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PubMed2000

Retrospective evaluation of the simplified Therapeutic Intervention Scoring System (TISS-28) in a surgical intensive care unit.

OBJECTIVE: To compare the simplified Therapeutic Intervention Scoring System (TISS-28) with its original version, to provide reference values of daily TISS-28 assessment and to describe its association with severity of illness in surgical patients. DESIGN: Retrospective evaluation of prospectively collected audit data; four documentation periods. SETTING: Ten-bed intensive care unit (ICU) in a surgical university hospital. PATIENTS: One thousand nine hundred eighty-six consecutive admissions (1,808 patients; 10,448 observation days) who stayed on ICU for at least 6 h. Patients were in hospital for abdominal, vascular or trauma surgery. The average age was 61.5 years, the mean APACHE II score on admission 10.3 points. INTERVENTIONS: None. MEASUREMENTS: Raw data for APACHE II score and TISS were recorded daily. TISS-28 was calculated retrospectively from the original TISS data. RESULTS: Average TISS-28 values (28.7 points; SD = 9.7) do not differ substantially from the original TISS values (28.2 points, SD = 10.9) and overall correlation is high (r = 0.935). Of the patients, 57.3 % left the ICU after 1-2 days as survivors with a mean daily TISS-28 of 20.0 points. Variability between documentation periods was higher with the original TISS. On average, patients with increasing severity of disease require an increasing amount of care. Survivors have lower TISS-28 values than non-survivors (27.6 vs 34.9). CONCLUSIONS: In a surgical ICU the simplified version of TISS with 28 items (TISS-28) sufficiently reflects the amount of intensive care provided and may provide useful additional information on severity of disease and prognosis. It should replace the original index, at least in these cases.

APACHE↗

PubMed2004

Are we getting the message across? Trends among young men attending an inner city young people's clinic.

BACKGROUND: A young people's clinic has been running at the Archway Sexual Health Clinic since 1997. This offers a weekly walk-in service to both young men and women under 20 years old. OBJECTIVES: To review the audit data of over 7 years' experience from the dedicated young people's clinic at the Archway Sexual Health Clinic, the "Arch." METHODS: These data were collected by retrospective notes review of a consecutive series of all male attendees over a 7 year period from 1997 to the end of 2003 with collection of data in Microsoft Excel database. RESULTS: These figures show an overall increase in attendee numbers, but also a relative rise in the numbers of young men using the service. A high number of bacterial sexually transmitted infections were detected. In 2001 and 2003 respectively, 14.5% and 17.8% of the young men using the service were diagnosed with Chlamydia trachomatis. A user survey aimed to identify factors that may be encouraging the young men to access the service. CONCLUSIONS: Responding to the views of young men using the service has played a part in service development. Initiatives at the "Arch" such as the condom policy and choice of gender of staff may be factors encouraging increasing attendances. Continuing to work with other agencies to develop ways to engage young men are recommended. Word of mouth recommendation cannot be underestimated in publicising the service.

Adolescent↗

PubMedDate not supplied

Nurse-led elective cardioversion: an evidence-based practice review.

By posing a clinical practice question, this article aims to document and explore the published evidence base supporting nurse-led cardioversion. A literature review was undertaken to determine the best evidence for practice. Five articles and two conference abstracts describing practice were found to be pertinent to the question. Description of the methodology used was a weakness of all the articles studied, with only one article purported to be framed as a research study. The remainder describe a planned change in nursing practice to encompass the delivery of a service previously, organizationally viewed as, physician led. Evaluations of practice were descriptive and supported by audit data in most articles, however, appropriate evidential comparisons were not offered. These articles were critically appraised in relation to safety and efficacy. Whilst the evidence may be seen to be limited and weak, it does add credence to the notion that a nurse with a suitable experiential background and knowledge base can make a significant contribution to the care of this group of patients. It is clearly evident that further developments in practice should be framed within a research context to support and strengthen the evidence base. Four prominent themes emerged from the review, 'change milieu', 'reshaping boundaries', 'nurse-led', 'efficacy of practice', which are modelled into a conceptual framework. Nursing roles are expanding within the cardiological setting, affording practitioners unprecedented practice opportunities within a supportive organizational framework, however, these roles must be subject to appropriate evaluation in order to continue informing a robust evidence base.

Benchmarking↗

PubMed2004

A perinatal psychiatric service audit in New Zealand: patient characteristics and outcomes.

As part of a clinical audit, data were collected on all patients assessed and offered treatment by the Christchurch 'Mothers and Babies' Service between 1-7-98 and 30-6-2000. At assessment and discharge a comprehensive psychiatric interview and the Marcé Checklist were completed by clinicians and self-rating questionnaires were completed by the patient. Univariate analysis and logistic regression were performed on the variables collected. A significant proportion of women suffered from chronic recurrent psychiatric disorders. Pure 'postnatal depression' was uncommon. Thirty-eight percent of women were pregnant at assessment. Risk factors for poor maternal outcomes included history of chronic illness, high symptomatic scores at assessment, the presence of more than one Axis I diagnosis (excluding nicotine dependence) or an Axis II diagnosis, and poor interpersonal relationships. Perinatal psychiatric services need resources to treat women with a range of severe and chronic disorders and should pay attention to interpersonal issues in treatment.

Adolescent↗

PubMed1998

Outcomes in rural obstetrics, Atherton Hospital 1981-1990.

Analysis of annual obstetric audit data collected over the decade 1981-1990 from the Atherton Hospital in far north Queensland provides evidence of safe obstetric practice provided by a group of non-specialist doctors in a rural community. During that period, there were 2883 deliveries with an overall perinatal mortality of 5.2/1000. There were 1974 public confinements (perinatal mortality 5.1/1000) and 909 private confinements (perinatal mortality 5.5/1000). By including those perinatal deaths that occurred in public patients who were transferred because of intrapartum complications, such as premature labour or neonatal problems, the corrected perinatal mortality rate for the public patients was 9.6/1000, which compares favourably with rates for Queensland and the Far North Statistical Division in 1987 of 13.5/1000 and 16.9/1000, respectively. This was achieved with low intervention, as indicated by an overall Caesarean section rate of 13.0% (public 10.6%, private 18.3%) and an antenatal referral rate of less than 2% of patients from the hospital public clinic for delivery under specialist care.

Adult↗

PubMed2003

Recent trends in tracheal intubation: a retrospective analysis of 97904 cases.

We conducted a review of routine anaesthetic audit data collected between April 1995 and December 2001 at Northampton General Hospital. A total of 97 904 anaesthetics were given. The average monthly rate of tracheal intubation fell during the study period from approximately 450 per month to approximately 280 per month. This was largely at the expense of tracheal tubes used during normal working hours, which fell by 40% (from approximately 390 per month to approximately 230 per month). Use outside normal working hours did not change. Of those cases managed in normal working hours with a tracheal tube, the decline in use over time was most obvious in patients of ASA physical status 1-2, and whose surgery was classified as elective or scheduled. The proportion of cases classified as ASA 3-5 or whose surgery was urgent or emergency increased (from 15.5% to 22.3%, and from 7.5% to 15.5%, respectively.) There was considerable variation across surgical specialities, with the greatest decline in tracheal intubation in head and neck surgery. These changes in practice have implications for the teaching of airway management skills.

Anesthesia, General↗

PubMed2002

Acute pain services in Hong Kong: facilities, volume, and quality.

Acute pain services in public hospitals in Hong Kong were studied. Audit data on the volume and quality of acute pain services were collected prospectively from 1997 to 1999, and data on related facilities were collected in 2000. About 20% of patients undergoing a major operation received an acute pain service; of these, 78.6% were satisfied with the treatment provided. In 2000, 86% (18/21) of hospitals providing anaesthetic services were running an acute pain service. Staffing was better in hospitals providing a high volume of acute pain services, ranging from a full-time specialist anaesthesiologist assisted by a half-time trainee to a half-time specialist assisted by a full- or half-time trainee. However, only four hospitals were staffed with pain nurses. In total, 57% of patients received intravenous patient-controlled analgesia and 32% epidural analgesia. The mean duration of acute pain service treatment was 3.1 days. Currently anaesthesiologist-based acute pain services take care of a limited number of patients. To expand the coverage, there should be a move towards an anaesthesiologist-led, pain nurse-based, acute pain service. The present shortage of pain nurses should be addressed.

Analgesia, Patient-Controlled↗

PubMed1995

Vascular trauma of the upper limb and associated nerve injuries.

In an analysis of vascular audit data on upper limb vascular trauma over a 10 year period in a major UK injury centre it was found that 15 patients required operation for subclavian or axillary artery injuries. Eleven cases were the result of blunt injury. Twelve patients had an ischaemic arm on presentation, all of whom had an associated brachial plexus lesion. Subclavian or axillary artery transections, irrespective of limb viability, also were found to have associated plexus trauma. Twenty-eight patients had brachial artery injuries repaired, 46 per cent of whom had an associated nerve injury. A good functional result was achieved in only half of the patients who underwent repair of a peripheral nerve injured in association with the brachial artery. Vascular reconstruction was successful in all cases. The long-term outcome of brachial plexus lesions was very poor and the role of exploratory surgery is discussed. The long-term outcome of upper limb injury is not dependent on the vascular injury which can be successfully managed, but upon the recognition, treatment, and outcome of the associated nerve injuries.

Adolescent↗

PubMed2006

The dental health and preventative habits of cardiac patients attending the Royal Hospital for Sick Children Glasgow.

AIM: To assess the dental health and preventive practices of child patients with congenital heart disease treated at the Royal Hospital for Sick Children, Glasgow. STUDY DESIGN: A retrospective study using an audit data collection sheet. METHODS: Data collected for 370 paediatric cardiac patients between January 2002 and December 2003 was analysed to obtain an insight into these patients' tooth brushing methods, use of fluoride (F), dental attendance and past dental treatment. An oral examination assessed the patient's caries experience. RESULTS: There were 195 subjects aged between 1 and 5 years, 105 were 6 - 11 years and 70 were 12 -16 years of whom 291 (78%) children were registered for dental care. Of these children 331 (90%) maintained that they brushed their teeth regularly with F- toothpaste. Experience of dental treatment revealed that 132 (36%) children had undergone previous dental treatment. Oral examination showed that out of 370 patients, 236 (64%) had no active caries. The dental health of the cardiac subjects was poor compared with that of Scottish primary school children (5 year-olds) and the 12 year-olds but compared favourably with the 14-year old group. STATISTICS: The relationship between caries activity and frequency of toothbrushing was significant (p<0.01). The relationship between caries activity and attendance for dental care was not significant. CONCLUSION: Children with cardiac problems should be identified in early infancy through liaison with medical colleagues and the family offered all the preventive advice and regular dental care necessary to prevent dental disease.

Adolescent↗

PubMed2006

Prospective audit of laparoscopic cholecystectomy experience at a secondary referral centre in South australia.

BACKGROUND: Laparoscopic cholecystectomy is now the gold standard procedure for symptomatic gallstone disease. Nevertheless, there are still several controversies such as the need for routine intraoperative cholangiogram (IOC), the indications for and results of early laparoscopic cholecystectomy in the setting of acute cholecystitis and the use of endoscopic retrograde cholangiopancreatography versus laparoscopic common bile duct (CBD) exploration for intraoperatively detected choledocholithiasis. The aim of this study was to investigate some of these controversies. METHODS: All laparoscopic cholecystectomies carried out at our institution, a secondary referral centre in Adelaide, South Australia, over a 9-month period were prospectively audited. Data were collected regarding indications for surgery, rate of conversion to open operation, use of IOC, rate of choledocholithiasis and complication rate. RESULTS: There were 202 patients, of whom 152 were women and 50 men. Age range was 15-83 years. Sixty-one per cent of emergency operations were for acute cholecystitis. The conversion rate for emergency operations was 20.6% and for elective procedures was 4.2% (P = 0.003). One hundred and eighty-four patients had an IOC performed. Twelve of these patients had choledocholithiasis. Six of these 12 patients had both normal preoperative ultrasound and liver function tests. Four of the patients went on to postoperative endoscopic retrograde cholangiopancreatography, four had successful laparoscopic CBD exploration, two had open CBD exploration and two had their distal CBD filling defects flushed away with normal saline. There was no morbidity associated with performance of the IOC. There were three patients with postoperative bile leak and one with a bile duct injury. CONCLUSION: Selective IOC would miss a proportion of patients with choledocholithiasis. Early laparoscopic cholecystectomy for acute cholecystitis is associated with a higher conversion rate than elective laparoscopic cholecystectomy. Overall complication rate is low, with 95% of patients having no complications. Laparoscopic CBD exploration is feasible with a reasonable success rate. This can all be achieved at a secondary referral centre staffed by general surgeons.

Adolescent↗

PubMed2001

The accessibility of research-based knowledge for nurses in United Kingdom acute care settings.

BACKGROUND: The successful dissemination of the results of the National Health Service (NHS) research and development strategy and the development of evidence based approaches to health care rely on clinicians having access to the best available evidence; evidence fit for the purpose of reducing the uncertainties associated with clinical decisions. AIM: To reveal the accessibility of those sources of information actually used by nurses, as well as those which they say they use. DESIGN: Mixed method case site, using interview, observational, Q sort and documentary audit data in medical, surgical and coronary care units (CCUs) in three acute hospitals. RESULTS: Three perspectives on accessibility were identified: (a) the humanist--in which human sources of information were the most accessible; (b) local information for local needs--in which locally produced resources were seen as the most accessible and (c) moving towards technology--in which information technology begins to be seen as accessible. Nurses' experience in a clinical specialty is positively associated with a perception that human sources such as clinical nurse specialists, link nurses, doctors and experienced clinical colleagues are more accessible than text based sources. Clinical specialization is associated with different approaches to accessing research knowledge. Coronary care unit nurses were more likely to perceive local guidelines, protocols and on-line databases as more accessible than their counterparts in general medical and surgical wards. Only a third of text-based resources available to nurses on the wards had any explicit research base. These, and the remainder were out of date (mean age of textbooks 11 years), and authorship hard to ascertain. CONCLUSION: A strategy to increase the use of research evidence by nurses should harness the influence of clinical nurse specialists, link nurses and those engaged in practice development. These roles could act as 'conduits' through which research-based messages for practice, and information for clinical decision making, could flow. This role should be explored and enhanced.

Acute Disease↗

PubMed1989

Acute ischaemia of the lower limb: the effect of centralizing vascular surgical services on morbidity and mortality.

Surgical audit data for two 5-year periods (1974-78 and 1983-87) have been compared in a Health Board Area to assess the impact of centralization of emergency vascular services on the treatment of the acutely ischaemic lower limb. Patient populations in each period were comparable. Mortality rates remained constant in both periods at approximately 30 per cent. A significant improvement in overall limb salvage was observed (from 54 to 67 per cent, P less than 0.05). Limb salvage in survivors was improved from 80 to 95 per cent (P less than 0.001) and was paralleled by an increase in the number of reconstructive vascular procedures performed. We concluded that the centralization of emergency vascular services has not led to a reduced risk of mortality but has been associated with improved limb salvage.

Acute Disease↗

PubMed2005

Teleconferenced educational detailing: diabetes education for primary care physicians.

INTRODUCTION: Formal didactic continuing medical education (CME) is relatively ineffective for changing physician behaviour. Diabetes mellitus is an increasingly prevalent disease, and interventions to improve adherence to clinical practice guidelines (CPGs) are needed. METHODS: A stratified, cluster-randomized, controlled trial design was used to evaluate the effects of a teleconferenced educational detailing (TED) CME on glycemic control (hemoglobin [Hb] A1c) and family physician adherence to national diabetes guidelines. TED employed sequential, small-group, case-based education using CPGs delivered by a diabetes specialist. Medical record audit data from baseline through the end of a 12-month postintervention period were compared for the control and intervention groups. Satisfaction with the intervention was evaluated. RESULTS: Sixty-one physicians provided 660 medical records. The intervention did not affect mean Hb A1c levels but did significantly (p = .04) alter the distribution of patients by category of glycemic control, with fewer in the intervention group in inadequate control (15.8% versus 23.9%). More patients took insulin (alone or with oral agents) in the intervention group (21.2% versus 12.0%, p = .03), and more took oral agents only in the control group (89.0% versus 82.9%, p = .005). More patients in the intervention group had documentation of body mass index (7.8% versus 1.9%, p < .02), eye exam (12.1% versus 5.1%, p = .02), and treatment plan (43.5% versus 23.6%, p = .01) and used a flow sheet (14.6% versus 7.7%, p < .03). Although there was general satisfaction with the teleconferencing format, specialist educators found the format more challenging than the family physicians. DISCUSSION: CME delivered by teleconference was feasible, well attended, well received by participants, and improved some key diabetes management practices and outcomes.

Diabetes Mellitus↗

PubMed1995

Costs of Laparoscopic cholecystectomy. Analysis of potential savings.

Despite the growing acceptance of laparoscopic cholecystectomy the costs remain unclear. Therefore, a detailed cost analysis was performed to determine potential savings. As part of a continuing audit, data of 508 consecutive laparoscopic cholecystectomies have been prospectively collected. Pre-, intra-, and postoperative variables were assessed by standardized questionnaires. These data were used to estimate the average use of diagnostics, drug consumption, operation time, and hospital stay. In addition, costs for loss in income, "hotel services", diagnostic procedures, and for the operation itself were calculated in detail. The total costs for a standard laparoscopic cholecystectomy were 3,395 deutsche marks (DM). The costs for the operation itself represented 19%, "hotel services" and medical treatment except the operation such as nursing, visits, or diagnostic procedures represented 47%, and the loss of income another 33% of the total costs. Thus, most effective savings may be achieved by shortening the hospital stay and the time of inability to work. However, each additional 30 min of operating time costed 146 DM (4.88 DM/min) and an "ideal" operation performed within 40 mins and with a 3-day hospital stay would save 20% of the total and 31% of the hospital costs. An increase in the number of operations per year would not have a relevant impact on the cost. Disposable instruments would have increased the costs by 1,118 DM (33%). The costs for cleaning, packing, and disposal were only marginal. Reusable instruments were not related to any disadvantage either to the patients or to the staff.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed2000

Security model for picture archiving and communication systems.

The modern information revolution has facilitated a metamorphosis of health care delivery wrought with the challenges of securing patient sensitive data. To accommodate this reality, Congress passed the Health Insurance Portability and Accountability Act (HIPAA). While final guidance has not fully been resolved at this time, it is up to the health care community to develop and implement comprehensive security strategies founded on procedural, hardware and software solutions in preparation for future controls. The Virtual Radiology Environment (VRE) Project, a landmark US Army picture archiving and communications system (PACS) implemented across 10 geographically dispersed medical facilities, has addressed that challenge by planning for the secure transmission of medical images and reports over their local (LAN) and wide area network (WAN) infrastructure. Their model, which is transferable to general PACS implementations, encompasses a strategy of application risk and dataflow identification, data auditing, security policy definition, and procedural controls. When combined with hardware and software solutions that are both non-performance limiting and scalable, the comprehensive approach will not only sufficiently address the current security requirements, but also accommodate the natural evolution of the enterprise security model.

Computer Communication Networks↗

PubMed2005

Analysis of the SAGES Outcomes Initiative groin hernia database.

BACKGROUND: In 1999, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) introduced the SAGES Outcomes Initiative as a way for its members to track their own outcomes. It contains perioperative and postoperative data on nearly 20,000 operations. This report provides a descriptive analysis of the groin hernia database. METHODS: The SAGES Outcomes Initiative database was accessed for all groin hernia cases from September 1999 to February 2005. The data from the preoperative, intraoperative, and postoperative entries were summarized. These data are purely descriptive and no statistical analysis was done. RESULTS: The hernia registry contains 1,607 entries, with 1,070 follow-up entries. Males comprised 85% of patients, 63% were employed, 62% had at least one comorbidity, with 84% ASA class I or II. Primary, unilateral hernia accounted for 86% of cases, whereas 14% were recurrent, 11% bilateral, 6% incarcerated, and 3% required emergency repair. The operating surgeon was the attending surgeon in 83% of cases. Anesthetic techniques were general anesthesia in 74% of cases, regional in 7%, and local in 34%, with only 16% of cases local only. Most patients had symptomatic hernias and symptoms were improved in more than 95% of patients. Most repairs were open, although 45% were endoscopic. The most frequently cited postoperative event was significant bruising (6%), with more than 99% of complications being class I or II. More than 95% of patients were able to return to work by the first postoperative visit. Patients who underwent endoscopic repair were reported to have fewer days of narcotic use than patients undergoing open repairs (0 vs 3). CONCLUSIONS: First analysis of the SAGES Outcomes Initiative groin hernia database demonstrates that (a) this is one of the largest prospective; voluntary hernia registries; (b) missing data are infrequent; and (c) the data are similar to published data from national, mandatory registries and randomized trials. Although the SAGES Outcomes Initiative is a voluntary registry, initially designed for surgeon self-assessment, and it therefore has the potential for methodological concerns inherent to voluntary registries, the findings from this first analysis are encouraging. Efforts are ongoing to simplify data entry (PDA), refine data parameters, increase surgeon participation, and determine the role of data audit and thereby the potential for clinical research.

Adult↗

PubMed2005

Massachusetts cardiac surgery report card: implications of statistical methodology.

BACKGROUND: Choice of statistical methodology may significantly impact the results of provider profiling, including cardiac surgery report cards. Because of sample size and clustering issues, logistic regression may overestimate systematic interprovider variability, leading to false outlier classification. Theoretically, the use of hierarchical models should result in more accurate representation of provider performance. METHODS: Extensively validated and audited data were available for all 4,603 isolated coronary artery bypass grafting procedures performed at 13 Massachusetts hospitals during 2002. To produce the official Massachusetts cardiac surgery report card, a 19-variable predictor set and a hierarchical generalized linear model were employed. For the current study, this same analysis was repeated with the 14 predictors used in the New York Cardiac Surgery Reporting System. Two additional analyses were conducted using each set of predictor variables and applying standard logistic regression. For each of the four combinations of predictors and models, the point estimates of risk-adjusted 30-day mortality, 95% confidence or probability intervals, and outlier status were determined for each hospital. RESULTS: Overall unadjusted mortality for coronary bypass operations was 2.19%. For most hospitals, there was wide variability in the point estimates and confidence or probability intervals of risk-adjusted mortality depending on statistical model, but little variability relative to the choice of predictors. There were no hospital outliers using hierarchical models, but there was one outlier using logistic regression with either predictor set. CONCLUSIONS: When used to compare provider performance, logistic regression increases the possibility of false outlier classification. The use of hierarchical models is recommended.

Aged↗

PubMed2004

Quality of life after non-surgical treatment of anal carcinoma: a case control study of long-term survivors.

AIMS: To evaluate the quality of life (QOL) of a cohort of patients after non-surgical treatment of anal carcinoma with chemotherapy and radiation. MATERIALS AND METHODS: Patients treated for anal carcinoma at the British Columbia Cancer Agency between 1990 and 2001 were identified from audit data. A total of 92 suitable patients were found among these. They were approached by letter and encouraged to complete questionnaires regarding their QOL. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC QLQ-CR38 instruments were used to evaluate general QOL, and more disease and site-related aspects. Fifty responses were received and were compared with those of a sample of matched local volunteer control participants who had not received any treatment to their abdomen or pelvis. Responses were scored and the results analysed with the SPSS statistical package. RESULTS: Significant differences were detected in global QOL and in more specific areas of both general and site/disease-specific nature. Identified general areas involved physical, social, and role functions, and symptoms of fatigue, nausea and vomiting, dyspnoea, appetite loss, diarrhoea, constipation, and financial problems, with cancer/site-related micturition, gastrointestinal and chemotherapy side-effect symptoms, and male and female sexual problems. CONCLUSION: This study reveals that after curative treatment for anal carcinoma with chemoradiation that has spared the patient of surgery, issues affecting QOL can present in a significant proportion of patients.

Aged↗