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PubMed2002

Changing surgical practice through feedback of performance data.

BACKGROUND: Changing health care practice is commonly attempted by feedback of performance data measured by clinical audit. However, empirical evidence of the effectiveness of clinical audit in changing practice is limited. Few studies have attempted to evaluate practice development or clinical outcomes within the conceptual framework of change theory. Several published studies have used passive feedback in an attempt to promote a change in practice. Sending information to health care workers on their performance is one of the simplest ways of attempting to change performance. AIMS: To evaluate the impact on infection rates of the passive feedback of surgical wound infection rate data to nurses and surgeons within an empirical rational approach to change, and the active feedback of data within a normative re-educative approach to change. METHODS: A prospective cohort study over a 3-year period of all surgical patients undergoing clean elective surgery (n = 2241). Patients were monitored whilst an inpatient and up to 30 days postoperatively by an independent observer to determine surgical wound infection rates. The method employed was 'gold standard' surveillance, whereby patients were followed up into the community setting. INTERVENTIONS: Interventions of feedback and withdrawal of feedback of infection rate data and introduction of guidelines for evidence-based surgical practice within a change theory framework were monitored by the incidence of infection during the periods of the particular intervention. RESULTS: Although the feedback of infection rate data impacted on the subsequent infection rates, the reduction was not statistically significant. However, a significant reduction in the infection rates was achieved following the introduction of guidelines for best surgical practice (P < 0.05). CONCLUSIONS: The findings indicate that if change in practice is to be achieved by the feedback of performance data, then the process of feedback should be active and within a normative re-educative approach to change.

General Surgery↗
PubMed2005

Improving case ascertainment of a population-based birth defects registry in New York State using hospital discharge data.

BACKGROUND: The assessment of the data quality of population-based registration systems is essential to understanding the reliability and usefulness of disease surveillance and research findings resulting from the use of registry data. Since the New York State Congenital Malformations Registry (CMR) uses passive case ascertainment, the completeness of the registry data is an important aspect of the quality of information. This paper presents the results of hospital audits, which were conducted to capture the unreported cases using hospital discharge files, and evaluates the effectiveness of the audits. METHODS: Children age 2 years or younger and diagnosed with reportable birth defects for the birth years 1998-2000 were selected from hospital discharge files of all reporting hospitals in the New York Statewide Planning and Research Cooperative System (SPARCS) and matched to the CMR database for the same birth year period. The unmatched reports from the SPARCS hospital discharge files that the CMR possibly missed were sent to hospitals, requesting submission of the missed reports. Two audits on all reporting hospitals in New York State were conducted: 1) 1998 and 1999 birth cohorts audited from June 2000 to March 2002, and 2) 2000 birth cohort audited from November 2001 to November 2002. RESULTS: Hospital audits using SPARCS hospital discharge data identified 5,460 reports that the CMR missed for the selected 66 hospitals analyzed. About 86% of these reports had reportable conditions and were added to the CMR, which comprised 21.4% of all reports from the 66 hospitals for the birth years 1998-2000. The number of reports that would have been missed without audits decreased from the 1998 and 1999 birth cohort (25.1%) to the 2000 birth cohort (13.9%). Low reporting rates and, thus, a high percent of added reports, were found for hospitals with a relatively small number of annual reports and for some specific birth defects such as chromosomal anomalies, anencephalus and congenital anomalies of the urinary system. CONCLUSION: The current study demonstrates that using hospital discharge data to improve case ascertainment is a valuable and effective method of enhancing birth defect surveillance, particularly for those hospitals with low reporting rates.

Abnormalities, Multiple↗
PubMed1999

[Delivery logbook: pertinence of the collected data for scientific exploitation].

OBJECTIVES: To determine if the data recorded in the delivery logbook are relevant and complete compared to the data registered in the patient's medical chart. MATERIAL AND METHODS: Prospective study during one month recording all the data registered by the midwives or the medical doctors in the delivery room immediately after the birth. To compare them to the information collected in the patient's medical chart. Our delivery logbook has 55 headings for each patient. During October 1998, we had 156 births. RESULTS: We had 5.3% of errors divided by missing data and erroneous entries. More precisely, we recorded 9.5% of errors in the antepartum data, 3.2% in intrapartum or postpartum events and 5.8% in the newborn information. CONCLUSION: This study demonstrates that medical data used for scientific projects and recorded in the delivery logbook, have to be interpreted very cautiously. It seems to be reasonable that each obstetrical unit should standardize its registration of data and carry out internal audits.

Bias↗
PubMedDate not supplied

Enabling care: working through obscurity and uncertainty a basic social process used in selected acute care settings.

Using grounded theory methodology this study explored the process that nurses used to determine, deliver, and communicate patient care in acute care hospital settings and to assess whether or not this was congruent with the nursing process structure (O'Connell, 1998). Data were obtained from semi-structured interviews, participant field observations and in-depth audits of patient records. Textual data were managed using NUD*IST and analysed using the constant comparative method. The findings of this study revealed a number of factors that hindered nurses from using the nursing process in its current form. Instead, nurses used a basic social process termed: Enabling Care: Working through obscurity and uncertainty. This paper describes a basic social process used in selected acute care settings and discusses its implications for nursing practice. An understanding of this process will assist the profession to critique some nursing theories and to construct ideas of nursing practice based on current clinical realities.

Acute Disease↗
PubMed1998

An audit of personal logs--1997.

Since 1991 all registered members of the Royal College of Speech and Language Therapists (RCSLT) have made a personal commitment to continuing education and continuing professional development (CPD). To support this commitment individual members have been required each year to complete a personal log of appropriate activities. The 1996-97 Department for Education and Employment (DfEE)/RCSLT 'Lifetime Learning Project' aimed to enhance and develop CPD services for members. One strand of the project was to make more use of the data available through and audit of members' personal logs. The range of CPD activities recorded were examined in relation to the type of practive, location, grade and work setting of respondents.

Education, Continuing↗
PubMed1990

Variations in the provision of extended-trained ambulance personnel within the Welsh ambulance services.

This paper describes the distribution of extended-trained ambulance personnel within the nine Welsh Ambulance Services. While over a quarter of all emergency ambulance crews possess some extended skills, there is a wide variation in their distribution and protocols of treatment. Increasing numbers of ambulance personnel will receive such training in the future, leading to improved standards of pre-hospital care. To justify the use of such skills in terms of clinical outcome and expenditure, the ambulance services must provide accurate data to allow subsequent audit of pre-hospital clinical practice. It is therefore essential that the medical profession becomes aware of these developments and participates in advising, assessing and training extended-trained ambulance personnel.

Ambulances↗
PubMed1995

[Quality assurance, audit and quality control of radiotherapy at radiology departments in Hungary].

The first quality assurance, audit and control system in the Hungarian "'health" care industry" is described for the medical specialty of radiotherapy. The prerequisites of the elaboration of the programme were an exact knowledge of the current Hungarian infrastructural and staffing conditions, and the radiotherapeutic activities. The recommendations cover the 5 medical universities including the national institute (the Debrecen, Pécs, Semmelweis, Szent-Györgyk Albert Medical Universities, and Haynal Imre University of Health Sciences) and the 5 regional oncological centres in hospitals (Jósa András, Markusovszky, Petz Aladár, Szentpéteri kapu and Uzsoki Hospitals). The departmental functions (patient care, teaching-education, research work and scientific organizing activity) and the structure (organization, infrastructure, staffing conditions, etc.) are described first, followed by the therapeutic principles and clinical process (patient referral and selection, decision-making, priorities in therapy initiation, treatment preparation and execution, etc.). The informal daily/weekly quality assurance programme long applied in the routine patient care has been formalized and supplemented with a weekly audit conference. In the course of the medical audit, all relevant clinical data are reviewed and scored by an internal or an external expert (not participating directly in the treatment process), e.g. for the adequacy of the medical decision preparative process, conformation to the institutional treatment protocol, equipment selection, treatment planning, simulation and portal film, etc. If a major deviation is detected, an immediate correction is initiated; minor deviations need analysis and then preventive and correcting action. As concern the audit of the other activities of the departments, the important indicators and their minimally desirable level are defined. The final goal of the implementation of this programme is high-precision radiotherapy with the best achievable treatment result.

Dose-Response Relationship, Radiation↗
PubMed2006

Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback.

BACKGROUND: Many people advocate audit and feedback as a strategy for improving professional practice. The main results of an update of a Cochrane review on the effects of audit and feedback are reported. DATA SOURCES: The Cochrane Effective Practice and Organisation of Care Group's register up to January 2004 was searched. Randomised trials of audit and feedback that reported objectively measured professional practice in a healthcare setting or healthcare outcomes were included. REVIEW METHODS: Data were independently extracted and the quality of studies were assessed by two reviewers. Quantitative, visual and qualitative analyses were undertaken. MAIN RESULTS: 118 trials are included in the review. In the primary analysis, 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback was a component to no intervention. For dichotomous outcomes, the median-adjusted risk difference of compliance with desired practice was 5% (interquartile range 3-11). For continuous outcomes, the median-adjusted percentage change relative to control was 16% (interquartile range 5-37). Low baseline compliance with recommended practice and higher intensity of audit and feedback appeared to predict the effectiveness of audit and feedback. CONCLUSIONS: Audit and feedback can be effective in improving professional practice. The effects are generally small to moderate. The absolute effects of audit and feedback are likely to be larger when baseline adherence to recommended practice is low and intensity of audit and feedback is high.

Education, Medical, Continuing↗
PubMed1996

Computerised data collection for a cancer centre: a Queensland perspective.

The Queensland Radium Institute has had a computerised database for 15 years but there was little uniformity in the data collected and there was considerable scope for improvement. In 1991 the institute decided to upgrade and standardise its data collection system. The improvements will allow easier access to the data for research and audit purposes. The process was effective and the implementation straightforward because of effective planning and training. This paper outlines the process used in the review and implementation of the new database system and describes the date sets in some detail.

Abstracting and Indexing↗
PubMed1994

Audit in maternal and child health.

Audit in medicine is a well tried means of assessing the quality of practice by using acceptable measures of outcome. Audit in maternal and child health has been limited to fatal outcomes such as maternal and perinatal deaths. The outcome of audit is of interest to the providers, the health authorities and the consumers. The utility of audit lies in effective use of data to improve quality of service. Quality control of instruments and education of junior staff are some other benefits of audit. The limitations of manpower, money, means, fear of litigation and above all dislike of clinicians for handling data are hurdles in the way of effective audit. The concept of 'Standard Primipara' and 'Total Fetal Wastage' are likely to add new dimension to perinatal audit.

Child Health Services↗
PubMed2001

An economic analysis of surgical wound infection.

Audit of surgical wound infection is not only an outcome indicator, but also an important aspect of infection control. The literature suggests an expensive 'gold standard' involving a full-time audit nurse collecting prospective data, including a 30-day follow-up into the community.Our study indicates that the cost of surgical wound infection is three-fold: cost to the hospital, the community services and the patient. Although the greatest costs were due to prolonged stay or re-admission to hospital (just under pound90 000), costs to the community and patient cannot be ignored. Hospital expenditure varied according to the type of operation. The study clearly demonstrated the potential cost savings to be highlighted by this type of audit.

Costs and Cost Analysis↗
PubMed1986

NTP Toxicology and Carcinogenesis Studies of Marine Diesel Fuel (NO CAS) and JP-5 Navy Fuel (CAS No. 8008-20-6) in B6C3F1 Mice (Dermal Studies).

Toxicology and carcinogenesis studies were conducted by applying marine diesel fuel or JP-5 navy fuel to clipped dorsal interscapular skin of male and female B6C3F1 mice to determine both systemic and dermal effects. Doses for the 2-year studies were set by conducting 14-day and 13-week studies. Doses of 2,000-40,000 mg/kg marine diesel fuel were applied neat in the 14-day studies; in the 13-week studies, doses of 250-4,000 mg/kg marine diesel fuel in acetone were applied with a dose volume of 0.1 ml. Doses of 5,000-40,000 mg/kg JP-5 navy fuel in ethanol were applied in the 14-day studies with a dose volume of 0.5 ml; in the 13-week studies, doses of 500-8,000 mg/kg JP-5 navy fuel in acetone were applied with a dose volume of 0.2 ml. For the 2-year studies, doses were selected which did not cause deaths, decrease body weight gain, or produce excessive dermatitis in the 14-day or 13-week studies. Two-year studies were conducted by administering marine diesel fuel or JP-5 navy fuel by dermal application to groups of 49 or 50 male and 50 female B6C3F1 mice at doses of 0, 250, or 500 mg/kg in an acetone vehicle with a dose volume of 0.1 ml. Both sexes of mice dosed with 500 mg/kg marine diesel fuel (84-week exposure) and female mice dosed with 500 mg/kg JP-5 navy fuel (90-week exposure) were killed early because of excessive irritation and ulceration at the site of application and to prevent the spread of infection. Survival rates at those times were 26/50 males and 29/50 females dosed with marine diesel fuel and 17/50 females dosed with JP-5 navy fuel. Survival rates at the end of the studies (104 weeks) were reduced (P<0.01) in low dose female mice receiving marine diesel fuel (40/50 in vehicle controls compared with 12/50 in the low dose group) or with JP-5 navy fuel (44/50 in vehicle controls compared with 33/50 in the low dose group). Body weight gain was decreased below that of the vehicle controls after week 30 in all groups of mice receiving marine diesel fuel and in both sexes of mice receiving the high dose of JP-5 navy fuel. There was a marked increase in the incidence of chronic dermatitis in mice receiving marine diesel fuel or JP-5 navy fuel. Chronic dermatitis was defined as a composite lesion of epidermal histopathologic changes generally consisting of acanthosis, hyperkeratosis, and in some instances necrosis and ulceration of the overlying epidermis. Dermal changes frequently included fibrosis, increased amounts of melanin, and the presence of acute and chronic inflammatory cell infiltrates. A dose-related, proportional increase in the severity of the lesions was twofold to threefold greater in the dosed groups than in the vehicle controls. The averagedegree of severity of the lesions was judged to be minimal in the vehicle controls, mild in the low dose groups, and moderate in the high dose groups of mice dosed with marine diesel fuel or JP-5 navy fuel. There were similar responses at the site of inguinal skin to which the chemicals had migrated after application, but the degree of severity of the lesions was judged to be minimal to mild in the vehicle control and dosed groups of mice. Squamous cell papillomas or carcinomas (combined) occurred with a positive trend (P<0.05) at the site of application in male mice administered marine diesel fuel (vehicle control, 0/49; low dose, 0/49; high dose, 3/49). The total numbers of mice with squamous cell papillomas or carcinomas (combined) both for the site of application and the adjacent inguinal skin were 1/50, 2/49, and 3/50 for the vehicle control, low dose, and high dose groups of male mice and 0/50, 1/45, and 2/48 for female mice. There are no NTP historical data for B6C3F1 mice that received acetone by dermal application. The NTP historical incidence of squamous cell papillomas or carcinomas (combined) in untreated male and female B6C3F1 mice is 0.3%-0.4% in over 3,500 observations. Marine diesel fuel was not mutagenic in Salmonella typhimurium TA98, TA100, TA1535, or TA1537, and JP-5 navy fuel was not mutagenic in strains TA97, TA98, TA100, or TA1535 in th100, or TA1535 in the presence or absence of Aroclor 1254-induced male Sprague-Dawley rat or male Syrian hamster S9 when tested according to the preincubation protocol. Audits of the experimental data were conducted for these 2-year studies on marine diesel fuel and JP-5 navy fuel. No data discrepancies were found that influenced the final interpretations. Under the conditions of these 2-year dermal studies, marine diesel fuel at doses of 250 and 500 mg/kg resulted in dose-related increased incidences of squamous cell neoplasms of the skin (primarily carcinomas), providing equivocal evidence of carcinogenicity for male and female B6C3F1 mice. The sensitivity for detecting systemic carcinogenicity in female mice dosed with marine diesel fuel was reduced by poor survival. Under the conditions of these 2-year dermal studies, JP-5 navy fuel at doses of 250 and 500 mg/kg provided no evidence of carcinogenicity for male and female B6C3F1 mice.

Journal Article↗
PubMedDate not supplied

Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study.

BACKGROUND: Case fatality rates after all types of blunt injury have not improved since 1994 in England and Wales, possibly because not all patients with severe head injury are treated in a neurosurgical centre. Our aims were to investigate the case fatality trends in major trauma patients with and without head injury, and to establish the effect of neurosurgical care on mortality after severe head injury. METHODS: We analysed prospectively collected data from the Trauma Audit and Research Network database for patients presenting between 1989 and 2003. Mortality and odds of death adjusted for case mix were compared for patients with and without head injury, and for those treated in a neurosurgical versus a non-neurosurgical centre. FINDINGS: Patients with head injury (n=22,216) had a ten-fold higher mortality and showed less improvement in the adjusted odds of death since 1989 than did patients without head injury (n=154,231). 2305 (33%) of patients with severe head injury (presenting between 1996 and 2003) were treated only in non-neurosurgical centres; such treatment was associated with a 26% increase in mortality and a 2.15-fold increase (95% CI 1.77-2.60) in the odds of death adjusted for case mix compared with patients treated at a neurosurgical centre. INTERPRETATION: Since 1989 trauma system changes in England and Wales have delivered greater benefit to patients without head injury. Our data lend support to current guidelines, suggesting that treatment in a neurosurgical centre represents an important strategy in the management of severe head injury.

Adolescent↗
PubMed1996

DIALOG: co-ordination of the annual review process through a District Diabetes Register linked to the FHSA database.

A working party was established by the Population Screening Project Board (UK), in conjunction with the Family Health Services Computer Unit, in order to develop a system for diabetes care (DIALOG) that would create a District Diabetes Register and prompt the process of diabetes annual review across both primary and secondary care. To simplify the creation and maintenance of the Diabetes Register, DIALOG has been designed to interface with the Family Health Services Authority population register to enable realtime download of demographic data. The system will also accumulate clinical information for the continuing audit diabetes services according to the data items specified in the standard UK diabetes dataset and can deliver detailed statistical analyses. Data input can be manual or electronic. DIALOG has been created to complement and integrate with existing diabetes information systems in primary and secondary care; it is not intended to be a clinic management system. It has the potential to become a National Diabetes Register.

Diabetes Mellitus↗
PubMed2005

A knowledge audit of the managers of primary care organizations: top priority is how to use routinely collected clinical data for quality improvement.

Technology has provided improved access to the rapidly expanding evidence base and to computerized clinical data recorded as part of routine care. A knowledge audit identifies from within this mass of information the knowledge requirements of a professional group or organization, enabling implementation of an appropriately tailored knowledge-management strategy. The objective of the study is to describe perceived knowledge gaps and recommend an appropriate knowledge-management strategy for primary care. The sample comprised 18 senior managers of Primary Care Trusts: the Chairman, Chief Executive Officer, or Research and Development Lead. A series of interviews were recorded verbatim, transcribed and analysed. Knowledge requirements were broad, suggesting that a broadly based knowledge-management strategy is needed in primary care. The biggest gap in current knowledge identified is how to perform needs assessment and quality improvement using aggregated routinely collected, general practice computer data.

Data Collection↗
PubMed1999

Hospitalization of British troops during Operation Joint Endeavor (Bosnia).

Of 414 recorded hospitalizations among British troops during Operation Joint Endeavor (Bosnia) in 1996, 2% were attributable to battle injuries, 46% to routine injuries, and 52% to disease; most injuries were to the lower limbs, and most diseases were of the skin and musculoskeletal system. The median length of inpatient stay was 4 days for injury (range, 1-146 days) and 3 days for disease (range, 1-60 days). Correcting for uncaptured data, the number of hospitalizations attributable to both injury and disease was significantly lower than the number predicted from the NATO planning figures (p < 0.0001). The NATO planning estimates for expected hospitalizations need to be revised. The electronic recording at source of all patient information should be introduced during military deployments to optimize data capture, facilitate the audit of clinical activity, and inform future medical planning. All hospitalizations occurring during military missions should be recorded, and surgical interventions during deployments should be coded at source. Ineffective paper-based morbidity surveillance procedures such as Jefferson 97 (or J97) must be discontinued and replaced by an electronic, fully integrated, NATO-wide clinical information system. This clinical information system should encompass primary care, secondary care, medical training, and medical supply. It should be built on a Microsoft Office platform and should be capable of interfacing electronically with existing civilian databases. Important clinical outcomes should be structured hierarchically within the data set. The database should be configured so that it can be accessed locally by clinicians and remotely by epidemiologists and planners.

Bosnia and Herzegovina↗
PubMed1998

The implementation of prompted retinal screening for diabetic eye disease by accredited optometrists in an inner-city district of North London: a quality of care study.

Diabetic retinopathy remains the most common cause of blindness in people of working age but the provision of high quality eye screening for diabetic patients is still erratic in many health districts in the UK. National consensus guidelines recommend comprehensive population coverage, high sensitivity (>80%), high specificity (>95%), agreed clinical criteria, referral procedures and centralized data collection to facilitate audit. This study looks at the effectiveness of implementing a prompted recall programme for retinal screening in an inner-city district of North London. The scheme uses trained, accredited optometrists to screen patients with diabetes who are looked after in the community by their general practitioner. During the first 17 months of the scheme, 63 optometrists attended training and gained accreditation. Of the 666 patients recruited, 645 were scheduled for screening and 536 (83%) attended. Fourteen per cent of patients screened were found to have background retinopathy and 2.3% sight-threatening eye disease. In two audits, carried out 15 months apart in a random sample of GP practices, the incidence of recorded dilated fundoscopy increased from 48% at baseline to 56%, an increase of 8% (95% CIs 2%-14%). For referable eye disease, the sensitivity of this screening technique was 100%, the specificity 94% (95% CIs 90%-98%), the positive predictive value 79% (95% CIs 72%-86%) and the negative predictive value 100%. The administrative cost per case screened was Pound Sterling 12.60 (excluding clinical costs and any additional optometry payment).

Diabetic Retinopathy↗