patients with CRLM, who had been referred for decision making to our MDT meeting between January 1, 2004 and December 31, 2004. All patient and tumour characteristics were entered onto the Oncosurge decision model, which was accessed at www.evidis.com/oncosurge/

RESULTS

There was concordance between Oncosurge and MDT decisions in 93/98 cases. The observed kappa (kappa) was 0.850 (95% CI: 0.728-0.972). In descriptive terms, a kappa score greater than 0.8 equates to "almost perfect agreement".

CONCLUSIONS

Our results demonstrate the validity of the Oncosurge system when compared to one year of decision making in an established hepatobiliary MDT meeting. This confirms the utility of the Oncosurge system for decision making, audit and educational purposes.