Pre-treatment assessment of chemotherapy for cancer patients: a multi-site evidence implementation project of 74 hospitals in China

BACKGROUND

Chemotherapy, whilst treating tumours, can also lead to numerous adverse reactions such as nausea and vomiting, fatigue and kidney toxicity, threatening the physical and mental health of patients. Simultaneously, misuse of chemotherapeutic drugs can seriously endanger patients' lives. Therefore, to maintain the safety of chemotherapy for cancer patients and to reduce the incidence of adverse reactions to chemotherapy, many guidelines state that a comprehensive assessment of the cancer patient should be conducted and documented before chemotherapy. This recommended procedure, however, has yet to be extensively embraced in Chinese hospitals. As such, this study aimed to standardise the content of pre-chemotherapy assessment for cancer patients in hospitals and to improve nurses' adherence to pre-chemotherapy assessment of cancer patients by conducting a national multi-site evidence implementation in China, hence protecting the safety of cancer patients undergoing chemotherapy and reducing the incidence of adverse reactions to chemotherapy in patients.

METHODS

The national multi-site evidence implementation project was launched by a JBI Centre of Excellence in China and conducted using the JBI approach to evidence implementation. A pre- and post-audit approach was used to evaluate the effectiveness of the project. This project had seven phases: training, planning, baseline audit, evidence implementation, two rounds of follow-up audits (3 and 9 months after evidence implementation, respectively) and sustainability assessment. A live online broadcast allowed all participating hospitals to come together to provide a summary and feedback on the implementation of the project.

RESULTS

Seventy-four hospitals from 32 cities in China participated in the project, four withdrew during the project's implementation, and 70 hospitals completed the project. The pre-and post-audit showed a significant improvement in the compliance rate of nurses performing pre-chemotherapy assessments for cancer patients. Patient satisfaction and chemotherapy safety were also improved through the project's implementation, and the participating nurses' enthusiasm and belief in implementing evidence into practice was increased.

CONCLUSION

The study demonstrated the feasibility of academic centres working with hospitals to promote the dissemination of evidence in clinical practice to accelerate knowledge translation. Further research is needed on the effectiveness of cross-regional and cross-organisational collaborations to facilitate evidence dissemination.

Barriers to research progress for perioperative care practitioners working in cardiothoracic surgery

Policy and research literature worldwide support the need to build research capacity and capability among non-medical practitioners within healthcare systems. However, there exists a paucity of evidence on whether practitioners in cardiothoracic surgery are attuned to this and on what barriers or enablers exist. A survey was carried out with non-medical practitioners working in cardiothoracic surgery in the United Kingdom to explore attitudes towards health research and audit, and to identify current challenges and barriers to surgical research and audit as perceived by cardiothoracic nurses and allied health professionals. A total of 160 completed questionnaires were returned. 99% of respondents supported the need for research and believed that evidence-based surgical care improves outcomes for patients. Seventy-two percent reported that their employer motivates them to take part in national research or audit but, only 22% were allocated time to do so within their role; 96% reported their interest in being involved in research and audit, yet only 30% believed they had the skills to undertake research, and 96% reported needing additional training. More work is needed to increase awareness, capacity and capability among cardiothoracic surgery care practitioners, and indeed other specialities to achieve research progress.

Do medical specialists accept claims-based Audit and Feedback for quality improvement? A focus group study

OBJECTIVES

Audit and Feedback (A&F) is a widely used quality improvement (QI) intervention in healthcare. However, not all feedback is accepted by professionals. While claims-based feedback has been previously used for A&F interventions, its acceptance by medical specialists is largely unknown. This study examined medical specialists' acceptance of claims-based A&F for QI.

DESIGN

Qualitative design, with focus group discussions. Transcripts were analysed using discourse analysis.

SETTING AND PARTICIPANTS

A total of five online focus group discussions were conducted between April 2021 and September 2022 with 21 medical specialists from varying specialties (urology; paediatric surgery; gynaecology; vascular surgery; orthopaedics and trauma surgery) working in academic or regional hospitals in the Netherlands.

RESULTS

Participants described mixed views on using claims-based A&F for QI. Arguments mentioned in favour were (1) A&F stimulates reflective learning and improvement and (2) claims-based A&F is more reliable than other A&F. Arguments in opposition were that (1) A&F is insufficient to create behavioural change; (2) A&F lacks clinically meaningful interpretation; (3) claims data are invalid for feedback on QI; (4) claims-based A&F is unreliable and (5) A&F may be misused by health insurers. Furthermore, participants described several conditions for the implementation of A&F which shape their acceptance.

CONCLUSIONS

Using claims-based A&F for QI is, for some clinical topics and under certain conditions, accepted by medical specialists. Acceptance of claims-based A&F can be shaped by how A&F is implemented into clinical practice. When designing A&F for QI, it should be considered whether claims data, as the most resource-efficient data source, can be used or whether it is necessary to collect more specific data.

Improving the clinical monitoring of extrapyramidal symptoms: a local quality improvement project

BACKGROUND

Extrapyramidal symptoms (EPS) can cause significant morbidity and impact negatively on patients' quality of life. Clinical guidelines provide recommendations regarding screening frequency and the use of structured tools to ensure adequate monitoring of EPS. Despite this, the literature indicates that the documentation and monitoring of EPS remain suboptimal.

AIMS

To devise an intervention that would lead to the improvement in the documentation and hence monitoring of EPS.

METHODS

An initial paper chart survey was conducted to assess the current extent of documentation and monitoring of EPS carried out in patient files of three distinct settings in our Mental Health Service (MHS): inpatient, rehabilitation, and assertive outreach. An intervention aimed at improving practice was subsequently designed and implemented. This involved adoption by the MHS of a new EPS monitoring tool and delivery of an educational session regarding its use. The extent of documentation and monitoring of EPS was re-surveyed post-intervention.

RESULTS

Initially, only 14.8% of inpatient records contained evidence of EPS documentation while no evidence at all was found across the other two MHS settings. Following the intervention, there was evidence of guideline concordant EPS monitoring using a structured tool in the clinical records of 75% of inpatients, 79.6% in the rehabilitation setting, and 18% in the assertive outreach programme.

CONCLUSION

Documentation of EPS monitoring improved significantly across several settings affiliated with a Dublin North City MHS following the systematic adoption of the Extrapyramidal Symptom Scale (EPSS) and clinician education regarding its use.

Process evaluation of a tailored nudge intervention to promote appropriate care and treatment of older patients at the end-of-life

BACKGROUND

Non-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) intervention was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop. However, the trial results indicated that the expected practice change did not occur. The process evaluation aimed to assess implementation using the Consolidated Framework for Implementation Research, identify barriers and enablers to implementation and provide insights into the lack of effect of the InterACT intervention.

METHODS

Qualitative data collection involved 38 semi-structured interviews with participating clinicians, members of the executive advisory groups overseeing the intervention at a site level, clinical auditors, and project leads. Online interviews were conducted at two times: implementation onset and completion. Data were coded to the Consolidated Framework for Implementation Research and deductively analysed.

RESULTS

Overall, clinicians felt the premise and clinical reasoning behind InterACT were strong and could improve patient management. However, several prominent barriers affected implementation. These related to the potency of the nudge intervention and its integration into routine clinical practice, clinician beliefs and perceived self-efficacy, and wider contextual factors at the health system level.

CONCLUSIONS

An intervention designed to change clinical practice for patients at or near to end-of-life did not have the intended effect. Future interventions targeting this area of care should consider using multi-component strategies that address the identified barriers to implementation and clinician change of practice.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 06/05/2019).

Development of clinically meaningful quality indicators for contemporary lung cancer care, and piloting and evaluation in a retrospective cohort; experiences of the Embedding Research (and Evidence) in Cancer Healthcare (EnRICH) Program

OBJECTIVES

Lung cancer continues to be the most common cause of cancer-related death and the leading cause of morbidity and burden of disease across Australia. There is an ongoing need to identify and reduce unwarranted clinical variation that may contribute to these poor outcomes for patients with lung cancer. An Australian national strategy acknowledges clinical quality outcome data as a critical component of a continuously improving healthcare system but there is a need to ensure clinical quality indicators adequately measure evidence-based contemporary care, including novel and emerging treatments. This study aimed to develop a suite of lung cancer-specific, evidence-based, clinically acceptable quality indicators to measure quality of care and outcomes, and an associated comparative feedback dashboard to provide performance data to clinicians and hospital administrators.

DESIGN

A multistage modified Delphi process was undertaken with a Clinical Advisory Group of multidisciplinary lung cancer specialists, with patient representation, to update and prioritise potential indicators of lung cancer care derived from a targeted review of published literature and reports from national and international lung cancer quality registries. Quality indicators were piloted and evaluated with multidisciplinary teams in a retrospective observational cohort study using clinical audit data from the Embedding Research (and Evidence) in Cancer Healthcare Program, a prospective clinical cohort of over 2000 patients with lung cancer diagnosed from May 2016 to October 2021.

SETTING AND PARTICIPANTS

Six tertiary specialist cancer centres in metropolitan and regional New South Wales, Australia.

RESULTS

From an initial 37 potential quality indicators, a final set of 10 indicators spanning diagnostic, treatment, quality of life and survival domains was agreed.

CONCLUSIONS

These indicators build on and update previously available measures of lung cancer care and outcomes in use by national and international lung cancer clinical quality registries which, to our knowledge, have not been recently updated to reflect the changing lung cancer treatment paradigm.

Exploring important service characteristics of telephone cancer information and support services for callers: protocol for a systematic review of qualitative research

INTRODUCTION

As cancer incidence continues to rise, challenges remain in how to communicate accurate, timely information to people with cancer, their families and healthcare professionals. One option is to provide support and comprehensive, tailored information via a telephone cancer information and support service (CISS). This systematic review aims to summarise the service characteristics of telephone CISS and identify what aspects of services are important from callers' perspectives.

METHODS AND ANALYSIS

A comprehensive literature search will be conducted for articles published from database inception to 30 March 2023 (OVID MEDLINE, EMBASE, CINAHL, PsycINFO and SocINDEX). Published, peer-reviewed, articles reporting qualitative research on the service characteristics of telephone CISS important to callers in any language will be included. One researcher will complete the searches, two researchers will independently screen results for eligible studies and a third researcher will resolve any disagreement. A narrative and thematic synthesis of studies will be provided. Study characteristics will be independently extracted by one researcher and checked by a second. Included studies' methodological quality will be evaluated independently by two researchers using the 2022 Critical Appraisal Skills Programme Qualitative Studies Checklist. Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research tool will assess the confidence of the review findings.

ETHICS AND DISSEMINATION

Ethics approval is not required for this research as it is a planned systematic review of published literature. Findings will be presented at leading cancer, health economic and supportive care conferences, published in a peer-reviewed journal, and disseminated via websites and social media.

PROSPERO REGISTRATION NUMBER

CRD42023413897.

The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study)

BACKGROUND

This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations.

METHODS

Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators.

RESULTS

Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators.

CONCLUSIONS

This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms

BACKGROUND

Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.

METHODS

Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.

RESULTS

The program's audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.

CONCLUSIONS

Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

Strength in numbers: Utilization of an innovative electronic audit to enhance the completion of central line maintenance audits

BACKGROUND

Health care systems use auditing processes to monitor compliance with evidence-based practices. The auditing process for a bundle targeting central line-associated bloodstream infection prevention at a large children's hospital was suboptimal. The purpose of this project was to implement a revised audit and feedback data collection process. The specific aims of the project were to evaluate (1) the number of completed audits and, (2) central line maintenance bundle compliance rates before and after implementing a new process.

METHODS

An innovative, electronic audit process was developed to allow data entry in real-time as central line-associated bloodstream infection prevention champions conducted audits. Data were fed into a robust electronic dashboard, allowing units to readily visualize their performance. Data was analyzed over a 52-month period (26 months pre- and post-implementation).

RESULTS

The number of central line maintenance bundle audits significantly increased post-implementation from an average of 36 to 64 per month, P = .001. Central line maintenance bundle compliance scores also increased from an average compliance score of 76.3% to 89.3%, P = .001. Special cause variation was also noted in the statistical process control charts.

DISCUSSION

This project demonstrated the effectiveness of using an electronic process to capture audit data to assist with quality improvement efforts.

CONCLUSIONS

Other institutions may consider implementing a similar electronic audit process to capture infection prevention compliance data.

Care and three-year outcomes of children with Benign Epilepsy with Centro-Temporal Spikes in England

PURPOSE

Benign Epilepsy with Centro-Temporal Spikes (BECTS) is a pediatric epilepsy with typically good seizure control. Although BECTS may increase patients' risk of developing neurological comorbidities, their clinical care and short-term outcomes are poorly quantified.

METHODS

We retrospectively assessed adherence to National Institute for Health and Care Excellence (NICE) guidelines relating to specialist referral, electroencephalogram (EEG) conduct and annual review in the care of patients with BECTS, and measured their seizure, neurodevelopmental and learning outcomes at three years post-diagnosis.

RESULTS

Across ten centers in England, we identified 124 patients (74 male) diagnosed with BECTS between 2015 and 2017. Patients had a mean age at diagnosis of 8.0 (95% CI = 7.6-8.4) years. 24/95 (25%) patients were seen by a specialist within two weeks of presentation; 59/100 (59%) received an EEG within two weeks of request; and 59/114 (52%) were reviewed annually. At three years post-diagnosis, 32/114 (28%) experienced ongoing seizures; 26/114 (23%) had reported poor school progress; 15/114 (13%) were diagnosed with a neurodevelopmental disorder (six autism spectrum disorder, six attention-deficit/hyperactivity disorder); and 10/114 (8.8%) were diagnosed with a learning difficulty (three processing deficit, three dyslexia). Center-level random effects models estimated neurodevelopmental diagnoses in 9% (95% CI: 2-16%) of patients and learning difficulty diagnoses in 7% (95% CI: 2-12%).

CONCLUSIONS

In this multicenter work, we found variable adherence to NICE guidelines in the care of patients with BECTS and identified a notable level of neurological comorbidity. Patients with BECTS may benefit from enhanced cognitive and behavioral assessment and monitoring.

Inhaled Maintenance Therapy in the Follow-Up of COPD in Outpatient Respiratory Clinics. Factors Related to Inhaled Corticosteroid Use. EPOCONSUL 2021 Audit

OBJECTIVE

The aim of this analysis was to describe the patterns of inhaled maintenance therapy according to risk level and to explore the determinants associated with the decision to prescribe inhaled corticosteroids (ICS) in addition to bronchodilator therapy according to risk level as strategy in the follow-up of COPD in daily clinical practice.

METHODS

EPOCONSUL 2021 is a cross-sectional audit that evaluated the outpatient care provided to patients with a diagnosis of chronic obstructive pulmonary disease (COPD) in respiratory clinics in Spain with prospective recruitment between April 15, 2021 and January 31, 2022.

RESULTS

4225 patients from 45 hospitals in Spain were audited. Risk levels were analyzed in 2678 patients. 74.5% of patients were classified as high risk and 25.5% as low risk according to GesEPOC criteria. Factors associated with the prescription of ICS in low-risk COPD were symptoms suggestive of asthma [OR: 6.70 (3.14-14.29), p<0.001], peripheral blood eosinophilia>300mm3 [OR: 2.16 (1.10-4.24), p=0.025], and having a predicted FEV1%<80% [OR: 2.17 (1.15-4.08), p=0.016]. In high-risk COPD, factors associated with triple therapy versus dual bronchodilator therapy were a mMRC dyspnea score of ≥2 [OR: 1.97 (1.41-2.75), p<0.001], symptoms suggestive of asthma [OR: 6.70 (3.14-14.29), p<0.001], and a predicted FEV1%<50% [OR: 3.09 (1.29-7.41), p<0.011].

CONCLUSIONS

Inhaled therapy in the follow-up of COPD does not always conform to the current guidelines. Few changes in inhaled therapy are made at follow-up visits. The use of ICS is common in COPD patients who meet low-risk criteria in their follow-up and triple therapy in high-risk COPD patients is used as an escalation strategy in patients with high clinical impact. However, a history of exacerbations and eosinophil count in peripheral blood were not factors predicting triple therapy.

The impact of rurality on patient experience and diagnostic pathway intervals in Scotland's cancer patients: Further results from a national cancer diagnosis audit

BACKGROUND

In Scotland 17 % of the population reside rurally and previous research has demonstrated worse cancer outcomes in this group. The underlying reason for this is unclear. This study aims to determine whether patient presenting factors, GP consultation factors or the diagnostic pathways differ between urban and rural patients within Scotland.

METHODS

This study combined two Scottish National Cancer Diagnosis Audits. Participating GPs collected data on the diagnostic pathway from primary to secondary care for cancer patients diagnosed during the audit period. Using the Scottish Government Urban Rural Classification, patients were designated as rural or urban dwellers and compared in descriptive analyses. Key cancer intervals (primary, diagnostic, secondary and treatment interval) were compared between urban and rural dwellers with an additional adjusted analysis for the main cancer sites.

RESULTS

A total of 4309 cancer diagnoses were included in the study; 22 % were in patients from rural locations. Rural patients had significantly more consultations and investigations prior to referral than their urban counterparts. There was no difference in prolonged cancer pathways between the two groups except in lung cancer patients where rural patients had a significantly increased odds of a diagnostic interval of >90 days.

CONCLUSION

Our findings suggest differences in the interaction between patients and GPs prior to referral in urban and rural settings. However, this does not appear to lead to prolonged patient pathways, except in lung cancer. Further research is needed to determine whether this delay is clinically significant and contributing to poorer outcomes in Scottish rural dwellers with lung cancer.

Scale up of anaesthesia services in underserved rural Tanzania

BACKGROUND

Because of critical shortage of physician anaesthesiologists, the government of Tanzania adopted a task shifting strategy for provision of anaesthesia services. This paper describes the results of an operational study designed to increase the number of anaesthesia providers for emergency obstetric surgeries in order to reduce maternal and perinatal mortality in underserved rural Tanzania.

METHODS

In 2016 a before-after cohort study was conducted in seven health centres in rural Tanzania. Five health centres received an intervention and two were selected to track secular trends (control group). Ten associate clinicians, i.e. assistant medical officers, clinical officers, and nurse midwives, from five health centres were trained in anaesthesia skills for emergency obstetric surgeries for three months followed by quarterly supportive supervision, mentoring and teleconsultation to reinforce skills. Primary and secondary outcome measures included Caesarean delivery (CD) rate, quality and safety of anaesthesia, and uptake of the educational program for anaesthesia.

RESULTS

Out of the 2,179 CDs performed in the intervention facilities from 2016 to 2019, two women died from complications of anaesthesia. The risk of death from anaesthetic complications was 0.9 per 1000 CD (95% CI 0.1-3.3. The risk of death was not established in the control group because of inadequate documentation and records keeping. The proportion of CD performed under spinal anaesthesia in intervention facilities doubled from 28% (60/214 with 95% CI 22-35) at baseline (July 2014 - June 2016) to 57% (558/971 with 95% CI of 54-61) in year three (July 2018 - June 2019), while in the control group increased by only 40% from 19% (92/475 with 95% CI of 16-23) at baseline and 27% (68/251 with 95% CI of 22-33) in year three. In 2020I, this educational training program was then adopted by the government with minor content changes and increasing duration of training to six months.

CONCLUSIONS

This three month educational training program for associate clinicians in anaesthesia, complemented by supportive supervision, can increase the CD rate to one that fills the "unmet need" and the proportion of operations performed under spinal anaesthesia, the gold standard technique for CD. The program can be used to meet the urgent demand for anaesthesia services in other underserved areas in Africa.

Presentation and management of insect bites in out-of-hours primary care: a descriptive study

OBJECTIVES

To describe the population presenting to out-of-hours primary care with insect bites, establish their clinical management and the factors associated with antibiotic prescribing.

DESIGN

An observational study using routinely collected data from a large out-of-hours database (BORD, Birmingham Out-of-hours general practice Research Database).

SETTING

A large out-of-hour primary care provider in the Midlands region of England.

PARTICIPANTS

All patients presenting with insect bites between July 2013 and February 2020 were included comprising 5774 encounters.

OUTCOME MEASURES

This cohort was described, and a random subcohort was created for more detailed analysis which established the clinical features of the presenting insect bites. Logistic regression was used to model variables associated with antibiotic prescribing.

RESULTS

Of the 5641 encounters solely due to insect bites, 67.1% (95% CI 65.8% to 68.3%) were prescribed antibiotics. General practitioners were less likely to prescribe antibiotics than advanced nurse practitioners (60.5% vs 71.1%, p<0.001) and there was a decreasing trend in antibiotic prescribing as patient deprivation increased. Pain (OR 2.13, 95% CI 1.18 to 3.86), swelling (OR 2.88, 95% CI 1.52 to 5.46) and signs of spreading (OR 3.45, 95% CI 1.54 to 7.70) were associated with an increased frequency of antibiotic prescribing. Extrapolation of the findings give an estimated incidence of insect bite consultations in England of 1.5 million annually.

CONCLUSION

Two-thirds of the patients presenting to out-of-hours primary care with insect bites receive antibiotics. While some predictors of prescribing have been found, more research is required to understand the optimal use of antibiotics for this common presentation.

Risk factors in cardiovascular patients: Challenges and opportunities to improve secondary prevention

BACKGROUND

Effective management of major cardiovascular risk factors is of great importance to reduce mortality from cardiovascular disease (CVD). The Survey of Risk Factors in Coronary Heart Disease (SURF CHD) II study is a clinical audit of the recording and management of CHD risk factors. It was developed in collaboration with the European Association of Preventive Cardiology and the European Society of Cardiology (ESC). Previous studies have shown that control of major cardiovascular risk factors in patients with established atherosclerotic CVD is generally inadequate. Azerbaijan is a country in the South Caucasus, a region at a very high risk for CVD.

AIM

To assess adherence to ESC recommendations for secondary prevention of CVD based on the measurement of both modifiable major risk factors and their therapeutic management in patients with confirmed CHD at different hospitals in Baku (Azerbaijan).

METHODS

Six tertiary health care centers participated in the SURF CHD II study between 2019 and 2021. Information on demographics, risk factors, physical and laboratory data, and medications was collected using a standard questionnaire in consecutive patients aged ≥ 18 years with established CHD during outpatient visits. Data from 687 patients (mean age 59.6 ± 9.58 years; 24.9% female) were included in the study.

RESULTS

Only 15.1% of participants were involved in cardiac rehabilitation programs. The rate of uncontrolled risk factors was high: Systolic blood pressure (BP) (SBP) (54.6%), low-density lipoprotein cholesterol (LDL-C) (86.8%), diabetes mellitus (DM) (60.6%), as well as overweight (66.6%) and obesity (25%). In addition, significant differences in the prevalence and control of some risk factors [smoking, body mass index (BMI), waist circumference, blood glucose (BG), and SBP] between female and male participants were found. The cardiovascular health index score (CHIS) was calculated from the six risk factors: Non- or ex-smoker, BMI < 25 kg/m2, moderate/vigorous physical activity, controlled BP (< 140/90 mmHg; 140/80 mmHg for patients with DM), controlled LDL-C (< 70 mg/dL), and controlled BG (glycohemoglobin < 7% or BG < 126 mg/dL). Good, intermediate, and poor categories of CHIS were identified in 6%, 58.3%, and 35.7% of patients, respectively (without statistical differences between female and male patients).

CONCLUSION

Implementation of the current ESC recommendations for CHD secondary prevention and, in particular, the control rate of BP, are insufficient. Given the fact that patients with different comorbid pathologies are at a very high risk, this is of great importance in the management of such patients. This should be taken into account by healthcare organizers when planning secondary prevention activities and public health protection measures, especially in the regions at a high risk for CVD. A wide range of educational products based on the Clinical Practice Guidelines should be used to improve the adherence of healthcare professionals and patients to the management of CVD risk factors.

A systematic review of studies reporting the development of core outcome sets for use in routine care

OBJECTIVES

Core outcome sets (COS) represent the minimum health outcomes to be measured for a given health condition. Interest is growing in using COS within routine care to support delivery of patient-focused care. This review aims to systematically map COS developed for routine care to understand their scope, stakeholder involvement, and development methods.

METHODS

Medline (Ovid), Scopus, and Web of Science Core collection were searched for studies reporting development of COS for routine care. Data on scope, methods, and stakeholder groups were analyzed in subgroups defined by setting.

RESULTS

Screening 25,301 records identified 262 COS: 164 for routine care only and 98 for routine care and research. Nearly half of the COS (112/254, 44%) were developed with patients, alongside input from experts in registries, insurance, legal, outcomes measurement, and performance management. Research publications were often searched to generate an initial list of outcomes (115/198, 58%) with few searching routine health records (47/198, 24%).

CONCLUSION

An increasing number of COS is being developed for routine care. Although involvement of patient stakeholders has increased in recent years, further improvements are needed. Methodology and scope are broadly similar to COS for research but implementation of the final set is a greater consideration during development.

Francis' Hospital of Katete District: A clinical audit in Zambia

Background

Most imaging examinations use ionising radiation which causes biological effects on the body. For this reason, only justified examinations should be requested by adequately completing the radiology request form (RRF) by clinicians. The RRF allows radiographers and radiologists to assess if the benefit outweighs the risk associated with medical radiation exposure. Inadequately or incorrectly filled RRFs leads to unnecessary radiation exposures, imaging errors, and delays in performing the examination. Therefore, this study aimed at auditing the adequacy of completion of general RRFs at St. Francis' Hospital of Katete District in Zambia.

Methods

This was a quantitative study in which RRFs for general radiography from January to December 2020 were audited. Data were collected retrospectively using a checklist from a total of 974 RRFs. The filled-in forms were assessed for completeness of information related to the patient, examination, and referring clinician. Data were analysed using descriptive statistics. The standard of completeness was based on the Royal College of Radiologists (RCR) guidelines requiring all the designated variables completed on the RRF.

Results

Most N=881(90.5%), RRFs were incompletely filled. With regards to patient's identification, the findings revealed N=4(0.5%), N=597(61.3%), N=3(0.4%), and N=2(0.3%) RRFs devoid of patient's name, hospital number, age, and gender, respectively. Regarding the examination, the findings revealed N=3(0.4%), N=68(7%), N=449(46.2%), and N=336 (37%) RRFs devoid of requested examination, indication, clinical history, and level of urgency, respectively. Regarding the referrer, the findings revealed N=135(13.9%), N=173(17.8 %), N=472(48.5%), and N=31(3.2%) RRFs were devoid of information relating to the ward, clinicians' name, referring department, and signature, respectively.

Conclusion

This audit reports that most of the RRFs were incompletely filled-in at St. Francis' Hospital. Furthermore, the hospital number, clinical history and level of urgency were the frequently unfilled variables. Overall, there were gaps in completion of RRFs requiring remedying.

["Red code" C-sections: A new tool developed with Delphi method is enabling analysis of practices]

OBJECTIVE

In France, C-sections are classified through a color code according to their degree of urgency. A red-classified C-section is triggered when life of mother or fetus is immediately threatened These cases happen very rarely and represent less than 1% of total deliveries. Many French maternity hospitals are above this rate. This risky procedure should remain an exception. The main purpose of this study is to develop a new tool enabling to determine the relevance of red C-sections in order to improve obstetrical practices.

METHODS

Eleven national obstetrical experts were submitted with relevant-estimated indications of red C-sections. A two-round Delphi methodology was then used to reach a consensus on a new table of relevance.

RESULTS

Five different groups of indications were proposed to the panel of experts. After two rounds, four groups achieved a consensus by being qualified "very relevant" or "relevant" by more than 80% of the 11 experts.

CONCLUSION

The aim of this new consensual table of relevance is to improve quality of care. It allows to evaluate the relevance of red C-sections and determine when red C-sections are non-relevant but it particularly helps teams to identify ways of improvements. Finally, this tool enables a reproductible analysis that can be further intra- or inter-hospitals developed towards harmonization of practices.

Fostering practice-based evidence through routine outcome monitoring in a university psychotherapy service for common mental health problems: a protocol for a naturalistic, observational study

INTRODUCTION

Data-informed psychotherapy and routine outcome monitoring are growing as referents in psychotherapy research and practice. In Ecuador, standardised web-based routine outcome monitoring systems have not been used yet, precluding data-driven clinical decisions and service management. Hence, this project aims at fostering and disseminating practice-based evidence in psychotherapy in Ecuador by implementing a web-based routine outcome monitoring system in a university psychotherapy service.

METHODS AND ANALYSES

This is a protocol for an observational naturalistic longitudinal study. Progress and outcomes of treatment in the Centro de Psicología Aplicada of the Universidad de Las Américas in Quito, Ecuador will be examined. Participants will be adolescents and adults (≥11 years) seeking treatment, as well as therapists and trainees working at the centre between October 2022 and September 2025. Clients' progress will be monitored by a range of key variables: psychological distress, ambivalence to change, family functioning, therapeutic alliance and life satisfaction. Sociodemographic information and satisfaction with treatment data will be collected before and at the end of treatment, respectively. Also, semi-structured interviews to explore therapists' and trainees' perceptions, expectations and experiences will be conducted. We will analyse first contact data, psychometrics of the measures, reliable and clinically significant change, outcome predictors as well as trajectories of changes. Moreover, we will conduct a framework analysis for the interviews.

ETHICS AND DISSEMINATION

The protocol for this study was approved by the Human Research Ethics Committee of the Pontificia Universidad Católica del Ecuador (#PV-10-2022). The results will be disseminated in peer-reviewed scientific articles, at conferences and in workshops.

TRIAL REGISTRATION NUMBER

NCT05343741.

QuADRANT: a study on uptake and implementation of clinical audit of medical radiological procedures in Europe-expert recommendations for improvement, endorsed by the ESR

BACKGROUND

QuADRANT was a study funded by the European Commission to evaluate clinical audit uptake and implementation across Europe, with an emphasis on clinical audit as mandated within the BSSD (Basic Safety Standards Directive).

AIMS

QuADRANT objectives-obtain an overview of European clinical audit activity; identify good practices and resources, barriers and challenges; provide guidance and recommendations going forwards; identify the potential for European Union action on quality and safety in the three core project specialties, radiology, radiotherapy and nuclear medicine.

FINDINGS AND RECOMMENDATIONS

QuADRANT identified that developments in national clinical audit infrastructure are required. National professional societies can be pivotal in improving clinical audit implementation, but resource allocation and national prioritisation of clinical audit are needed in many countries. Lack of staff time and expertise are also barriers. Enablers to enhance clinical audit participation are not widely employed. Development of hospital accreditation programmes can facilitate clinical audit uptake. An active and formalised role for patients in clinical audit practice and policy development is recommended. There is persisting variation in European awareness of BSSD clinical audit requirements. Work is needed to improve dissemination of information on the legislative requirements relating to clinical audit in the BSSD and in relation to inspection processes to ensure these include clinical audit and that they encompass all clinics and specialties involved in medical applications using ionising radiation.

CONCLUSION

QuADRANT provides an important step towards enhancing clinical audit uptake and implementation across Europe and improving patient safety and outcomes.

Cross-sectional health centre and community-based evaluation of the impact of pneumococcal and malaria vaccination on antibiotic prescription and usage, febrile illness and antimicrobial resistance in young children in Malawi: the IVAR study protocol

INTRODUCTION

Vaccination is a potentially critical component of efforts to arrest development and dissemination of antimicrobial resistance (AMR), though little is known about vaccination impact within low-income and middle-income countries. This study will evaluate the impact of vaccination on reducing carriage prevalence of resistant Streptococcus pneumoniae and extended spectrum beta-lactamase-producing Escherichia coli and Klebsiella species. We will leverage two large ongoing cluster-randomised vaccine evaluations in Malawi assessing; first, adding a booster dose to the 13-valent pneumococcal conjugate vaccine (PCV13) schedule, and second, introduction of the RTS,S/AS01 malaria vaccine.

METHODS AND ANALYSIS

Six cross-sectional surveys will be implemented within primary healthcare centres (n=3000 users of outpatient facilities per survey) and their local communities (n=700 healthy children per survey): three surveys in Blantyre district (PCV13 component) and three surveys in Mangochi district (RTS,S/AS01 component). We will evaluate antibiotic prescription practices and AMR carriage in children ≤3 years. For the PCV13 component, surveys will be conducted 9, 18 and 33 months following a 3+0 to 2+1 schedule change. For the RTS,S/AS01 component, surveys will be conducted 32, 44 and 56 months post-RTS,S/AS01 introduction. Six health centres in each study component will be randomly selected for study inclusion. Between intervention arms, the primary outcome will be the difference in penicillin non-susceptibility prevalence among S. pneumoniae nasopharyngeal carriage isolates in healthy children. The study is powered to detect an absolute change of 13 percentage points (ie, 35% vs 22% penicillin non-susceptibility).

ETHICS AND DISSEMINATION

This study has been approved by the Kamuzu University of Health Sciences (Ref: P01-21-3249), University College London (Ref: 18331/002) and University of Liverpool (Ref: 9908) Research Ethics Committees. Parental/caregiver verbal or written informed consent will be obtained prior to inclusion or recruitment in the health centre-based and community-based activities, respectively. Results will be disseminated via the Malawi Ministry of Health, WHO, peer-reviewed publications and conference presentations.

Clinical audit in European radiology: current status and recommendations for improvement endorsed by the European Society of Radiology (ESR)

Clinical audit is an important quality improvement activity and has significant benefits for patients in terms of enhanced care, safety, experience and outcomes. Clinical audit in support of radiation protection is mandated within the European Council Basic Safety Standards Directive (BSSD), 2013/59/Euratom. The European Society of Radiology (ESR) has recognised clinical audit as an area of particular importance in the delivery of safe and effective health care. The ESR, alongside other European organisations and professional bodies, has developed a range of clinical audit-related initiatives to support European radiology departments in developing a clinical audit infrastructure and fulfilling their legal obligations. However, work by the European Commission, the ESR and other agencies has demonstrated a persisting variability in clinical audit uptake and implementation across Europe and a lack of awareness of the BSSD clinical audit requirements. In recognition of these findings, the European Commission supported the QuADRANT project, led by the ESR and in partnership with ESTRO (European Association of Radiotherapy and Oncology) and EANM (European Association of Nuclear Medicine). QuADRANT was a 30-month project which completed in Summer 2022, aiming to provide an overview of the status of European clinical audit and identifying barriers and challenges to clinical audit uptake and implementation. This paper summarises the current position of European radiological clinical audit and considers the barriers and challenges that exist. Reference is made to the QuADRANT project, and a range of potential solutions are suggested to enhance radiological clinical audit across Europe.

Feedback on clinical team performance: how does it work, in what contexts, for whom, and for what changes? A critical realist qualitative multiple case study

BACKGROUND

Feedback on clinical performance aims to provide teams in health care settings with structured results about their performance in order to improve these results. Two systematic reviews that included 147 randomized studies showed unresolved variability in professional compliance with desired clinical practices. Conventional recommendations for improving feedback on clinical team performance generally appear decontextualized and, in this regard, idealized. Feedback involves a complex and varied arrangement of human and non-human entities and interrelationships. To explore this complexity and improve feedback, we sought to explain how feedback on clinical team performance works, for whom, in what contexts, and for what changes. Our goal in this research was to present a realistic and contextualized explanation of feedback and its outcomes for clinical teams in health care settings.

METHODS

This critical realist qualitative multiple case study included three heterogeneous cases and 98 professionals from a university-affiliated tertiary care hospital. Five data collection methods were used: participant observation, document retrieval, focus groups, semi-structured interviews, and questionnaires. Intra- and inter-case analysis performed during data collection involved thematic analysis, analytical questioning, and systemic modeling. These approaches were supported by critical reflexive dialogue among the research team, collaborators, and an expert panel.

RESULTS

Despite the use of a single implementation model throughout the institution, results differed on contextual decision-making structures, responses to controversy, feedback loop practices, and use of varied technical or hybrid intermediaries. Structures and actions maintain or transform interrelationships and generate changes that are in line with expectations or the emergence of original solutions. Changes are related to the implementation of institutional and local projects or indicator results. However, they do not necessarily reflect a change in clinical practice or patient outcomes.

CONCLUSIONS

This critical realist qualitative multiple case study offers an in-depth explanation of feedback on clinical team performance as a complex and open-ended sociotechnical system in constant transformation. In doing so, it identifies reflexive questions that are levers for the improvement of team feedback.

From coding to clinical nurse specialist: how a review of coding practice enabled hysteroscopy nurse development

Clinical coding, the method by which departments are reimbursed for providing services to patients, is widely mispractised within the NHS. Improving clinical coding accuracy therefore offers an opportunity to increase departmental income, guide efficient resource allocation and enable staff development. The authors audited the clinical coding in outpatient hysteroscopy clinics at their institution and found that coding errors were both prevalent and correctable. By implementing simple changes in coding procedure, and without any additional administrative cost, they significantly improved coding accuracy and achieved an increase in total annual tariffs. Although not applicable in a block contract, this will become highly relevant in a restoration of the Payment by Results tariff system. Nurse development is a key objective of the NHS Long Term Plan but can be hindered by staff costs, which require departmental funding. In the authors' institution, improved clinical coding accuracy directly led to a departmental restructuring, funded the development of a new hysteroscopy nurse development and improved care delivery. Coding errors are not unique to the authors' trust, yet simple amendments led to meaningful changes. Therefore, careful auditing and implemented change are needed to raise national clinical coding standards, to enable clinical restructuring, staff development, and provide more efficient, patient-centred care.

Variations in Chronic Obstructive Pulmonary Disease Outpatient Care in Respiratory Clinics: Results From the 2021 EPOCONSUL Audit

INTRODUCTION

The aim of our work has been to describe the results of the clinical audit carried out in 2021 and to compare the results with 2015 EPOCONSUL audit.

METHODS

EPOCONSUL 2021 is a cross-sectional audit that evaluated the outpatient care provided to patients with a diagnosis of chronic obstructive pulmonary disease (COPD) in respiratory clinics in Spain with prospective recruitment between April 15, 2021, and January 31, 2022.

RESULTS

A total of 45 hospitals participated in the 2021 audit and 4.225 clinical records of patients were evaluated. Clinical phenotype according to the Spanish National Guidelines for COPD care (GesEPOC) was reported in 63.1% of the audited patients, and the COPD type assessment for the Global initiative for chronic Obstructive Lung Disease (GOLD) was present in 38.3%. There was an improved compliance with clinical practice guideline (CPG) recommendations in the 2021 audit with respect to the 2015 audit. There was an increase in the proportion of cases with alfa-1-antitrypsin serum level testing available (audit 1: 18.9%; audit 2: 38.7%, p<0.001) and 6-min walk test carried out (audit 1: 24%; audit 2: 45.2%, p<0.001). However, these significant variations adherence to CPG recommendations were not reached for the clinical evaluation and therapeutic intervention category when adjusting for patient and resource variables.

CONCLUSIONS

The 2021 EPOCONSUL audit showed increased adherence to recommendations although they seem to be related to the availability of resources for care. These results should be taken into account in order to establish improvements in resources to achieve a better quality of care.

Using body cameras to quantify the duration of a Code Stroke and identify workflow issues: a continuous observation workflow time study

OBJECTIVE

'Code Stroke' (Code) is used in health services to streamline hyperacute assessment and treatment delivery for patients with ischaemic stroke. However, there are few studies that detail the time spent on individual components performed during a Code. We sought to quantify the time taken for each process during a Code and investigate associations with modifiable and non-modifiable factors.

DESIGN

Continuous observation workflow time study.

SETTING AND PARTICIPANTS

Recordings of 100 Codes were performed at a high-volume primary stroke centre in Melbourne, Australia, between January and June 2020 using a body camera worn by a member of the stroke team.

MAIN OUTCOME MEASURES

The main measures included the overall duration of Codes and the individual processes within the Code workflow. Associations between variables of interest and process times were explored using linear regression models.

RESULTS

100 Codes were captured, representing 19.2% of all Codes over the 6 months. The median duration of a complete Code was 54.2 min (IQR 39.1-74.7). Administrative work performed after treatment is completed (median 21.0 min (IQR 9.8-31.4)); multimodal CT imaging (median 13.0 min (IQR 11.5-15.7)), and time between decision and thrombolysis administration (median 8.1 min (IQR 6.1-10.8)) were the longest components of a Code. Tenecteplase was able to be prepared faster than alteplase (median 1.8 vs 4.9 min, p=0.02). The presence of a second junior doctor was associated with shorter administrative work time (median 10.3 vs 25.1 min, p<0.01). No specific modifiable factors were found to be associated with shorter overall Code duration.

CONCLUSIONS

Codes are time intensive. Time spent on decision-making was a relatively small component of the overall Code duration. Data from body cameras can provide granular data on all aspects of Code workflow to inform potential areas for improvement at individual centres.

Clinical audit of the Consultation-Liaison psychiatric service of a metropolitan hospital

OBJECTIVE

The primary objective of this study was to use clinical indicators to track changes in efficiency of a Consultation-Liaison service as part of a clinical audit cycle.

METHODS

This was a clinical audit cycle. The auditing phase involved measuring the efficiency of the service. The 'intervention' was simply the team's awareness and involvement in tracking these statistics. Subsequently, these indicators were re-audited.

RESULTS

In the initial audit cycle, 315 referrals to the C-L service were audited over a 3 month period, showing a 24 hour time-to-seen rate of 80% and a 36 hour time-to-seen rate of 89.2%. Upon re-auditing of 112 referrals following our intervention, 24 hr timeliness had risen to 92% and 36 hr timeliness had risen to 96.4%.

CONCLUSION

The measuring of clinical indicators of efficiency in C-L may give service improvement personnel a reflection of the functionality of a C-L service. By involving team members in the measuring and tracking of these indicators, we may be able to boost overall clinical efficiency and outcomes.

Clinical audit and research in radiography practice: An exploration of the English landscape

BACKGROUND

Research and clinical audit are central to the quality improvement (QI) process in healthcare; whereas research produces new knowledge, clinical audit establishes if practice is meeting set standards. Thus, radiographers have responsibility to engaging in these QI activities. This study aimed to explore radiographers' understanding, attitudes and level of involvement in clinical research and audit across England.

METHODS

A cross-sectional survey using an online questionnaire for data collection over a 6-week period was employed. The questionnaire consisted of open and closed ended questions. Participants were recruited through social media. The quantitative data obtained was analysed using Statistical Package for Social Sciences (SPSS) Version 26 (IBM Inc, Armonk, NY) whilst content analysis was used to analyse the free-response data.

RESULTS

A total of 100 valid responses were obtained after exclusion of 45 partial and/or incomplete responses. Radiographers showed a positive attitude towards involvement in research and audit with overall mean score of 3.85 (SD 0.80) and 4.01 (SD 0.80), respectively. Of the respondents, 35.7% (n = 35/98) were currently involved in clinical audit projects whilst 78.6% (n = 77/98) have previously been involved. Radiographers with postgraduate degrees were significantly more likely to have initiated research, 61.5% (n = 16/26) (p = 0.01) and to have previously been involved with research, 80.8% (n = 21/26) (p = 0.02). A significant association between radiographers' role and implementation of changes, following an audit (p = 0.03) was noted. Similarly, a significant association was noted between radiographers' role and initiation of research (p = 0.05).

CONCLUSION

Clinical radiographers in England showed a positive attitude towards research and audit. However, this did not translate into actual participation in research and audit activities.

IMPLICATIONS FOR PRACTICE

The need to stimulate clinical radiographers' interest in clinical audit and research is highlighted. Additionally, the findings support the rationale for managers to give more support including protected time to radiographers to engage in QI activities.

The Hawthorne Effect: Quality and Outcomes in Neurosurgery

Measure something, and it gets better-this is what is called as the Hawthorne effect (also known as the observer effect). The Hawthorne factory experiments in 1920s were remarkable industrial data collection and analysis exercises that lead to Edwards Deming's quality revolution. The Harvard Medical Practice Study (1991), Leape's "Error in Medicine" (1994), and the Bristol pediatric cardiac report (2001) are among many documents that have revealed the huge gap between best practices and actual medical practice. Alarmed by the poor standards of quality at the most respected institutions, the medical fraternity therefore began visiting facilities in different fields and observing their quality assessment processes. The next leap for neurosurgery is to realize that it is unacceptable to treat patients with no regard for the standard of clinical outcomes. The traditional neurosurgery residency training has long ignored the most important issues of self-assessment, reappraisal, relearning, and measurement of skill and surgical outcomes. However, the experience taken from disparate fields, especially cardiac surgery, may encourage research and progress in measurement and improvement of quality in neurosurgery. Like cardiac surgeons, neurosurgeons must examine and analyze the results of their interventions. The concept of quality measurement is the most important single advance we can make in neurosurgery practice. Meticulous and precise measurement of outcomes will allow future progress of our specialty.

Quest to Improve Management of Prostate Cancer in West Africa: Development of a Clinical Audit Tool

In 2010 and during the following decade, two guidelines were published for the management of prostate cancer in West Africa. A key recommendation of the guidelines was the need for the development of a Clinical Audit Tool which should help surgeons and institutions to identify the gaps between the recommended standards and current practice. In this paper, a Clinical Audit Tool, WAPCAT, was developed to facilitate and implement the audit process for the management of Prostate cancer in a West African healthcare institution.

Effectiveness of treatments for symptoms of post-trauma related guilt, shame and anger in military and civilian populations: a systematic review

INTRODUCTION

Individuals who have been exposed to a traumatic event can develop profound feelings of guilt, shame and anger. Yet, studies of treatments for post-traumatic stress disorder (PTSD) have largely investigated changes in PTSD symptoms relating to a sense of ongoing fear or threat and the effectiveness of such treatments for post-trauma related guilt, shame or anger symptom reduction is comparatively not well understood.

METHODS

This review systematically examined the effectiveness of existing treatment approaches for three symptoms associated with exposure to traumatic events: guilt, shame and anger. Studies included had to be published after 2010 with a sample size of n=50 or greater to ensure stable treatment outcome estimates.

RESULTS

15 studies were included, consisting of both civilian and (ex-) military population samples exposed to a wide range of traumatic events (eg, combat-related, sexual abuse). Findings indicated a moderate strength of evidence that both cognitive-based and exposure-based treatments are similarly effective in reducing symptoms. Cognitive-based treatments were found to effectively reduce post-trauma related guilt and anger, while exposure-based treatments appeared effective for post-trauma related guilt, shame and anger.

CONCLUSIONS

The findings suggest the importance of confronting and discussing the traumatic event during therapy, rather than using less directive treatments (eg, supportive counselling).Nonetheless, while these results are promising, firm conclusions regarding the comparative effectiveness and long-term impact of these treatments could not be drawn due to insufficient evidence. Further empirical research is needed to examine populations exposed to traumatic events and investigate which treatment approaches (or combination thereof) are more effective in the long-term.

Study protocol for developing a novel approach for improving supply chain management for SARS-CoV-2 point of care diagnostic services in resource-limited settings: a case study of Mopani District in Limpopo province, South Africa

INTRODUCTION

Recent evidence shows that point-of-care (POC) testing is a more feasible alternative for diagnosis of COVID-19 in settings that have poor access to laboratory diagnostic services. Equitable access to POC testing can be optimised through well-established supply chain management (SCM) systems. The proposed study aims to develop a novel approach for improving SCM for COVID-19 POC diagnostic services in resource-limited settings with poor access to laboratory diagnostic services, using Mopani District in Limpopo Province, South Africa as a study setting.

METHODS AND ANALYSIS

This study was guided by results of the scoping review. Following the scoping review, we propose a mixed-methods study, which will be implemented in three phases. First, we will perform a geospatial analysis to investigate the spatial distribution of COVID-19 testing services. Second, we will perform an audit of POC diagnostic services including its supply chain to evaluate the effect of SCM on accessibility of COVID-19 POC diagnostic services and reveal SCM barriers and enablers of accessibility of COVID-19 POC diagnostic services. Third, we will perform a nominal group technique to collaborate with key stakeholders in co-creation of a novel approach for improving SCM systems for COVID-19 POC diagnostic services. For the geospatial analysis, we will employ the ArcGIS Software. For the analysis of quantitative and qualitative data that will be generated from the audit and nominal group discussion, we will employ Stata software and NVivo software, respectively.

ETHICS AND DISSEMINATION

This study has been ethically reviewed and approved by two institutional review boards: University of Pretoria Faculty of Health Sciences Research Ethics Committee (approval number 655/2021) and Limpopo Department of Health Research Ethics Committee (approval number LP-2021-12-007). The results of this study will be disseminated through national and international presentations and peer-reviewed publications.

Mortality as an indicator of quality of neurosurgical care in England: a retrospective cohort study

OBJECTIVES

Postoperative mortality is a widely used quality indicator, but it may be unreliable when procedure numbers and/or mortality rates are low, due to insufficient statistical power. The objective was to investigate the statistical validity of postoperative 30-day mortality as a quality metric for neurosurgical practice across healthcare providers.

DESIGN

Retrospective cohort study.

SETTING

Hospital Episode Statistics data from all neurosurgical units in England.

PARTICIPANTS

Patients who underwent neurosurgical procedures between April 2013 and March 2018. Procedures were grouped using the National Neurosurgical Audit Programme classification.

OUTCOMES MEASURED

National 30-day postoperative mortality rates were calculated for elective and non-elective neurosurgical procedural groups. The study estimated the proportion of neurosurgeons and NHS trusts in England that performed sufficient procedures in 3-year and 5-year periods to detect unusual performance (defined as double the national rate of mortality). The actual difference in mortality rates that could be reliably detected based on procedure volumes of neurosurgeons and units over a 5-year period was modelled.

RESULTS

The 30-day mortality rates for all elective and non-elective procedures were 0.4% and 6.1%, respectively. Only one neurosurgeon in England achieved the minimum sample size (n=2402) of elective cases in 5 years needed to detect if their mortality rate was double the national average. All neurosurgical units achieved the minimum sample sizes for both elective (n=2402) and non-elective (n=149) procedures. In several neurosurgical subspecialties, approximately 80% of units (or more) achieved the minimum sample sizes needed to detect if their mortality rate was double the national rate, including elective neuro-oncology (baseline mortality rate=2.3%), non-elective neuro-oncology (rate=5.7%), neurovascular (rate=6.7%) and trauma (rate=11%).

CONCLUSION

Postoperative mortality lacks statistical power as a measure of individual neurosurgeon performance. Neurosurgical units in England performed sufficient procedure numbers overall and in several subspecialty areas to support the use of mortality as a quality indicator.

Factors influencing receipt of an antibiotic prescription among insured patients in Tanzania: a cross-sectional study

OBJECTIVES

There are limited data on factors influencing antibiotic prescription among insured patients. We assessed for correlates of an antibiotic prescription among insured patients.

DESIGN

A cross-sectional study.

SETTING

The study was conducted at the National Health Insurance Fund offices, Dar es Salaam, Tanzania.

DATA SOURCE

We captured data from the claim forms, containing inpatient and outpatient treatment information for insured patients, for the month of September 2019.

OUTCOME VARIABLE

Receipt of an antibiotic prescription.

EXPOSURE VARIABLES

Age, sex, diagnosis, prescriber qualification, health facility level, ownership and department were exposure variables. Predictors of receipt of an antibiotic prescription were determined by Poisson regression analysis.

RESULTS

Of 993 analysed patients, the mean (±SD) age was 36.3 (±23.2) years, 581 (58.5%) were females and 535 (53.9%) were adults. The prevalence of antibiotic prescription was 46.4% (95% CI 42.8% to 50.0%). Strong predictors of an antibiotic prescription were being a child (1.7, 95% CI 1.3 to 2.2); acute upper respiratory tract infection (URTI) of multiple and unspecified sites (1.6, 95% CI 1.3 to 1.4); chronic rhinitis, nasopharyngitis and pharyngitis (4.0, 95% CI 2.4 to 6.4); being attended by a clinical officer (1.9, 95% CI 1.2 to 3.0); attending a health centre (1.5, 95% CI 1.1 to 2.0); attending a public facility (1.2, 95% CI 1.0 to 1.4) and visiting an inpatient department (2.0, 95% CI 1.2 to 3.4).

CONCLUSIONS

Among insured patients, being a child, acute URTI, being attended by a clinical officer or dental therapist, being attended by an assistant medical/dental officer, attending a health centre or a district hospital, attending a public health facility and visiting an inpatient department predicted an antibiotic prescription. Incorporation of these findings in revisions or establishment of targeted antimicrobial stewardship programmes may lead to better antibiotic prescribing practices that are critical for combating antibiotic resistance.

Therapeutic audit of patients on warfarin in an anticoagulation clinic of a tertiary care hospital

BACKGROUND

Studies have reported huge variations in the prescribing practice of warfarin. We carried out a clinical audit of warfarin use in an anticoagulation clinic of a tertiary care hospital.

METHODS

Patients receiving warfarin for at least 6 months were recruited and the following details were collected: demographics (age, body weight and gender); diagnoses; concomitant drugs. We calcula-ted CHA₂DS₂-VASc, HASBLED and SAMe-TT2R2 scores for each study participant. Statins, proton pump inhibitors, carbamazepine and amiodarone were the concomitant drugs identified with potential drug interaction with warfarin in patients.

RESULTS

Two hundred and three patients were recruited. Almost one-third of the study population had poor anticoagulation status. CHA₂DS₂-VASc and HASBLED scores were the significant predictors of appropriate anticoagulation. Poor anticoagulation status was observed more commonly in the first 6 months following which improvements were seen. Nearly half-of the time abnormal PT-INR was observed to be either between 2 to 2.4 (for patients with heart valve replacements) or 1.5 to 1.9 (for other indications). Significant number of patients without any potentially interacting drugs was observed with higher risk of supra-therapeutic PT-INR.

CONCLUSION

We observed a similar proportion of patients with adequate anticoagulation in our study participants as reported in other populations; and have identified categories at risk for poor anticoagulation. It is the need of the hour to develop in-house algorithm in compliance to international standards for dose titration of warfarin.

JBI series paper 3: The importance of people, process, evidence, and technology in pragmatic, healthcare provider-led evidence implementation

In this paper, we describe and discuss evidence implementation as a venture in global human collaboration within the framework of "people, process, evidence, and technology" as a roadmap for navigating implementation. At its core implementation is not a technological, or theoretical process, it is a human process. That health professionals central to implementation activities may not have had formal training in implementation, highlights the need for processes and programs that can be integrated within healthcare organization structures. Audit with feedback is an accessible implementation approach that includes the capacity to embed theory, frameworks, and bottom-up change processes to improve the quality of care. In this third paper in the JBI series, we discuss how four overarching principals necessary for sustainability (Culture, Capacity, Communication, and Collaboration) are combined with evidence, technology, and resources for evidence-based practice change. This approach has been successfully used across hundreds of evidence implementation projects around the globe for over 15 years. We present healthcare practitioner-led evidence-based practice improvement as sustainable and achievable in collaborative environments such as the global JBI network as a primary interest of the practicing professions and provide an overview of the JBI approach to evidence implementation.

Pretreatment hearing grades and hearing recovery outcomes after primary hyperbaric oxygen treatment in patients with idiopathic sudden sensorineural hearing loss

INTRODUCTION

Previous studies suggest the effectiveness of hyperbaric oxygen treatment (HBOT) in idiopathic sudden sensorineural hearing loss (ISSNHL) but it is mostly used as an adjuvant and salvage treatment. This study evaluated the effect of primary HBOT according to pretreatment hearing grades and hearing recovery outcomes using modified Siegel's criteria in patients with ISSNHL.

METHODS

Fifty-nine ISSNHL patients treated with only HBOT were included. A pure-tone audiogram was recorded before and after a course of HBOT (90 min at 203 kPa daily for 20 days). Using the modified Siegel's criteria, patients were divided into groups according to hearing threshold before and after treatment.

RESULTS

Hearing thresholds were significantly lower after HBOT compared to pre-treatment values across all patients (P < 0.001) with a median value of recovery of 22.5 dB (interquartile range 12.5-33.7 dB). Significantly lower hearing threshold values were recorded at 500, 1,000, 2,000, and 4,000 Hz after treatment (P < 0.001). The greatest recovery was at 1,000 Hz, (change in median threshold = 32 dB) but without a significant difference compared to other frequencies (P = 0.10).

CONCLUSIONS

HBOT is a legitimate choice as the primary treatment for ISSNHL, especially if it is readily accessible, and if there are contraindications for corticosteroid therapy.

Growth management and prevalence of underweight of indigenous children (Orang Asli) in Peninsular Malaysia: a clinical audit

Background

Most indigenous people (Orang Asli in Peninsular Malaysia) live in poverty, and their children are at risk of growth problems due to nutrition deficiency. Routine health and growth assessments are essential to identify these children. This clinical audit aimed to determine the growth management of indigenous children and the prevalence of underweight among these children in Perak state, Malaysia.

Methods

A clinical audit was conducted in 2016 after obtaining consensus from stakeholders for audit criteria, forms, and procedures. All weight-for-age growth charts of Orang Asli children aged 2 and below were sampled for retrospective audit. This audit excluded children who required special needs. Growth charts were examined against audit criteria: (i) quality of growth chart plotting (charts were not plotted, incompletely plotted, or incorrectly plotted), (ii) presence of underweight, and (iii) appropriateness of action taken (appropriate or inappropriate action) according to local standard operating policies. Eligible auditors were first trained using simulated growth charts.

Results

Out of 1329 growth charts audited, 797 (60%) growth charts were correctly plotted, 527 (39.7%) were incompletely or incorrectly plotted, and five (0.3%) were not plotted. Overall, 40.0% of the growth chart was plotted incorrectly or completely not plotted. 550 (41.4%) children were found to be underweight, and 71.5% of them received inappropriate care management. Where growth charts were correctly plotted, 283 children were identified with underweight problems, and 194 (68.6%) of them received inappropriate care. For growth charts that were plotted incompletely or incorrectly, 267 children were identified as having underweight problems, and 199 (74.5%) received inappropriate care. The growth status of 265 (19.9%) children was unable to be determined due to incomplete plotting.

Conclusion

Approximately 40% of indigenous Orang Asli children aged 2 years and under were underweight, and most of them received inappropriate care.

Reasons for day of surgery cancellation of orthopaedic cases following a major earthquake in Trinidad and Tobago

An earthquake in 2018 resulted in irreparable damage to the Port of Spain General Hospital, Trinidad and Tobago, and severely affected orthopaedic services. This study investigates the rate and reasons for cancellation on the day of surgery of orthopaedic cases during the post-earthquake period. We prospectively collected data on all cases scheduled to undergo surgery during the study period. Information was gathered on patient demographics, the number and reasons for cancellation. Data were analysed using Analyse-it for Microsoft Excel 5.40 (Analyse-it Software Ltd). Our results show that 43 patients were cancelled, resulting in a 44.3% cancellation rate. Patients who had their surgery cancelled were older, with a higher American Society of Anesthesiologists class compared with patients whose surgery was not cancelled. Hospital-related factors were found to be responsible for the majority of cancellations. Placed in context, our findings suggest that limited operating time due to the earthquake-induced hospital damage was the principal reason for the high rate of surgery cancellations.

Content and comprehensiveness in the nursing documentation for residents in long-term dementia care: a retrospective chart review

Background

Insight into and understanding of content and comprehensiveness in nursing documentation is important to secure continuity and high-quality care planning in long-term dementia care. The accuracy of nursing documentation is vital in areas where residents have difficulties in communicating needs and preferences. This study described the content and comprehensiveness of nursing documentation for residents living with dementia in nursing homes.

Methods

We used a retrospective chart review to describe content and comprehensiveness in the nursing documentation. Person-centered content related to identity, comfort, inclusion, attachment, and occupation was identified, using an extraction tool derived from person-centered care literature. The five-point Comprehensiveness in the Nursing Documentation scale was used to describe the comprehensiveness of the nursing documentation in relation to the nursing process.

Results

The residents’ life stories were identified in 16% of the reviewed records. There were variations in the identified nursing diagnoses related to person-centered information, across all the five categories. There were variations in comprehensiveness within all five categories, and inclusion and occupation had the least comprehensive information.

Conclusion

Findings from this study highlights challenges in documenting person-centered information in a comprehensive way. To improve nursing documentation of residents living with dementia in nursing homes, nurses need to include residents’ perspectives and experiences in their planning and evaluation of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00863-9.

Systems-level audit and feedback interventions to improve oncology care: a scoping review

Audit and feedback is commonly used as a method of both monitoring and attempting to improve the quality of healthcare. No review has examined the literature on systems-level audit and feedback strategies to improve the quality of oncology care. This scoping review examines the number, care focus (technical, nontechnical, or both) and methodological quality of published intervention studies which have used systems-level audit and feedback intended to improve the quality of care delivered in oncology treatment centers. Medline, Embase, PsycINFO, and the Cochrane database were searched, from inception to March 2021, for intervention studies which examined the effectiveness of systems-level audit and feedback in improving care for cancer patients. Studies which met the Effective Practice and Organization of Care (EPOC) minimum design criteria were then assessed using the EPOC risk of bias tool. Study characteristics and outcomes were extracted for those meeting methodological criteria. A narrative approach was used to synthesize the results. A total of 32 intervention studies met the inclusion criteria, of which 53% focused on technical aspects of care, 31% focused on nontechnical and 16% focused on both. Four of the included 32 studies met the EPOC minimum design criteria (13%). Most studies had a before-after study design (75%; n = 24) and methodological quality of the final four studies was moderate. Audit and feedback studies involving oncology treatment centers have primarily focused on technical care aspects. The low number and moderate methodological quality of the studies make it difficult to draw clear inferences about the effectiveness of systems-level audit and feedback. Furthermore, high-quality audit and feedback interventions are required across technical and nontechnical aspects of care to quantify the effectiveness of strategies for improving cancer care and ensure healthcare resources are being optimized.

Implementation of clinical audit to improve adherence to guideline-recommended therapy in acute coronary syndrome

BACKGROUND

Despite global consensus on the management of acute coronary syndrome (ACS), implementation of strategies to improve adherence of guideline-directed medical therapy (GDMT) remains sub-optimal, especially in developing countries. Thus, we aimed to assess the effect of clinical pharmacist-led clinical audit to improve the compliance of discharge prescriptions in patients admitted with ACS. It is a prospective clinical audit of ACS patients which was carried out for 12 months. The discharge prescriptions were audited by clinical pharmacists for the appropriateness in the usage of statins, dual antiplatelet therapy (DAPT), beta-blockers, and angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blocker (ARB). A feedback report was presented every month to the cardiologists involved in the patient care, and the trend in the adherence to GDMT was analyzed over 12 months.

RESULTS

The discharge prescriptions of 1072 ACS patients were audited for the justifiable and non-justifiable omissions of mandated drugs. The first-month audit revealed unreasonable omissions of DAPT, statin, ACE-I/ARB, and beta-blockers in 1%, 0%, 14%, and 11% respectively, which reduced to nil by the end of the 11th month of the audit-feedback program. This improvement remained unchanged until the end of the 12th month.

CONCLUSIONS

The study revealed that periodic clinical audit significantly improves adherence to GDMT in patients admitted with ACS.

Emoqol 100, an ultra ultra-brief mood case-finding tool: A diagnostic accuracy study

Background:

Case-finding for low mood in primary care can be time-consuming using current depression inventories.

Aim:

To assess the diagnostic accuracy, of a single verbally administered question on the emotional quality of life (Emoqol 100), for low mood in patients with symptoms of distress in an ambulatory care setting.

Design and setting:

Eligible patients were consecutive patients seen by one of the authors over 13 months with possible distress/low mood. The index test was the verbally asked Emoqol 100, which is the patient's emotional quality of life now, with 100 being perfect emotional health and 0 being the worst imaginable. The reference standard is the written version of the PHQ-9 with a cut point of ≥10.

Methods:

A retrospective audit of consecutive consultations in a single primary care clinic.

Results:

One hundred two patients were seen during the study period, of which 76 met the eligibility criteria for this audit, and there were 215 test results. For a cut point of <50 on the Emoqol 100 and the PHQ-9 ≥10 the sensitivity was 47% (95% CI 39-54), and the specificity was 93% (95% CI 86-100). The positive predictive value was 95%, and the negative predictive value was 37%.

Conclusion:

This is the first accuracy estimation of the Emoqol 100. It appears to have a high specificity which means when it is positive (<50) it is a good estimate of a high PHQ-9, i.e. a mood issue probably exists. The test will be helpful for busy primary care clinicians as it takes less than 15 seconds to verbally administer.

The introduction of the trauma triage clinic at a district general hospital: safety and efficacy during the first year of implementation

INTRODUCTION

Previously published work has shown that there are no missed injuries following the introduction of a trauma triage clinic (TTC). This study aimed to assess both the safety and efficacy of the TTC model in a district general hospital in the United Kingdom. We aimed to assess the rate of missed 'high-risk' injuries, including posterior shoulder dislocations, talar injuries, Lisfranc injuries and complex carpal instability.

METHODS

Data were collected retrospectively between November 2017 and October 2018 (inclusive). During this time, 3,721 patients were reviewed (mean age 38 years, SD 25.5, range 1-103 years). Case notes and x-rays were reviewed for all patients. Compliance was assessed against British Orthopaedic Association Standards for Trauma (BOAST 7) guidelines for fracture clinic services. The standard for adherence to guidelines was 100%.

RESULTS

Thirty-two of 3,721 patients had a missed injury during the study period, and 66% of these injuries were high risk. TTC was effective in reducing the number of patients seen in the fracture clinic, with 23% of patients discharged directly from the TTC. Eighty-nine per cent of patients were reviewed in clinic within 72 hours of presentation, with a median time to review of 2 days.

CONCLUSION

This study has shown that TTC is efficient in reducing the burden of patients seen in the fracture clinic, but it is not as safe as reported previously. Although the prevalence of missed injuries is low, hospitals introducing a TTC model should consider departmental processes to help accurately identify and triage high-risk injuries.

Geriatric Choosing Wisely choice of recommendations in France: a pragmatic approach based on clinical audits

Background

The international Choosing Wisely campaign seeks to improve the appropriateness of care, notably through large campaigns among physicians and users designed to raise awareness of the risks inherent in overmedication.

Methods

In deploying the Choosing Wisely campaign, the French Society of Geriatrics and Gerontology chose early operationalization via a tool for clinical audit over a limited area before progressive dissemination. This enabled validation of four consensual recommendations concerning the management of urinary tract infections, the prolonged use of anxiolytics, the use of neuroleptics in dementia syndromes, and the use of statins in primary prevention. The fifth recommendation concerns the importance of a dialogue on the level of care. It was written by patient representatives directly involved in the campaign.

Results

The first cross-regional campaign in France involved 5337 chart screenings in 43 health facilities. Analysis of the results showed an important variability in practices between institutions and significant percentage of inappropriate prescriptions, notably of psychotropic medication.

Discussion

The high rate of participation of target institutions shows that geriatrics professionals are interested in the evaluation and optimization of professional practices. Frequent overuse of psychotropic medication highlights the need of campaigns to raise awareness and encourage deprescribing.

Evaluation of data quality in the Spanish EURECCA Esophagogastric Cancer Registry

BACKGROUND

Although the number of nationwide clinical registries in upper gastrointestinal cancer is increasing, few of them perform regular clinical audits. The Spanish EURECCA Esophagogastric Cancer Registry (SEEGCR) was launched in 2013. The aim of this study was to assess the reliability of the data in terms of completeness and accuracy.

METHODS

Patients who were registered (2014-2017) in the online SEEGCR and underwent esophagectomy or gastrectomy with curative intent were selected for auditing. Independent teams of surgeons visited each center between July 2018 and December 2019 and checked the reliability of data entered into the registry. Completeness was established by comparing the cases reported in the registry with those provided by the Medical Documentation Service of each center. Twenty percent of randomly selected cases per hospital were checked during on-site visits for testing the accuracy of data (27 items per patient file). Correlation between the quality of the data and the hospital volume was also assessed.

RESULTS

Some 1839 patients from 19 centers were included in the registry. The mean completeness rate in the whole series was 97.8% (range 82.8-100%). For the accuracy, 462 (25.1%) cases were checked. Out of 12,312 items, 10,905 were available for verification, resulting in a perfect agreement of 95% (87.1-98.7%). There were 509 (4.7%) incorrect and 35 (0.3%) missing entries. No correlation between hospital volume and the rate of completeness and accuracy was observed.

CONCLUSIONS

Our results indicate that the SEEGCR contains reliable data.

[The Spanish National Hip Fractures Registry (RNFC) and the Minimum Basic Data Set (CMBD) are useful for research on hip fractures: comparison of two registries.]

OBJECTIVE

National hip fracture registries have been established in several countries and recent publications show that the care process has been audited inspecting the representativeness according to quality standards. The aim of this study was to analyse if the Spanish National Hip Fracture Registry (RNFC) represents the Spanish population aged 75 and older admitted for hip fractures, and to compare its results regarding the care process with the national average, according to the National Inpatient register (Minimum Basic Dataset, CMBD).

METHODS

The 2017-2018 National Minimum Basic Dataset (Conjunto Mínimo Básico de Datos, CMBD) was used as reference. For analysis, we included 83,110 cases from the CMBD and 21,130 from the RNFC. Eight common variables of both registries were selected for comparison.

RESULTS

No significant differences were observed in the patient-related common variables (age, sex, type of fracture and fracture side), but statistically significant differences were found in the variables describing the care process (proportion of patients operated, deceased, surgical procedures and postoperative length of stay).

CONCLUSIONS

The RNFC, designed as a convenience sample, is also representative of the population of patients aged 75 and older treated for hip fractures in Spain. However, there is a participation bias related to the professionals and the hospitals interested in voluntarily participating in a quality improvement program, which would explain the better results observed in the care process, compared to the national average as collected by the CMBD.

Is it feasible to learn research skills in addition to audit skills through clinical audit? A mixed methods study in general practice

Background

Involving medical students in research in their undergraduate careers may increase the likelihood that they will be research active after graduation. To date, there has been a paucity of published research of students doing research in general practice.

Aim

The study aims to evaluate the impact of general practice clinical audits on early-stage graduate entry students’ audit and research self-efficacy and explore feasibility issues from the student and GP perspective.

Methods

Two student questionnaires (pre- and post-intervention), a qualitative GP survey of the 25 participating GPs and semi-structured interviews of a purposeful sample of GPs were conducted.

Results

Participating students who completed the follow-up survey found that it had a positive educational impact (55%), increased their understanding of the audit cycle (72%) and real-world prescribing (77%). Research confidence wise, there was a statistically significant difference in the student group who completed the audit project compared to those students who did not in knowledge of the audit cycle and the difference between research and audit (p = 0.001) but not in other research skills. Ninety-six percent of responding GPs would be happy for students to do future audits in their practice but some feasibility issues similar to other research initiatives in general practice were identified.

Conclusion

We found this audit initiative feasible and useful in helping students learn about audit skills, patient safety and real-world prescribing. GPs and students would benefit more if it were linked to a substantial clinical placement, focussed on a topic of interest and given protected time. Separate research projects may be needed to develop research skills confidence.