The impact of web-based and face-to-face simulation on patient deterioration and patient safety: protocol for a multi-site multi-method design

Background

There are international concerns in relation to the management of patient deterioration which has led to a body of evidence known as the ‘failure to rescue’ literature. Nursing staff are known to miss cues of deterioration and often fail to call for assistance. Medical Emergency Teams (Rapid Response Teams) do improve the management of acutely deteriorating patients, but first responders need the requisite skills to impact on patient safety.

Methods/design

In this study we aim to address these issues in a mixed methods interventional trial with the objective of measuring and comparing the cost and clinical impact of face-to-face and web-based simulation programs on the management of patient deterioration and related patient outcomes. The education programs, known as ‘FIRST²ACT’, have been found to have an impact on education and will be tested in four hospitals in the State of Victoria, Australia. Nursing staff will be trained in primary (the first 8 min) responses to emergencies in two medical wards using a face-to-face approach and in two medical wards using a web-based version FIRST²ACTWeb. The impact of these interventions will be determined through quantitative and qualitative approaches, cost analyses and patient notes review (time series analyses) to measure quality of care and patient outcomes.

Discussion

In this 18 month study it is hypothesised that both simulation programs will improve the detection and management of deteriorating patients but that the web-based program will have lower total costs. The study will also add to our overall understanding of the utility of simulation approaches in the preparation of nurses working in hospital wards. (ACTRN12616000468426, retrospectively registered 8.4.2016).

Current status of laparoscopy for acute abdomen in Italy: a critical appraisal of 2012 clinical guidelines from two consecutive nationwide surveys with analysis of 271,323 cases over 5 years

BACKGROUND

Several authors have demonstrated the safety and feasibility of laparoscopy in selected cases of abdominal emergencies. The aim of the study was to analyse the current Italian practice on the use of laparoscopy in abdominal emergencies and to evaluate the impact of the 2012 national guidelines on the daily surgical activity.

METHODS

Two surveys (42 closed-ended questions) on the use of laparoscopy in acute abdomen were conducted nationwide with an online questionnaire, respectively, before (2010) and after (2014) the national guidelines publication. Data from two surveys were compared using Chi-square or Fisher's exact test, and data were considered significant when p < 0.05.

RESULTS

Two-hundred and one and 234 surgical units answered to the surveys in 2010 and 2014, respectively. Out of 144,310 and 127,013 overall surgical procedures, 23,407 and 20,102, respectively, were abdominal emergency operations. Respectively 24.74 % (in 2010) versus 30.27 % (in 2014) of these emergency procedures were approached laparoscopically, p = 0.42. The adoption of laparoscopy increased in all the considered clinical scenarios, with statistical significance in acute appendicitis (44 vs. 64.7 %; p = 0.004). The percentage of units approaching Hinchey III acute diverticulitis with laparoscopy in 26-75 % of cases (14.0 vs. 29.7 %; p = 0.009), those with >25 % of surgeons confident with laparoscopic approach to acute diverticulitis (29.9 vs. 54 %; p = 0.0009), the units with >50 % of surgeons confident with laparoscopic approach to acute appendicitis, cholecystitis and perforated duodenal ulcer, all significantly increased in the time frame. The majority of respondents declared that the 2012 national guidelines influenced their clinical practice.

CONCLUSIONS

The surveys showed an increasing use of laparoscopy for patients with abdominal emergencies. The 2012 national guidelines profoundly influenced the Italian surgical practice in the laparoscopic approach to the acute abdomen.

Primary ventriculoperitoneal shunting outcomes: a multicentre clinical audit for shunt infection and its risk factors

OBJECTIVES

To determine the frequency of primary ventriculoperitoneal shunt infection among patients treated at neurosurgical centres of the Hospital Authority and to identify underlying risk factors.

METHODS

This multicentre historical cohort study included consecutive patients who underwent primary ventriculoperitoneal shunting at a Hospital Authority neurosurgery centre from 1 January 2009 to 31 December 2011. The primary endpoint was shunt infection, defined as: (1) the presence of cerebrospinal fluid or shunt hardware culture that yielded the pathogenic micro-organism with associated compatible symptoms and signs of central nervous system infection or shunt malfunction; or (2) surgical incision site infection requiring shunt reinsertion (even in the absence of positive culture); or (3) intraperitoneal pseudocyst formation (even in the absence of positive culture). Secondary endpoints were shunt malfunction, defined as unsatisfactory cerebrospinal fluid drainage that required shunt reinsertion, and 30-day mortality.

RESULTS

A primary ventriculoperitoneal shunt was inserted in 538 patients during the study period. The mean age of patients was 48 years (range, 13-88 years) with a male-to-female ratio of 1:1. Aneurysmal subarachnoid haemorrhage was the most common aetiology (n=169, 31%) followed by intracranial tumour (n=164, 30%), central nervous system infection (n=42, 8%), and traumatic brain injury (n=27, 5%). The mean operating time was 75 (standard deviation, 29) minutes. Shunt reinsertion and infection rates were 16% (n=87) and 7% (n=36), respectively. The most common cause for shunt reinsertion was malfunction followed by shunt infection. Independent predictors for shunt infection were: traumatic brain injury (adjusted odds ratio=6.2; 95% confidence interval, 2.3-16.8), emergency shunting (2.3; 1.0-5.1), and prophylactic vancomycin as the sole antibiotic (3.4; 1.1-11.0). The 30-day all-cause mortality was 6% and none were directly procedure-related.

CONCLUSIONS

This is the first Hong Kong territory-wide review of infection in primary ventriculoperitoneal shunts. Although the ventriculoperitoneal shunt infection rate met international standards, there are areas of improvement such as vancomycin administration and the avoidance of scheduling the procedure as an emergency.

Proactive PICC placement: evaluating the patient experience

AIM

to evaluate patient experience following the proactive placement of a peripherally inserted central catheter (PICC).

METHOD

all patients with a PICC in situ who had attended the chemotherapy day unit over a period of 15 weeks were invited to complete a self-administered questionnaire. Questions related to: information giving, the degree of pain on insertion and any complications experienced by the patient while the device was in situ. There was also space to allow for free-text comments after each question.

RESULTS

the majority of patients felt they received enough information and that the procedure was fully explained. Pain on insertion was largely reported as being minimal, with the few patients who did report the procedure as painful also reporting there being difficulty with the insertion. Complication rates were low, the main complication reported was mechanical owing to difficulty with blood withdrawal.

CONCLUSION

irrespective of how uncomfortable the patient found the procedure, the majority of patients would recommend proactive PICC insertion to other patients as 'it made the whole process much easier'.

Compliance of ENT emergency surgery with the Royal College of Surgeons standards

Introduction In 2011 The Royal College of Surgeons of England (RCS) set out best practice standards for emergency surgery. This national pilot audit aimed to determine the compliance of otolaryngology departments in England with these published guidelines. Methods A 26-item online questionnaire was devised that encompassed all the 36 best practices as set out by the RCS for ear, nose and throat (ENT) surgery. This was sent to ENT trainees and consultants based at units in England providing emergency ENT services. Results Data were obtained from 55 of the 102 units (response rate: 54%). A mean compliance of 71% was achieved (range: 25-94%). No units achieved all of the best practices. The standards with the highest compliance included 24-hour availability of blood transfusion and haematology opinion for patients with epistaxis, availability of a consultant or ST3/equivalent for immediate discussion of severe post-tonsillectomy bleeding, 24-hour access to blood transfusion for arrest of haemorrhage and immediate theatre access for arrest of haemorrhage. The areas with the lowest compliance were provision of a pathway for angiography/embolisation for epistaxis and provision of an equipped ENT room on a paediatric ward. Conclusions This audit has highlighted that the majority of departments in England are providing a good standard of ENT emergency care. There is room for improvement in certain areas, such as the provision of an embolisation pathway in the context of refractory epistaxis. We hope that this audit will encourage ENT departments to evaluate their current provision of emergency care and institute changes (where necessary) to maintain and improve their practices.

Diagnostic reference levels and complexity indices in interventional radiology: a national programme

OBJECTIVES

To propose national diagnostic reference levels (DRLs) for interventional radiology and to evaluate the impact of the procedural complexity on patient doses.

METHODS

Eight interventional radiology units from Spanish hospitals were involved in this project. The participants agreed to undergo common quality control procedures for X-ray systems. Kerma area product (KAP) was collected from a sample of 1,649 procedures. A consensus document established the criteria to evaluate the complexity of seven types of procedures. DRLs were set as the 3rd quartile of KAP values.

RESULTS

The KAP (3rd quartile) in Gy cm² for the procedures included in the survey were: lower extremity arteriography (n = 784) 78; renal arteriography (n = 37) 107; transjugular hepatic biopsies (THB) (n = 30) 45; biliary drainage (BD) (n = 314) 30; uterine fibroid embolization (UFE) (n = 56) 214; colon endoprostheses (CE) (n = 31) 169; hepatic chemoembolization (HC) (n = 269) 303; femoropopliteal revascularization (FR) (n = 62) 119; and iliac stent (n = 66) 170. The complexity involved the increases in the following KAP factors from simple to complex procedures: THB x4; BD x13; UFE x3; CE x3; HC x5; FR x5 and IS x4.

CONCLUSIONS

The evaluation of the procedure complexity in patient doses will allow the proper use of DRLs for the optimization of interventional radiology.

KEY POINTS

• National DRLs for interventional procedures have been proposed given level of complexity • For clinical audits, the level of complexity should be taken into account. • An evaluation of the complexity levels of the procedure should be made.

Incidence and significance of postoperative complications occurring between discharge and 30 days: a prospective cohort study

BACKGROUND

Accurate documentation of complications is fundamental to clinical audit and research. While it is established that accurate diagnosis of surgical site infection (SSI) requires follow-up for 30 days; for other complications, there are minimal data quantifying their importance between discharge and 30 days.

METHODS

In this prospective cohort study, inpatients undergoing general or vascular surgery were reviewed daily for complications by the medical team and a research fellow. A standardized telephone questionnaire was performed 30 days following surgery. All complications were documented and classified according to severity.

RESULTS

A total of 237 of 388 patients who completed the telephone survey developed a complication, including 77 who developed a complication for the first time after discharge from hospital. Overall 135 (33%) of a total of 405 complications were identified after discharge. These complications included 36 of 63 (57%) SSI, 6 of 12 small bowel obstructions, and three of four major thromboembolic events and a number of space SSI, urinary infections, functional gastrointestinal problems, and pain management problems. Cardiac, respiratory, and neurologic complications were mainly diagnosed in hospital. Of the 135 "postdischarge" complications, 89 were managed in the community and 46 (34%) resulted in admission to hospital, including seven which required a major intervention. There was one death.

CONCLUSIONS

One-third of complications occurred after discharge, and one-third of these resulted in readmission to hospital. Research and audit based on inpatient data alone significantly underestimates morbidity rates. Discharge planning should include contingency plans for managing problems commonly diagnosed after discharge form hospital.

Assessment of bone health in breast cancer patients starting adjuvant aromatase inhibitors: A quality improvement clinical audit

Introduction

Adjuvant Aromatase Inhibitors (AIs) predispose breast cancer patients to accelerated bone loss. Guidelines recommend initial screening and follow up of bone mineral density with dual energy X-ray absorptiometry (DEXA) scan. In this audit we assessed the rate of adherence to these guidelines and introduced awareness measures to improve it.

Methods

All post-menopausal women who started upfront adjuvant AIs (letrozole in all patients) between January 2007 and December 2013 were retrospectively identified. The standard to be audited was “These patients should have a baseline DEXA scan requested within the first 3 months of starting adjuvant AIs therapy”. A 90% or more compliance was accepted as satisfactory. Corrective measures in the form of educational and awareness sessions followed by re-auditing of the practice over the subsequent 12 months were planned in case of lower compliance rate.

Results

Three hundred and sixty seven eligible patients were identified. Baseline DEXA scan was performed in 188 (51.2%) patients. As planned, this result triggered the conduction of 4 consecutive educational sessions over a period of 2 weeks. Re-auditing the practice in the pre-defined subsequent subjects showed compliance in 47/52 (90.4%) patients.

Conclusion

This study of a sizable cohort confirms previous observations that adherence to skeletal health guidelines in this patient population is less than adequate. Adherence is improved dramatically by raising the awareness of relevant physicians.

When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country

OBJECTIVE

To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.

DESIGN

Nationwide cross-sectional study.

SETTING

Forty-two tertiary hospitals.

POPULATION

Women admitted for pregnancy, childbirth and puerperal complications.

METHODS

All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period.

MAIN OUTCOME MEASURES

Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).

RESULTS

Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care.

CONCLUSIONS

Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care.

TWEETABLE ABSTRACT

Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

Granulocyte Colony-Stimulating Factor Use in a Large Iranian Hospital: Comparison with American Society of Clinical Oncology (ASCO) Clinical Practice Guideline

BACKGROUND

Granulocyte Colony Stimulating Factors (GCSF) is high-cost agents commonly recommended for primary and secondary prophylaxis of chemotherapy-induced neutropenia and febrile neutropenia. GCSFs have been shown to be beneficial in some patient subgroups, although they are probably overused in clinical settings. The American Society of Clinical Oncology (ASCO) guidelines summarize current data on the appropriate use of CSFs. The aim of this study was to assess and audit the use of GCSF in a tertiary care center according to the recommendation of ASCO guideline.

SUBJECTS AND METHODS

A prospective observational study from November 2014 to June 2015 was performed on all patients prescribed with filgrastim in the large teaching hospital (Isfahan, Iran). Data was collected on demographics, indication, dosing regimen and duration of treatment, the Absolute Neutrophil Count (ANC) and patient outcome.

RESULTS

91 patients were recorded over the period of the study. 63.7% of prescription complied with the ASCO guideline. Febrile neutropenia post chemotherapy/radiotherapy was the most common appropriate indication (29.3%) followed by primary prophylaxis (25.8%). Fourteen (32%) patients showed ANC recovery in 1-3 days and 16 (37%) within 4-7 days. Ten patients (23%) showed no recovery. The overall mortality was 8 (8.8%) patients.

CONCLUSION

This study revealed that at least one-third of prescribed GCSF was not in accordance with ASCO guideline. Considering the high cost of GCSF in our country and limitation of our resources, we proposed cost-effectiveness studies on GCSF treatment and also the development of a national guideline for optimizing GCSF use.

Does periodical department audit really works to make things fall in place: A Geriatric/General Oral Health Assessment Index based audit in prosthodontics

Purpose:

The purpose was to assess the outcome of improved staff supervision on the efficiency and quality of complete dentures delivered by clinical students.

Materials and Methods:

The audit was performed in two parts. In the first cycle, retrospective analysis for complete dentures delivered by clinical students was undertaken, and patient's satisfaction was graded using Geriatric/General Oral Health Assessment Index (GOHAI). All the impeding factors encountered in the first cycle were identified, and corrective measures were implemented. Subsequently, a prospective analysis for the dentures delivered under strict staff supervision was undertaken in the second cycle. Patient satisfaction was graded again using GOHAI.

Results:

Improved staff supervision increased the patient satisfaction significantly.

Conclusions:

The quality of care had improved in leaps and bounds compared to the first cycle due to increased level of supervision and strict adherence to the recommendations made at the end of the first cycle.

Early management of traumatic brain injury in a Tertiary hospital in Central Kenya: A clinical audit

Background:

Traumatic brain injury (TBI) is a major cause of death and disability worldwide and is mostly attributed to road traffic accidents in resource-poor areas. However, access to neurosurgical care is poor in these settings and patients in need of neurosurgical procedures are often managed by general practitioners or surgeons.

Materials and Methods:

A retrospective clinical audit of the initial management of patients with TBI in Thika Level 5 Hospital (TL5H), a Tertiary Hospital in Central Kenya. Seventeen audit criteria divided into five clinical domains were identified and patient case notes reviewed for compliance with each criterion. Data were analyzed separately for those below 13 years owing to differences in response to brain trauma in those below this age.

Results:

Overall, there was poor compliance with audit criteria in both groups. Among those below 13 years of age, only 3 out of 17 criteria achieved compliance and 4 out of 17 criteria achieved compliance for those above 13 years of age. Assessment for the need for a cervical radiograph (7.1% and 8.8% compliance) and administration of oxygen (21.4% and 20.6% compliance) had the worst performance in both groups.

Conclusion:

Poor compliance to audit criteria indicates the low quality of care for patients with TBI in TL5H. Quality improvement strategies with follow-up audits are needed to improve care. There is a need to develop and enforce evidence-based protocols and guidelines for use in the management of patients with TBI in sub-Saharan Africa.

Characterizing patients with chronic heart failure in community care after hospitalization: a potential role for ivabradine

AIMS

To identify the prevalence and characteristics of recently hospitalized chronic heart failure (CHF) patients in community care who meet the indication for ivabradine.

METHODS

A retrospective clinical audit of CHF patients recently hospitalized with acute decompensated heart failure (ADHF) and subsequently referred to the Tayside Heart Failure Nurse Liaison Service (THFNLS), a Scottish nurse-led community heart failure liaison service. Inclusion criteria were previous hospitalization with ADHF, subsequent referral to the THFNLS, data for ≥ 2 nurse visits, and a recorded pulse. The main outcome measure was the proportion of patients who meet the indicated criteria for ivabradine.

RESULTS

In the UK, ivabradine is indicated for CHF with systolic dysfunction in patients in sinus rhythm, with a heart rate ≥ 75 bpm, and NYHA class II-class IV. After up-titration of a beta-blocker, 19.0% of patients in the full dataset (158 of 830) met the indication for ivabradine at the last visit. Of these "ivabradine-suitable" patients, 101 of 158 (63.9%) received bisoprolol "at any time" during the study period; 20 of 158 (12.7%) achieved the target dose (10 mg daily); 52 of 158 (32.9%) received 5 mg or 7.5 mg daily; and 93 of 158 (58.9%) received <5 mg daily.

CONCLUSIONS

In this group of Scottish patients previously hospitalized with ADHF and under the care of a protocol-driven clinic, 19% met the indication for ivabradine and may benefit from the increased control of CHF that ivabradine can provide. Among these "ivabradine-suitable" patients, <15% achieved the target dose of beta-blockers, illustrating the substantial clinical need for a well-tolerated and effective therapy such as ivabradine.

Utility of peripheral intravenous cannulae inserted in one tertiary referral emergency department: A medical record audit

INTRODUCTION

Peripheral intravenous cannulation is a common intervention performed within the Emergency Department (ED). However, studies have shown that while patients may have a cannulae inserted they are often unused. Across Australia, it is unclear the frequency and use of peripheral intravenous cannulae (PIVC) within the emergency setting.

METHOD

A one-month retrospective randomised medical record audit of adult patients was conducted. Data were retrieved from the ED electronic database and the paper medical record. Data included: patient demographic (age, gender) and clinical information (time of arrival, triage category, presenting problem, discharge diagnostic code, and disposition) and cannula usage (time of fluids, pharmacological agents, pathology, radiological investigations, other diagnostic uses).

RESULTS

Of the 357 patients, 209 (58.5%) had a peripheral intravenous cannula inserted. Of the 209 patients a total of 233 cannulae were inserted. Of the patients with a cannulae 190 (90.9%) were used within 72 h. The majority of cannulae (68.9%; n=131) had more than one medical intervention.

CONCLUSION

The majority of PIVCs inserted during the ED visit were used for medical treatment. The majority of devices were used for intravenous fluids medications and were accessed for multiple interventions. For future audit purposes improved documentation of this procedure is needed.

Assessment of the quality of clinical documentation in India's JSY cash transfer program for facility births in Madhya Pradesh

OBJECTIVE

To gain insight into the quality of care in facilities implementing the Janani Suraksha Yojana (JSY) cash transfer program in Madhya Pradesh, India, by reviewing the level of documentation in the clinical records of women who delivered.

METHODS

The present retrospective, descriptive study reviewed case records of women who delivered at 73 primary, secondary, and tertiary level facilities in three districts of Madhya Pradesh between 2012 and 2013. Twenty elements of care were assessed encompassing clinical history and admission details, care during delivery and postnatal period, and discharge details.

RESULTS

A total of 1239 records were reviewed. The extent of documentation varied among the elements assessed-e.g. 24 (1.9%) records documented advice at discharge, 171 (13.8%) documented postnatal blood pressure, 437 (35.3%) documented fetal heart rate, and 1220 (98.5%) documented admission date. The extent of documentation was better at higher level facilities.

CONCLUSION

The quality of clinical documentation in the JSY program was found to be unacceptably poor in Madhya Pradesh. Improving staff skills and practices in clinical documentation and record keeping will be required to enable clinical processes to be assessed and quality of care to be improved.

Clinical audit of patients using DPP4 inhibitors in longstanding type 2 diabetes

AIMS

Dipeptidyl peptidase-4 inhibitors (DPP 4i) are oral hypoglycemic agents and are supposed to be beneficial in the early stages of diabetes. In this study, we evaluated the role of DPP4i in long standing type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

This retrospective data analysis was conducted from the patient records. All the patients (T2DM>5 years; Age>50 years; Gliptin use >12 months) were divided into 2 groups based on the duration of T2DM: Group A (<10 years) and Group B (>10 years). We excluded patients with type 1 diabetes and drug default of more than one month. Our primary objective was to study the change in HbA1c and secondary objectives were change in body weight and insulin requirement. Data are presented as mean ± S.D and comparison between the groups was done using Mann-Whitney and Fisher's exact tests.

RESULTS

The study participants (n=501) had a mean age (64.2 ± 8.2 yr), diabetes duration (10.1 ± 4.9 yr), body weight (65.3 ± 9.5 kg), BMI (23.4 ± 3.9 kg/m(2)) and HbA1c of 9.7 ± 1.3%. The use of gliptins resulted in similar HbA1c reduction between the groups (p=0.8405) and greater reduction of insulin requirement in group B (p=0.0433) at the end of one year. Body weight and hypoglycemia episodes did not differ between the groups.

CONCLUSION

DPP4 inhibitors give similar benefit irrespective of the duration of diabetes and our data gives reassurance about their role in long standing diabetes.

Meeting the needs of new ostomists: a patient evaluation survey

Nottingham University Hospitals (NUH) NHS Trust provides a care pathway for patients undergoing stoma formation surgery, with the stoma care nurse specialists providing ongoing support for patients, alongside the rest of the multidisciplinary team, from the preoperative consultation through to their community follow-up. In the past, the community service offered has not always been well-received and the whole pathway has not been evaluated in depth to date. This article reports on a patient evaluation survey of the stoma care pathway at NUH. The results showed that overall patients are very complimentary of the service offered to them by the stoma care team. They highly commend the stoma care nurse specialist. Two areas for amendment in the pathway have been identified: information provision and the length of time available for the stoma care nurse specialist to spend one-to-one with each patient. The results of this survey will aid the team in implementing positive changes to the stoma care pathway.

Cesarean section rates in Lithuania using Robson Ten Group Classification System

BACKGROUND AND OBJECTIVE

The aim of this study was to analyze cesarean section (CS) rates using Robson Ten Group Classification System (TGCS) and to identify the main contributors to the overall CS rate in Lithuania.

MATERIALS AND METHODS

A prospective cross-sectional study was carried out. All women who delivered between January 1 and December 31, 2012, in Lithuania were classified using the TGCS. The CS rates overall and in each Robson group were calculated, as was the contribution of each group to the overall CS rate.

RESULTS

The CS rate was 26.4% (6697 among 25,373 deliveries) in 2012. Nulliparous women with single cephalic full-term pregnancy in spontaneous labor (Group 1) or who underwent induction of labor or prelabor CS (Group 2) and multiparous women with a previous CS (Group 5) were the greatest contributors (67.7%) to the overall CS rate. In addition, significant variation of CS rates between different institutions was observed, especially in women with single cephalic full-term pregnancy without previous CS (Groups 1-4), showing big differences in obstetric care across country.

CONCLUSIONS

Women in Groups 1, 2 and 5 were the largest contributions to the overall CS rate in Lithuania. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy (Groups 1 and 2).

Monitoring and assessing the quality of care for youth: developing an audit tool using an expert consensus approach

BACKGROUND

The mental health needs of young people are often inadequately met by health services. Quality improvement approaches provide a framework for measuring, assessing and improving the quality of healthcare. However, a lack of performance standards and measurement tools are an impediment to their implementation. This paper reports on the initial stages of development of a clinical audit tool for assessing the quality of primary healthcare for Australian Indigenous youth aged 12-24 including mental health services provided within primary care.

METHODS

Audit items were determined through review of relevant guidelines, expert reference group consensus opinion and specific inclusion criteria. Pilot testing was undertaken at four Indigenous primary healthcare services. A focus group discussion involving five staff from a health service participating in pilot testing explored user experiences of the tool.

RESULTS

Audit items comprise key measures of processes and outcomes of care for Indigenous youth, as determined by the expert reference group. Gaps and conflicts in relevant guidelines and a lack of agreed performance indicators necessitated a tool development process that relied heavily on expert reference group advice and audit item inclusion criteria. Pilot testing and user feedback highlighted the importance of feasibility and context-specific considerations in tool development and design.

CONCLUSIONS

The youth health audit tool provides a first step in monitoring, assessing and improving the way Indigenous primary healthcare services engage with and respond to the needs of youth. Our approach offers a way forward for further development of quality measures in the absence of clearly articulated standards of care.

Improving efficiency and saving money in an otolaryngology urgent referral clinic

A closed loop audit of the ear nose and throat (ENT) urgent referral clinic at a London hospital was conducted assessing the number of patients reviewed, referral source, appropriateness of referral, presenting complaint and assigned follow-up appointments. Data was sourced from clinic letters and the patient appointment system over a 3-mo period. The initial cycle analysed 490 patients and the subsequent cycle 396. The initial audit yielded clinically relevant and cost effective recommendations which were implemented, and the audit cycle was subsequently repeated. The re-audit demonstrated decreased clinic numbers from an average 9.8 to 7.2 patients per clinic, in keeping with ENT United Kingdom guidelines. A 21% decrease in patient follow-up and 13% decrease in inappropriate referrals was achieved. Direct bookings into outpatient clinics decreased by 8%, due to correct referral pathway utilisation. Comparisons of all data sets were found to show statistical significance P < 0.05. We reported a total financial saving of £32490 in a period of 3 mo (£590 per clinic). We demonstrated that simple guidelines, supervision and consultant-led education which are non-labour intensive can have a significant impact on service provision and cost.

Adults with flexible pes planus and the approach to the prescription of customised foot orthoses in clinical practice: A clinical records audit

A clinical records audit of the University of South Australia's podiatry clinic clients attending in 2010 was undertaken to determine prevalence of symptomatic flexible pes planus, presenting reasons and treatment options most frequently used. Analysis of rearfoot measures (resting calcaneal stance position, subtalar joint range of motion) between those prescribed a vertical (heel) or inverted (heel) cast pour and a medial heel (Kirby) skive was undertaken. Of 223 clinical records audited, 50% (111/223) of clients were assessed with flexible pes planus, 77% (86/111) of clients with pes planus presented with back or lower limb pain and 58% (64/111) were prescribed customised foot orthoses. Of 42 prescriptions for customised foot orthoses audited; 64% (27/42) were prescribed a vertical (heel) cast pour, 36% (15/42) an inverted (heel) cast pour and 19% (8/42) received a medial heel (Kirby) skive. Those prescribed a medial heel (Kirby) skive had a more everted resting calcaneal stance position than those that were not (mean -8.6±2.8° vs. -5.5±3.4°, p=0.02). Those prescribed an inverted (heel) cast pour had a greater range of subtalar joint motion than those prescribed a vertical (heel) cast pour (median 36.0±10.0° vs. 29.0±5.0°, p=0.01).

Reducing inappropriate urinary catheter use: quality care initiatives

Healthcare-acquired urinary infection presents a substantial burden for patients and the healthcare system. Urinary tract infections have not gained the same level of media attention as other healthcare-associated infections, yet interventions to reduce urinary catheter use are one of the top ten recommended patient safety strategies. To improve practice around urinary catheter placement and removal requires interventions to change the expectations and habits of nurses, medical teams and patients regarding the need for a urinary catheter. In the authors' trust, a redesign of the existing urinary catheter device record was undertaken to help avoid unnecessary placement of catheters, and resulted in a reduction of urinary catheters in situ longer than 48 hours. Other strategies included implementation of catheter rounds in a high-usage area, and credit-card-sized education cards. A catheter 'passport' was introduced for patients discharged with a catheter to ensure information for insertion and ongoing use were effectively communicated.

Clinical audit of ultrasound guided fine needle aspiration in a general cytopathology service

Background:

Studies on ultrasonography (USG) guided fine needle aspiration cytology (FNAC) have been conducted in specialized settings such as thyroid, breast, and intra-abdominal aspirates. There is a paucity of literature on the practices of guided FNAC in a general cytopathology service.

Aim:

The aim was to determine prevailing practices of USG guided FNAC in a general cytopathology service of a teaching hospital.

Settings and Design:

Metropolitan hospital, clinical audit.

Materials and Methods:

Audit of 112 USG guided percutaneous FNAC done over 12 months.

Statistical Analysis:

Data were coded, entered in an excel spreadsheet and analyzed by translating into percentages and proportions.

Results:

The 112 guided FNACs included constituted 36 thyroid (32.14%), 45 intra-abdominal (40.17%), 11 breast (9.82%), 10 superficial lymph node (8.92%) and 10 soft tissue and miscellaneous (8.92%) lesions. Previous freehand FNAC was documented on the requisition forms in 14 cases. The reports were: Inadequate 33 (29.46%), nondiagnostic descriptive 35 (31.25%) or diagnostic 44 (39.28%). Inadequacy rates of aspirates from thyroid were 11 (30.56%) breast were 2 (18.18%), and intra-abdominal lesions were 13 (28.88%). Majority of the reports were nonstructured: 108 (96.42%) and nonrecommendatory: 101 (90.17%).

Conclusions:

Reporting practices varied and did not conform to a uniform structure. The inadequacy rates of breast and thyroid aspirates were comparable to the rates in the literature. Comparable studies were not available for intra-abdominal aspirates.

Targeted clinical audits immediately following the establishment of clinical practice guidelines for multiple sclerosis in 17 neurology departments: A pragmatic and collaborative study

Following the publication practice guidelines for multiple sclerosis by a group of neurologists (multiple sclerosis study group [GRESEP]), the primary objective of this study was to compare the reality of practice to the guidelines according to the targeted clinical audit (TCA) method. The study was conducted at 17 neurology sites and was administered during two periods of MS care (diagnostic - TCA-DIAG, and disease course - TCA-EVOL). Two complementary surveys were done on the record keeping and the root causes of the deviations. The percentages of compliance ranged from 8 to 98% for the TCA-DIAG, and from 15 to 99% for the TCA-EVOL, with wide disparity between sites. The audits were able to identify causes of the flaws in traceability or accessibility. At the end of the study, despite its limitations, we think that the sharing of the results from different sites provided interesting approaches for the use of the assessment criteria defined by GRESEP in a complete audit cycle. This study is to our knowledge the first report of an experiment in which guidelines were created, and subsequently followed by the development of assessment criteria and then the performance of targeted clinical audits using them, all by the same participants.

CONTEXT

Clinical practice guidelines (CPGs) are intended to help practitioners and patients make informed treatment choices, but their integration into actual practice remains problematic. This study was done immediately following the publication of CPGs for multiple sclerosis (MS) by the multiple sclerosis study group [GRESEP]. The primary objective was to generate quality criteria, to test them within the same group, and to analyze the observed deviations.

MATERIALS AND METHODS

The study was conducted in the 17 voluntary departments that had participated in the development of the CPGs. The targeted clinical audit method was administered during two periods of MS care (diagnostic - TCA-DIAG, and disease course - TCA-EVOL). All the files were evaluated by a clinical research technician using digital format, which ensured thoroughness of the collection. Two complementary surveys were done on the record keeping and the potential causes of the deviations.

RESULTS

The percentages of compliance to the criteria ranged from 8 to 98% (out of 240 files) for the TCA-DIAG, and from 15 to 99% (221 files) for the TCA-EVOL, with wide disparity between sites (interquartile distance ranges: TCA-DIAG between 0% and 55%; TCA-EVOL between 0% and 70%). The mean percentage of compliance with all the criteria as measured by the TCA-DIAG was 83.9% for the sites with digital files vs. 76.4% for those with only paper files (P<0.01). For the TCA-EVOL, the difference was not significant. Explanations for the observed deviations were suggested (1 to 9 according to the participants).

DISCUSSION AND CONCLUSION

The quantified results could not be compared to other studies given the unique nature of the experiment. The importance of the traceability of practices in the patient files was discussed and assessed with regard to continuity and safety of care, as well as the medical-legal perspectives. Causes of lack of compliance were suggested (particularly the absence of reminders, the lack of means and/or time). Despite the limitations of the study, we think it is advisable that when a group becomes involved in the development of CPGs that they follow with the development of assessment criteria in order to evaluate the validity as well as their character as intermediate indicators of the quality of practices.

Minimally invasive surgery for pedal digital deformity: an audit of complications using national benchmark indicators

Background

There is increasing global interest and performance of minimally invasive foot surgery (MIS) however, limited evidence is available in relation to complications associated with MIS for digital deformity correction. The aim of this prospective audit is to report the surgical and medical complications following MIS for digital deformity against standardised clinical indicators.

Methods

A prospective clinical audit of 179 patients who underwent MIS to reduce simple and complex digital deformities was conducted between June 2011 and June 2013. All patients were followed up to a minimum of 12 months post operatively. Data was collected according to a modified version of the Australian Council of Healthcare standards (ACHS) clinical indicator program. The audit was conducted in accordance with the National Research Ethics Service (NRES) guidelines on clinical audit.

Results

The surgical complications included 1 superficial infection (0.53%) and 2 under-corrected digits (0.67%), which required revision surgery. Two patients who underwent isolated complex digital corrections had pain due to delayed union (0.7%), which resolved by 6 months post-op. No neurovascular compromise and no medical complications were encountered. The results compare favourably to rates reported in the literature for open reduction of digital deformity.

Conclusion

This audit has illustrated that performing MIS to address simple and complex digital deformity results in low complication rates compared to published standards. MIS procedures were safely performed in a range of clinical settings, on varying degrees of digital deformity and on a wide range of ages and health profiles. Further studies investigating the effectiveness of these techniques are warranted and should evaluate long term patient reported outcome measures, as well as developing treatment algorithms to guide clinical decision making.