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PubMed1999

Adolescent pregnancy: psychopathology missed.

OBJECTIVES: Few data exist that explore the level of psychosocial problems and drug abuse in an Australian, adolescent, antenatal population. We set out to audit these data from a population of pregnant Western Australian adolescents. We also set out to examine whether social issues and the use of non-prescription drugs are routinely addressed in general public antenatal clinics. METHODS: One hundred and sixty patients were involved in the prospective cohort study. In the assessed group, 100 consecutive patients from the King Edward Memorial Hospital Adolescent Antenatal Clinic were interviewed during the antenatal period to determine if any major psychosocial issues or a history of non-prescription drug abuse was present. The control group consisted of 60 adolescent patients who delivered in general antenatal clinics at three Perth metropolitan hospitals. RESULTS: Sixty percent of the assessed group were identified as having a major psychosocial problem that interfered with their ability to carry out acts of daily living. Consumption of cigarettes, alcohol, marijuana, heroin and solvents were higher than that reported for the general Australian adolescent population. Of note, in the control group, many patients did not have a social, psychological, or drug use history taken by their caregivers. CONCLUSION: Failure to identify psychosocial problems and drug abuse during the antenatal period will result in missed opportunities for positive intervention. These problems are common in this population and interventions are required to offer these women alternative foundations upon which to base their mothercraft skills.

Adolescent↗
PubMed1997

A simple technique for data management in general dental practice audit.

General practice audit is essential in the process of developing an evidence-based approach to dental care. The CHAID (CHi-Squared Automatic Interaction Detector) statistical software package is both practical and user-friendly for many simple applications. The types of questions asked in general practice audit projects will frequently be suitable for analysis using this technique. This may include the identification of patients who are likely to fail appointments and place an additional financial burden on the practice. This paper illustrates the potential value of CHAID to general dental practitioners (GDPs) by using examples of commonly cited dental audit topics. This paper aims to illustrate how a simple statistical package (SPSS CHAID) may be of use for both audit and practice management activities.

Appointments and Schedules↗
PubMed2004

Reducing call-to-needle times: the critical role of pre-hospital thrombolysis.

BACKGROUND: Current guidelines recommend that patients with acute myocardial infarction should receive thrombolysis within 60 min of seeking professional help. AIM: To compare current rates of pre-hospital thrombolysis in Grampian with historical data, and assess the effect of pre-hospital thrombolysis on the proportion of patients achieving 'call-to-needle' times within national guidelines. DESIGN: Prospective audit. METHODS: Data were collected on all patients (n=535) admitted to the coronary care unit and thrombolysed, either in hospital or in the community from July 2000 to June 2002, using standardized forms. RESULTS: One hundred and thirty-three patients (25%) received pre-hospital thrombolysis and 402 (75%) received in-hospital thrombolysis. This compares with a 19% (195/1046) pre-hospital thrombolysis rate in the mid-1990s (p=0.005). Median 'call-to-needle' times were 45 min for pre-hospital thrombolysis and 105 min for patients who received in-hospital thrombolysis (p < 0.001). Only 24% (96/396) of patients receiving in-hospital thrombolysis were treated within the recommended guideline, vs. 79% (88/111) of pre-hospital thrombolysis patients (p <0.001). DISCUSSION: Pre-hospital thrombolysis rates in Grampian are increasing. Administration of thrombolysis in the community greatly increases the proportion of patients achieving a 'call-to-needle' time of 60 min, with a median time saving of approximately 1 h.

Acute Disease↗
PubMed1988

Audit of a surgical firm by microcomputer: five years' experience.

From 1982 to 1986 inclusive work of one surgical firm was audited with a microcomputer. Data were recorded on 4336 patients having 3355 operations, who were under the care of one consultant in a general surgical unit; fifty items of information were recorded on each patient, allowing a wide range of analyses to be performed--for example, the number of admissions and operations, grades of operation, diagnostic grouping, complications, and complication rates associated with individual surgeons. Data collected for the audit provided a valuable baseline for the unit, defining aspects of practice that could be reviewed and improved. During the audit the overall rate of complications as a percentage of admissions fell significantly from 13% to 9% and the rate of postoperative complications decreased significantly from 16% in 1982 to 11% in 1986. The incidence of chest and wound infections also decreased significantly. The system was improved by using the data to produce discharge summaries as well as audit; the microcomputer thus became an integral part of the office work of the unit.

Computers↗
PubMed2004

Early impact of centralization of oesophageal cancer surgery services.

BACKGROUND: In response to national guidance, oesophageal surgery from four hospitals within Wessex was centralized to a single site, with a provision for surgeons to travel to the centre to operate if they wished. This study assessed the clinical impact of this change. METHODS: Data for patients who had oesophageal cancer surgery at the single site were collected prospectively for 1 year from May 2002 and compared with the Wessex Oesophageal Cancer Audit (WOCA) data for the four hospitals from 1999 to 2000. RESULTS: Thirty-three patients underwent surgery on the single site compared with 40 patients from the four hospitals during the WOCA. Age, sex, co-morbidity, tumour site, and preoperative tumour and node stage were similar in the two groups. Six patients from the WOCA underwent 'open and close' laparotomy compared with none in the single-site group (P = 0.020). There were four anastomotic leaks in the WOCA group and two in the single-site group. Overall complication rates in those undergoing resection were similar in the two groups, but the in-hospital mortality rate was significantly higher in the WOCA group (five versus no patients; P = 0.022). Pathology reporting was incomplete in significantly more patients in the WOCA group (15 versus three; P = 0.001). The mean node harvest was greater in the single-site group (30.5 versus 19). CONCLUSION: Centralization of oesophageal surgery resulted in better preoperative staging, a lower 30-day mortality rate and more complete pathological reporting.

Adult↗
PubMed1991

Developing a system for surgical audit.

A system for surgical audit, which has been developed during a 6 year period in an active surgical unit of a teaching hospital, is described. Following a review of the first 3 years of our computerized audit, major modifications to the audit processes and computer program were made. The key lessons for systematic practical surgical audit include the collection of essential data only, establishing audit processes within current department practices, verification of data by consultants, and the provision of incentives for all users. The current system is proving a valuable resource for quality assurance, surgical training and departmental management.

Computer Systems↗
PubMed2005

HIPAA compliant auditing system for medical images.

As an official regulation for healthcare privacy and security, Health Insurance Portability and Accountability Act (HIPAA) mandates health institutions to protect health information against unauthorized use or disclosure. One such method proposed by HIPAA Security Standards is audit trail, which records and examines health information access activities. HIPAA mandates healthcare providers to have the ability to generate audit trails on data access activities for any specific patient. Although current medical imaging systems generate activity logs, there is a lack of formal methodology to interpret these large volumes of log data and generate HIPAA compliant auditing trails. This paper outlines the design of a HIPAA compliant auditing system (HCAS) for medical images in imaging systems such as PACS and discusses the development of a security monitoring (SM) toolkit based on some of the partial components in HCAS.

Computer Security↗
PubMed2006

Lower urinary tract injuries after transobturator tape insertion by different routes: a large retrospective study.

OBJECTIVES: To identify the rate of, and risk factors for, lower urinary tract (LUT) injuries associated with the transobturator tension-free vaginal tape (TOT) procedure. DESIGN: Retrospective cohort study. SETTING: Tertiary referral urogynaecology centre. POPULATION: 390 women who underwent transobturator suburethral tapes for management of urodynamic stress incontinence between July 2002 and January 2006. METHODS: Early cases were identified from theatre records and a case note review performed. From May 2005 (n = 94), data from an ongoing prospective audit were reviewed. Data for LUT injuries with TOT procedures were examined and routes of insertion were compared using Fischer's exact test. MAIN OUTCOME MEASURES: Rate of LUT injuries associated with the TOT procedures. Assessment of factors increasing risk of LUT injury, and comparison of the 'outside-in' and 'inside-out' techniques. RESULTS: 241 women underwent TOT outside-in technique and 148 of them underwent inside-out technique. Four LUT injuries occurred (1%): two urethral injuries (0.5%) and two bladder injuries (0.5%). All LUT injuries occurred in the outside-in group, although this difference did not reach significance (P = 0.146). Bladder injuries occurred in women who underwent concomitant vaginal surgery, while urethral injuries occurred in women undergoing secondary procedures. CONCLUSION: LUT injury is an uncommon complication of the TOT procedures, and in our hands only occurred with the outside-in technique. Intraoperative cystoscopy should be considered only in selected cases.

Adult↗
PubMed2006

Analysis of data-collection methods for an acute stroke care registry.

This study aims to assess and compare the completeness and reliability of data collected by prospective and retrospective methods for the Paul Coverdell National Acute Stroke Registry. The prototypes consisted of eight states that used the same data elements but differed in their collection approach. Three prototypes employed retrospective case ascertainment (n=1218), and five prototypes used prospective or a combination of prospective and retrospective case ascertainment (n=1602). RTI International performed an audit analysis of the eight prototypes. Completeness, exact match, and discrepancy analyses were performed with data elements grouped into 12 categories for this analysis. A sample of 2820 (37.6%) from a total of 7494 records from 91 hospitals was studied. The "in-hospital complications" section had the highest percentage of completeness (99.6%), followed by "demographic data" (97.7%), and "in-hospital diagnostic procedures" (93.4%). The section with the lowest percentage of completeness was "thrombolytic treatment" (53.5%), followed by "reasons for nontreatment with thrombolytics" (57.1%), and "signs and symptoms onset" (63.5%). Across all prototype elements, exact matches with audit data ranged from 62.8% to 95.9%. Documentation of the date/time of stroke onset and of arrival in the emergency department had a high number of discrepancies with audit data, with exact match percentages of 69.7% and 64.5%, respectively. No significant difference was found between retrospective and prospective case ascertainment in completeness or matching with audit data. Combined retrospective and prospective data-collection approaches for different types of data elements may be best in terms of both completeness and accuracy.

Acute Disease↗
PubMed2003

What do collaborative improvement projects do? Experience from seven countries.

BACKGROUND: Health care organizations are increasingly adopting multiorganizational collaborative approaches to quality improvement. Collaboratives have been conducted in many countries. There are large variations in the way collaboratives are structured and run, but there is no widely accepted framework for describing the components of collaboratives. Thus, it is difficult to study which approaches are most effective. METHOD: The authors conducted semistructured interviews with 15 leaders of collaboratives to ascertain the common components of collaboratives and identify variations in the ways these components are implemented. RESULTS: The study identified seven features of collaboratives that the leaders interviewed thought were critical determinants of how effective the collaboratives were: sponsorship, topic, ideas for improvements, participants, senior leadership support, preliminary work and learning, and strategies for learning about and making improvements. For example, every interviewee mentioned that having participants collect data, perform audit work, or analyze the system they were in before the collaboration started was important to understanding their organization and the nature of the problems they had and to developing baseline data for later comparison. The authors describe variations in how these features have been implemented and possible functions of these features. CONCLUSION: Systematically studying the impact of variations in the seven key features of collaboratives could yield important information about their role and impact.

Cooperative Behavior↗
PubMed1992

Need to measure outcome after discharge in surgical audit.

OBJECTIVE: To assess the accuracy of outcome data on appendicectomy routinely collected as part of a surgical audit and to investigate outcome in the non-audited period after discharge. DESIGN: Retrospective analysis of audit data recorded by the Medical Data Index (MDI) computer system for all patients undergoing emergency appendicectomy in one year; subsequent analysis of their hospital notes and notes held by their general practitioners for patients identified by a questionnaire who had consulted their general practitioner for a wound complication. SETTING: One district general hospital with four consultant general surgeons serving a population of 250,000. PATIENTS: 230 patients undergoing emergency appendicectomy during 1989. MAIN MEASURES: Comparison of postoperative complications recorded in hospital notes with those recorded by the MDI system and with those recorded by patients' general practitioners after discharge. RESULTS: Of the 230 patients, 29 (13%) had a postoperative complication recorded in their hospital notes, but only 14 (6%) patients had these recorded by the MDI system. 189 (82%) of the patients completed the outcome questionnaire after discharge. The number of wound infections as recorded by the MDI system, the hospital notes, and notes held by targeted patients' general practitioners were three (1%), eight (3%), and 18 (8%) respectively. None of 12 readmissions with complications identified by the hospital notes were identified by the MDI system. CONCLUSIONS: Accurate audit of postoperative complications must be extended to the period after discharge. Computerised audit systems must be able to relate readmissions to specific previous admissions.

Appendectomy↗
PubMed2002

Undetectable postoperative cortisol does not always predict long-term remission in Cushing's disease: a single centre audit.

OBJECTIVE: An undetectable postoperative serum cortisol has been regarded as a definition of cure in Cushing's disease. However, we noted disease recurrence amongst patients with Cushing's disease despite undetectable postoperative cortisol levels, and this led us to audit our data. We have also previously assessed surgical outcome for acromegaly and microprolactinoma for a single surgeon. The aims of this study were two-fold: (i) to investigate the treatment and surgical outcome of patients with Cushing's disease. In particular, we wished to compare the data with outcome for other pituitary tumours in our centre; and (ii) to determine whether undetectable cortisol following surgery is predictive of long-term cure for Cushing's disease. PATIENTS AND METHODS: We performed a retrospective audit of 97 patients; mean age 39.1 (range: 14-82) years, 78/97 (80.4%) female, mean follow-up 92 months (range: 6 months to 29 years), with Cushing's disease seen in our unit between 1969 and 1998. We documented diagnostic investigation, immediate surgical outcome and disease recurrence in these patients. RESULTS: All patients had elevated urinary free cortisol (mean 1270.6 nmol/l, range: 327-3245 nmol/l). In total, 95.5% of patients did not suppress with low-dose dexamethasone suppression testing. Hypokalaemia (K < 3.2 mmol/l) was present in 15.6% of patients; 17.5% of patients did not show cortisol suppression with high-dose dexamethasone and 15.8% of patients did not show an ACTH rise of > 50% following corticotrophic releasing hormone (CRH) administration. There was no significant (> 3) gradient in ACTH or cortisol following CRH during inferior petrosal sinus sampling in 27.3% of patients who had the test. A pituitary tumour was demonstrated on imaging in 55.8% of patients; 10.3% were macroadenomas. Mortality rate following trans-sphenoidal surgery was 1%. Following surgery, the immediate postoperative remission rate (undetectable postoperative cortisol) was 68.5%. However, 11.5% of these patients developed disease recurrence during a mean follow-up period of 36.3 months. Considering microadenomas, Cushing's disease patients had an immediate postoperative remission rate of 63.2% which is significantly lower (P < 0.05) compared to a remission rate of 91.1% in acromegaly. Additionally, new postoperative gonadotrophin deficiency (13.9%) and TSH deficiency (25.8%) was higher in patients with Cushing's disease compared to patients with acromegaly or microprolactinoma. Immediate postoperative remission rates improved from 50% in the first decade of a surgeon's career to consistently above 60% in the second and third decades, demonstrating a trend which may be attributed to surgical experience. CONCLUSIONS: (i) Despite strict criteria for immediate postoperative remission and recurrence, undetectable postoperative cortisol is not always predictive of long-term remission. (ii) Despite an aggressive surgical approach, immediate postoperative remission rates for Cushing's disease are lower compared to other microadenomas. The development of new pituitary hormonal deficiency following surgery is also commoner than that seen amongst other microadenomas. These data have important implications for the follow-up of patients with Cushing's disease.

Adenoma↗
PubMed2006

Malignant spinal cord compression: a retrospective audit of clinical practice at a UK regional cancer centre.

Malignant Spinal Cord Compression (MSCC) is a particularly challenging area of cancer care where early diagnosis and expert multiprofessional care and rehabilitation, are paramount in optimising quality of life. This audit reports data collected retrospectively over a period of 12 months on patients with MSCC referred to the West of Scotland Cancer Centre (n = 174). It was carried out to build on the work of the Clinical Resource and Audit Group (CRAG) and to examine current practice for symptom assessment, multiprofessional care and rehabilitation of patients with MSCC admitted to the cancer centre. Areas of concern include poor assessment of pain, the poor ambulatory status of patients on admission and the lack of clear plans for mobilisation and rehabilitation for the majority of patients. Recommendations include the development of regional guidelines for referral, treatment and rehabilitation, and the development of a pathway of care for use in all care settings across the region, together with improvements for use in patient information, staff education, audit and research. These are now being taken forward through the West of Scotland Cancer Network with dedicated funding from Macmillan Cancer Relief.

Humans↗
PubMed1991

Hospital audit committees: a comparative analysis of structural and functional characteristics.

In an effort to counteract rising costs and financial problems, many hospitals have adopted certain management practices that are followed by commercial corporations. In particular, the boards of directors for many hospitals have created audit committees to enhance organizational governance in the areas of internal control, accounting, auditing, and financial reporting. The formative stages in which most hospital audit committees currently exist creates a need for shared information. Such information can serve as a potential source of guidance for the further development of existing hospital audit committees, as well as for boards that are near the point of establishing an audit committee for the first time. The purpose of this study is to present an analysis of the structure, responsibilities, and activities of hospital audit committees. Data for the analysis was obtained through a questionnaire survey of 400 hospitals. The analysis of structural and functional differences affords a basis for suggesting several specific ways in which hospitals can improve their organizational governance through a more effective audit committee.

Decision Making, Organizational↗
PubMed2000

Structure and function in the saccule of the goldfish (Carassius auratus): a model of diversity in the non-amniote ear.

The vertebrate inner ear is comprised of a remarkable diversity of cell types, including several types of sensory hair cells. In amniotes (reptiles, birds, and mammals), the morphological and physiological characteristics that distinguish these cell types have been well documented, while cellular variation in the ears of non-amniotes (all other vertebrate groups) has remained underrecognized. Since non-amniotes have become increasingly popular models for developmental and genetic research, a more comprehensive understanding of structure and function in the inner ears of these species is warranted. This paper first reviews the large body of data describing the morphology and physiology of hair cells and afferent neurons in the inner ear of the goldfish (Carassius auratus). In particular, we examine the structure of the goldfish saccule, an endorgan that has been the subject of numerous investigations on audition. New data on the structural variation of synaptic bodies in saccular hair cells are also presented, and the functional implications of these data are discussed. Finally, we conclude that hair cell structure varies along the length of the goldfish saccule in a manner consistent with known physiological characteristics of the endorgan. The saccule provides an excellent model for investigating structure-function relationships in the vertebrate inner ear, as well as the development of auditory and vestibular sensory epithelia.

Animals↗
PubMed2003

Closing the audit loop--prevention of perioperative hypothermia: audit and reaudit of perioperative hypothermia.

BACKGROUND AND OBJECTIVE: Perioperative hypothermia is generally regarded as undesirable, but its incidence rate in the elective procedures in our hospital and the effect of the preventative measures taken against it were unknown. An initial audit indicated that postoperative hypothermia occurred. Therefore, changes in practice were implemented to address the problem. A further audit was then undertaken to assess the impact of these measures. METHODS: The first audit recorded data from 177 patients undergoing major elective surgical procedures. Variables recorded were: ASA classification, duration of operation, use and description of preventative measures for hypothermia, blood loss, intravenous fluids, and core and peripheral temperatures on arrival and discharge from the recovery room. The subsequent audit included 158 patients undergoing major general, orthopaedic or vascular surgical procedures. Patients had core temperatures measured preoperatively, immediately upon arrival in the recovery room, and just before discharge back to the ward. Core temperatures in both audits were measured using an infrared temperature probe. RESULTS: The mean body temperature on arrival in the recovery room of patients in the initial audit was 35.5 degrees C (range 32.2-37.2, SD +/- 0.74), and in the subsequent audit 36.6 degrees C (33.6-38.2, +/- 0.72). These differences reached significance (P < 0.0001). This was despite an average duration of surgery of 133.5 (25-330) min in the initial study compared with 154.7 (90-480) min subsequently. CONCLUSIONS: We found that with simple but consistently implemented changes in practice, postoperative hypothermia in elective patients could largely be eradicated.

Anesthesiology↗
PubMedDate not supplied

Quality assurance reviews: how they differ from peer reviews.

Research papers and reports written by scientists and engineers in the United States Environmental Protection Agency are reviewed by the agency's quality assurance staff. EPA papers and reports are subjected to peer reviews that check for the validity of conclusions and the general agreement with the body of technical knowledge in the subject area. Quality assurance reviews differ from peer reviews in that the focus of the quality assurance review is on the following criteria: Consistency: Were reasonable and consistent units of measurement and generally acceptable formulas used throughout? Are the appropriate number of significant figures reported? Correctness: Were matrix-compatible methods used? Were measurements within the working range of the method? Can measurements be traced to a recognized standard or source (e.g., the National Institute of Standards and Technology)? Can calculations be verified, starting from representative raw data and proceeding to the summary data presented in the paper or report? Coherence: Do the stated conclusions follow from the data presented? Are the assumptions clearly stated? Are inconsistencies between data and conclusions discussed? Clarity: Are special terms and acronyms defined? Can a person with a general technical background in the subject understand the paper or report? Conformance: Did the study follow the test/quality assurance plan, with appropriate calibrations and other quality-control checks, audits, and data validations? If not, is there a discussion of problems? Concordance: Were data quality objectives met? Were the data quality indicator goals achieved for precision, accuracy, representativeness, comparability, and completeness? The importance of these quality assurance review criteria are discussed along with examples from current work.

Authorship↗