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PubMed1996

A general practice records audit of the process of care for people with epilepsy.

BACKGROUND: The appropriateness of epilepsy as a topic for general practice audit activity has been emphasized, but few audits have been undertaken to data and those that have are small scale. Historically, management of epilepsy has been a neglected area, and services for people with epilepsy remain generally poor. AIM: The study was designed to examine the process of care for people with epilepsy through a region-wide audit of general practitioner records. METHOD: General practitioners in 31 randomly selected general practices in one UK health region undertook a notes audit for all patients identified as having active epilepsy (patients who had had seizures in the last 2 years, or were currently seizure-free but on antiepileptic medication). A standard pro forma was used to collect information relating to diagnosis, drug treatment, and primary and secondary care contacts. RESULTS: Recording of information in the notes was generally good, but poor for some key items essential to the effective management of the condition; results suggest that a number of recommendations about provision of care for epilepsy are not being met: in particular, EEG and CT investigations often appear poorly directed; prescribed antiepileptic therapy is not always optimal; significant numbers of patients are being treated in hospital by non-neurologists; there is little evidence of any regular review being undertaken by general practitioners of their patients with epilepsy; and counselling about the non-clinical aspects of epilepsy often appears inadequate. CONCLUSIONS: Despite recommendations in a number of recent reports, gaps and inconsistencies in epilepsy care persist, both at the primary and secondary level. The means by which such shortcomings can be reduced (e.g. by specialist epilepsy nurses working across the primary-secondary care interface) should now be systematically examined. The study has highlighted a need for evidence-based guidelines which span the primary-secondary care interface and clarify the contribution of the various practitioners involved in the provision of care for people with epilepsy.

Adolescent↗

PubMed1996

Pain management knowledge, attitudes and clinical practice: the impact of nurses' characteristics and education.

This study examined the knowledge, attitudes, and clinical practice of registered nurses (N = 120) regarding pain management. Data were collected from nine varied clinical units in a large, university-affiliated, teaching hospital in an urban area of the Northeast. Demographic information was also collected to explore the relationship between nurses' characteristics, including previous pain education, clinical experience, area of clinical practice, and other variables, and knowledge, attitudes, and clinical practice. Three instruments were used in the study: (a) the Pain Management: Nurses' Knowledge and Attitude Survey; (b) a 12-item demographic questionnaire; and (c) a Pain Audit Tool (PAT) to gather data regarding pain assessment, documentation, and treatment practices from charts. Mean scores from the nursing knowledge and attitudes survey on pain revealed knowledge deficits and inconsistent responses in many areas related to pain management (mean, 62%; range, 41%-90%). The top two nurse-ranked barriers to pain management were related to patient reluctance to report pain and to take opioids for pain relief. Demographic data revealed that education about pain was most inadequate in the following areas: nonpharmacological interventions to relieve pain, the difference between acute and chronic pain, and the anatomy and physiology of pain. Chart audits with the Pain Audit Tool revealed that 76% of the charts (N = 82) lacked documentation of the use of a patient self-rating tool by nurses to assess pain, despite a high reported use (76%) of such a self-rating tool. Adjunct medications were ordered with some consistency, but appeared to be underutilized. This was especially true of nonsteroidal anti-inflammatory agents (mean use, 1%). Ninety percent of the charts had no documentation of the use of nonpharmacological interventions to relieve pain. Although this clinical setting has policies and resources in place regarding the management of pain, it would appear that they are not optimal. Practical recommendations are presented for increasing nurses' knowledge about pain management; improving the quality and the consistency of the assessment, documentation and treatment of pain; and disseminating pain management information.

Attitude of Health Personnel↗

PubMed2004

Repeatability of Phase 1 habitat survey.

As the major part of a Habitat Survey of Wales, over 80% of the land surface was surveyed in the field between 1987 and 1997 using the Phase 1 method. A resurvey of 294 randomly selected points was carried out during the early stages to audit the quality of the data being collected, leading to the development of a set of recommendations for the surveyors to improve the consistency and accuracy of habitat mapping. Recent studies have indicated a high level of discrepancy between organisations in field habitat mapping using the Phase 1 method. The findings of the Phase 1 audit in Wales are presented here to show the level of repeatability that was achieved within an organisation. There was 76% correspondence in habitat mapping between 'surveyor' and 'assessor' at the level of individual Phase 1 habitat classes. The degree of repeatability varied according to habitat strata: it was highest for modified land cover types (88%), lowest for semi-improved types (56%) and intermediate for semi-natural types (75%). An overall estimate of the repeatability of Phase 1 survey in the study area of 83% was obtained by weighting the figures for the three strata by the proportion of land area occupied by each stratum. This figure increased to 85% when habitats were amalgamated into Broad Habitat groups. These results are considerably better than those reported by studies of consistency between organisations. Most of the discrepancies between surveyor and assessor were caused by differences in habitat identification. However, at almost two thirds of the points where such a difference occurred, the assessor noted that the vegetation was transitional or borderline with that mapped by the surveyor.

Agriculture↗

PubMed2006

Identifying hazardous alcohol consumption during pregnancy: implementing a research-based model in real life.

AIMS: It has been repeatedly demonstrated that hazardous alcohol use during pregnancy is rarely detected in regular antenatal care, and that detection can be markedly improved using systematic screening. A major challenge is to translate research-based strategies into regular antenatal care. Here, we examined whether a screening strategy using the Alcohol Use Disorder Test (AUDIT) and time-line follow-back (TLFB) could be implemented under naturalistic conditions and within available resources; and whether it would improve detection to the extent previously shown in a research context. METHODS: Regular midwives at a large antenatal care clinic were randomized to receive brief training and then implement AUDIT and TLFB ("intervention"); or to a waiting-list control group continuing to deliver regular care ("control"). In the intervention-condition, AUDIT was used to collect data about alcohol use during the year preceding pregnancy, and TLFB to assess actual consumption during the first trimester. Data were collected from new admissions over 6 months. RESULTS: Drop out was higher among patients of the intervention group than control midwives, 14% (23/162) versus 0% (0/153), and p<0.0001. A one-day training session combined with continuous expert support was sufficient to implement systematic screening with AUDIT and TLFB largely within resources of regular antenatal care. The use of these instruments identified patients with hazardous consumption during the year preceding pregnancy i.e. AUDIT score 6 or higher (17%, 23/139), and patients with ongoing consumption exceeding 70 g/week and/or binge consumption according to TLFB (17%, 24/139), to a significantly higher degree than regular antenatal screening (0/162). The AUDIT- and TLFB-positive populations overlapped partially, with 36/139 subjects screening positive with either of the instrument and 11/139 were positive for both. CONCLUSIONS: We confirm previous findings that alcohol use during pregnancy is more extensive in Sweden than has generally been realized. Systematic screening using AUDIT and TLFB detects hazardous use in a manner which regular antenatal care does not. This remains true under naturalistic conditions, following minimal training of regular antenatal care staff, and can be achieved with minimal resources. The proposed strategy appears attractive for broad implementation.

Adult↗

PubMed2002

Severe acute maternal morbidity and mortality in the Pretoria Academic Complex: changing patterns over 4 years.

OBJECTIVE: To compare the severe acute maternal morbidity (SAMM) and maternal mortality in the Pretoria Academic Complex for the year 2000 and the years 1997-1999. STUDY DESIGN: SAMM and maternal mortality was identified at daily audit meetings. The audit was performed from 1 January 2000 to 31 December 2000 and compared with the data obtained from the original 2-year audit [Br J Obstet Gynecol 105 (1998) 985]. The mortality index (MI) was defined as Maternal Death (MD) divided by SAMM and MD. This index is used to assess the standard of care in specific maternal conditions. Data was assessed using the Chi square test. RESULTS: SAMM and maternal mortality has significantly declined in all patients with a reduction in abortion complications as the main contributor (268/100,000 births versus 94/100,000 births P<0.006). There is a non-significant trend to increased morbidity and mortality in hypertension, hemorrhage and infections. CONCLUSIONS: The standard of care was constant. An audit of SAMM and maternal mortality allows for early detection of trends and early changes in health strategies.

Abortion, Induced↗

PubMed1994

An integrated system for multidisciplinary assessments in stroke rehabilitation.

BACKGROUND AND PURPOSE: There is increasing emphasis on the use of integrated systems for timely, accurate, and efficient data collection for a range of service, audit, quality, and research applications. The present study evaluates the acceptability and the quality of data collected on a ward-based system over a 6-month period. METHODS: A multidisciplinary system specific for stroke rehabilitation was used. Members of each discipline were required to enter demographic, medical, nursing, therapy, and psychosocial data as appropriate to their specialty. A users' survey was undertaken at the beginning and at the end of the study. The quality and completeness of data entry were assessed by a "snapshot" of the database at the end of the study period. Primary users (n = 13) included physicians, nurses, and therapists. RESULTS: The user survey at the end of the evaluation showed a significant increase in confidence in using the system. Although the frequency of use had increased, the time spent in data entry had decreased significantly. The increase in work load, estimated at 15 to 60 minutes per week, was considered to be balanced by the benefits in patient care, audit, and research. There were 67 medical and 1046 other assessments on 67 patients entered into the system. Seven patients (11%) had incomplete medical records. Nursing and therapy assessments had been entered for all patients at admission and on discharge, with more than 95% of all possible assessments monitoring recovery being recorded accurately compared with conventional records. CONCLUSIONS: The study showed that it was possible to introduce a computerized multidisciplinary assessment system on rehabilitation wards as a part of day-to-day work without the need for significant extra resources.

Cerebrovascular Disorders↗

PubMed1988

Surgical audit.

Explore the source record for details and available documents.

Data Collection↗

PubMed2001

Using data mining to find fraud in HCFA health care claims.

Data mining can be/used to detect health care fraud and abuse through visualization of very large data sets to isolate new and unusual patterns of activity. Data mining has allowed better direction and use of health care fraud detection and investigative resources by recognizing and quantifying the underlying indicators of fraudulent claims, fraudulent providers, and fraudulent beneficiaries. A large amount of work must be performed prior to the actual data mining. These precursory tasks include: customer discussions, data extraction and cleaning, transformation of the database, and auditing (basic statistics and visualization of the information) of the data. This paper describes the tasks performed in support of a project for HCFA (Health Care Financing Administration).

Centers for Medicare and Medicaid Services, U.S.↗

PubMed1978

Inpatient audit simplified.

One hospital's audit program identifies the necessary procedures for selecting criteria, performing audits, and conducting follow-up and shows how they can be accomplished most effectively and efficiently. In addition, it shows that a useful emergency department/outpatient audit can be conducted using data from telephone follow-up for the patients.

Anti-Bacterial Agents↗

PubMed1984

A survey. Financial accounting and internal control functions pursued by hospital boards.

Justification for a board committee's existence is its ability to devote time to issues judged to be important by the full board. This seems to have happened. Multiple committees pursue more functions than the other committee structures. Boards lacking an FA/IC committee pursue significantly fewer functions than their counterparts with committees. Substantial respondent agreement exists on those functions most and least frequently pursued, those perceived to be most and least important, and those perceived to be most and least effectively undertaken. Distinctions between committee structures and the full board, noted in the previous paragraph, hold true with respect to the importance of functions. All board structures identified reviewing the budget and comparing it to actual results as important. Committee structures are generally more inclined to address functions related to the work of the independent auditor and the effectiveness of the hospital's system and controls than are full board structures. Functions related to the internal auditor are pursued least frequently by all FA/IC board structures. The following suggestions are made to help boards pay adequate attention to and obtain objective information about the financial affairs of their hospitals. Those boards that do not have some form of an FA/IC committee should consider starting one. Evidence shows chief financial officers have been a moving force in establishing and strengthening such committees. Boards having a joint or single committee structure should consider upgrading their structure to either a single committee or multiple committees respectively. The complexity of the healthcare environment requires that more FA/IC functions be addressed by the board. The board or its FA/IC committee(s) should meet with their independent CPA's, fiscal intermediary auditors, and internal auditors. Where the hospital lacks an internal audit function a study should be undertaken to determine the feasibility of initiating such a function. In most cases, the benefits derived from an independent, properly staffed internal audit function far exceed the cost of such a function.

Data Collection↗

PubMedDate not supplied

Antidepressant medications and the relative risk of suicide attempt and suicide.

OBJECTIVE: Suicide by drug overdose is a major public health problem, and antidepressant medications are the most common agent involved. European studies suggest differences in the rates of suicide by overdose among antidepressants, but no reports have been published for the United States. We estimated the comparative risks of suicide attempts and suicides, and the relative risk of fatality in the event of an overdose for the major antidepressants currently marketed in the United States. DATA SOURCES: Information regarding suicide attempts and suicides by antidepressant overdose was obtained from the published reports of the Drug Abuse and Warning Network and the annual report of the American Association of Poison Control Centers, and corrected for differences in total annual prescriptions using data from the National Prescription Audit. RESULTS: The risk of a suicide attempt did not appear to differ among antidepressants. The tricyclic antidepressants were associated with a higher rate of death in the event of an overdose than the newer nontricyclic antidepressants in both the annual report of the American Association of Poison Control Centers and the Drug Abuse and Warning Network data. The chance of death after an overdose was greater for desipramine hydrochloride than for other tricyclics. CONCLUSION: The higher risk of suicide with tricyclics vs nontricyclics may be explained by a higher rate of death from overdose rather than more suicide attempts. Tricyclics carry the risk of greater cardiotoxicity. The basis for the even higher rate of death/overdose of desipramine is not known and requires further research. If these findings are replicated in a case-control study design, they have important implications for the choice of an antidepressant for the depressed patient at risk for suicidal behavior.

Antidepressive Agents↗

PubMed2003

The last forty-eight hours of life in a Portuguese palliative care unit: does it differ from elsewhere?

The last few days of life have received significant attention in the literature. Reports have shown similarities and differences between programs. As a palliative care service in a cultural context that has not been reported on, we thought that an audit of our own experience in the care of patients in the last 48 hours of life and a comparison with other programs would be important. A prospective audit was designed to record data for four general domains: general demographic information, symptom prevalence, patient performance status, and perceived level of comfort. The inclusion criteria of patients were: older than 15 years of age (an admission criterion for patients of the unit), diagnosis of cancer, no active cancer-direct treatments, and patients who were on the unit for longer than 48 hours. The audit was completed when the 300th eligible patient died in the unit. Twenty-nine of 300 patients (9.6%) required sedation and the most common cause was delirium. Morphine was the most widely prescribed medication (85% of patients). The subcutaneous route was utilized extensively. Only 12% of the patients received parenteral fluids, usually via hypodermoclisis. Death was considered by staff to have been peaceful in 86% of cases. Our practice appears to mirror that of other palliative care groups.

Drug Utilization Review↗

PubMed1986

NTP Toxicology and Carcinogenesis Studies of Benzyl Acetate (CAS No. 140-11-4) in F344/N Rats and B6C3F1 Mice (Gavage Studies).

Benzyl acetate, a water-white liquid with a pear-like odor, is a natural constituent of several essential oils and flower absolutes extracted from jasmine, hyacinth, gardenia, tuberose, ylang-ylang, cananga, and neroli. Commercial benzyl acetate, a liquid prepared synthetically from benzyl chloride, acetic acid, and triethylamine is used primarily as a component of perfumes for soaps and as a flavoring ingredient. This compound is practically insoluble in water but is miscible in alcohol and ether and soluble in benzene and chloroform. Toxicology and carcinogenesis studies of benzyl acetate (>99% pure) were conducted by administering benzyl acetate in corn oil gavage to groups of 50 male and 50 female F344/N rats at doses of 0, 250, or 500 mg/kg body weight and to groups of 50 male and 50 female B6C3F1 mice at doses of 0, 500, or 1,000 mg/kg once daily five days per week for 103 weeks. Dose selection for the 2-year study was based on mean body weight gain depression and decreased survival observed at higher doses in 13 week studies. The absence of any observable adverse effect of benzyl acetate on the survival or mean body weight gains of the rats or mice in the 2-year studies suggests that both the rats and the mice of each sex could have tolerated higher doses. An infection in the genital tract was probably responsible for the deaths of 26/35 control, 14/32 low-dose, and 8/20 high-dose female mice before the end of the study. Acinar-cell adenomas in the pancreas of male rats occurred with a positive trend (P<0.01), and the incidence in the high-dose group (37/49, 76%) was significantly (P<0.01) higher than in the vehicle controls (22/50, 40%). The incidence of these tumors in the low-dose group (27/50, 54%) was comparable to that in the gavage controls. Acinar-cell hyperplasia of the pancreas was observed in 37/50 control, 34/50 low-dose, and 36/49 high-dose male rats. No acinar-cell hyperplasia or adenoma of the pancreas was observed in female rats. The incidence of retinopathy and cataracts in the high-dose male rats was increased compared with the controls (retinopathy: 1/50; 0/50; 20/50; cataracts: 0/50; 0/50; 13/50). Low-dose female rats had an increased incidence of retinopathy (18/50). Retinopathy and cataracts in rats have been associated with proximity to fluorescent light in this and previous studies. Preputial gland neoplasms occurred with a positive trend (P<0.05) in male rats (cystadenocarcinoma: 0/50; 0/50; 3/50; all adenocarcinoma: 0/50; 1/50; 4/50; adenocarcinoma or carcinoma combined: 1/50; 1/50; 6/50). However, the incidence of all preputial gland tumors was not significantly elevated (2/50; 1/50; 6/50). For female rats the incidence of clitoral gland neoplasms was marginally increased (2/50; 0/50; 5/50). Hepatocellular adenomas occurred in mice of each sex with statistically positive trends (males: 0/50; 5/49; 13/50; females: 0/50; 0/50; 6/50), and the incidences in the high-dose groups were greater than those in the controls (males: P<0.001; females: P<0.05). Hepatocellular carcinomas were marginally elevated in dosed male and high-dose female mice (males: 10/50; 14/49; 12/50; females: 1/50; 0/50; 4/50). Squamous cell papillomas or carcinomas of the forestomach (uncommon neoplasms) occurred with a positive trend (P<0.05) in male mice (4/49; 4/48; 11/49). The incidence of these tumors was also marginally (P=0.054) increased in the high-dose female mice (0/50; 0/50; 4/48). The incidences of these tumors in both the high-dose male and the high-dose female mice were considerably higher than the historical corn oil gavage control rates at this laboratory (males, 2/296, 0.7%; females, 2/297, 0.7%) and throughout the program (males, 14/1,070, 1.3%; females, 3/1,073, 0.3%). Forestomach hyperplasia occurred at increased incidences in dosed mice of either sex (males: 1/49, 7/48, 22/49; females: 1/50, 6/50, 17/48). The neoplasms and hyperplasia of the forestomach were probably related to administration of benzyl acetate. In a separate metabolism study, benzyl acetate was absorbed from the gastrointestinal traolism study, benzyl acetate was absorbed from the gastrointestinal tract of rats and mice, with approximately 90&percnt; of the administered dose recovered as various metabolites in the urine within 24 hr. The primary metabolite was hippuric acid, with minor amounts of a mercapturic acid, and one or more unidentified metabolites. This capacity for absorption, metabolism, and disposition was unaffected by the amount or number of doses administered. Benzyl acetate was not mutagenic in strains TA100, TA98, TA135, or TA137 of Salmonella typhimurium in the presence or absence of Aroclor 1254-induced Sprague-Dawley rat or Syrian hamster S9 when tested according to the preincubation protocol. Benzyl acetate did not induce sister-chromatid exchanges or chromosomal aberrations in Chinese hamster ovary cells in the presence or absence of Aroclor 1254-induced Sprague-Dawley rat liver S9. Benzyl acetate was mutagenic in the mouse lymphoma L5178Y/TK± assay in the presence, but not in the absence, of Aroclor 1254-induced Fisher 344 rat liver S9. An audit was conducted on the experimental data and the draft technical report for these 2-year studies on benzyl acetate. Based on the results of this audit additional pathology examinations were conducted on all target organs in male rats and male and female mice. The Technical Report reflects these final pathology evaluations. The overall conclusions regarding the toxicology and carcinogenicity of benzyl acetate did not change as a result of this evaluation. Under the conditions of these gavage studies, benzyl acetate increased the incidence of acinar-cell adenomas of the exocrine pancreas in male F344/N rats; the gavage vehicle may have been a contributing factor. There was no evidence of carcinogenicity for female F344/N rats. For male and female B6C3F1 mice there was some evidence of carcinogenicity in that benzyl acetate caused increased incidences of hepatocellular adenomas and squamous cell neoplasms of the forestomach. Synonyms: alpha-acetoxytoluene; benzyl ethanoate; acetic acid, benzyl ester

Journal Article↗

PubMed1989

Blood component transfusion audit: a comprehensive microcomputer program.

Blood usage review is an essential aspect of hospital quality assurance. As part of a system for reviewing transfusion practices, the American Red Cross/New Jersey Blood Services has developed a series of microcomputer programs called the Blood Component Transfusion Audit. The programs use transfusion data collected on a standardized form to produce reports of utilization and analyses of transfusion practices, including the extent to which transfusions are justified by established criteria.

Blood Transfusion↗

PubMed1993

Audit: teaching medical students in general practice.

Audit is being seen as an increasingly important topic for medical students. Many departments of general practice in the UK now incorporate audit as part of their course work. It remains controversial as to whether this is perceived to be worthwhile by the students. Following an introductory seminar final-year medical students at the University of Glasgow were asked to perform a case-note review of 10 randomly chosen diabetic patients for a number of process and outcome measures during their practice attachments. Feedback was given in their final teaching session. 128/153 (84%) students completed an evaluation of the course on their knowledge and attitudes to audit. Unsurprisingly, 39% found the data collection boring or very boring; however, 60% found the feedback session very interesting or interesting. Both the data collection and the feedback were considered relevant by the majority of students (57% and 70% respectively). Students' self-reported knowledge also dramatically increased (P < 0.0001).

Curriculum↗

PubMed1998

Delayed referral reduces the success of video-assisted thoracoscopic surgery for spontaneous pneumothorax.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is now the generally preferred surgical treatment for spontaneous pneumothorax but is more difficult once pleural adhesions have developed. To test the hypothesis that VATS is under-used because of prolonged pleural intubation, we have audited the effect of preoperative management on subsequent surgical outcome. METHOD: Data are expressed as median (range). A prospective audit of clinical outcome in 42 consecutive patients (30 male, 12 female, aged 39 [19-81] years) referred to a Regional Unit for non-elective pneumothorax surgery. VATS was attempted whenever possible. RESULTS: VATS was successful in 32 patients (group V) but 10 (24%) patients (group T) required thoracotomy and decortication of an empyema thoracis. Only seven (17%) patients were operated upon within 7 days of presentation, and 10 patients (24%) waited for more than 21 days. The delay from presentation to operation was significantly longer in group T (22 days vs. 10 days, P < 0.05, Wilcoxon). There were significantly more preoperative pleural interventions in patients in group T than in group V (P < 0.05, Wilcoxon). Postoperative stay was longer in group T (7 days vs. 3 days, P < 0.05) and there was a significant overall correlation between preoperative delay and postoperative stay (r = 0.64). CONCLUSION: Delayed referral for pneumothorax surgery and multiple pleural interventions predispose to pleural sepsis and preclude VATS detrimentally affecting clinical outcome. Changes in referral practice are advocated.

Adult↗

PubMed1990

The Nelson general practice prescribing project. Part I: A pilot audit of the regional prescribing profile.

The Nelson general practice prescribing project has been set up to develop a model for cost effective prescribing in general practice. A pilot audit of regional prescribing patterns and trends for February 1989 was conducted to test data acquisition and presentation for the project, based on 12,690 scripts. There was marked variation in medicines choice, cost and number of scripts between general practitioners. The cost of prescriptions ranged from $2.20 to $127.70, median $10.77. Cardiovascular medicines were most frequently prescribed and most costly. Extemporaneous prescribing accounted for 20% of the February inventory and was highly individually variable. Benzodiazepine prescribing was not in line with current guidelines and was high, mean 6.7% of all prescribing, indicating an urgent need for unbiased drug information. Audited prescription data allows definitions of educational and pricing strategies.

Drug Prescriptions↗

PubMedDate not supplied

The RCP Information Laboratory (iLab): breaking the cycle of poor data quality.

A review of data quality in the NHS by the Audit Commission cited a lack of clinician involvement in the validation and use of centrally held activity data as one of the key issues to resolve. The perception that hospital episode statistics cannot support the needs of the individual clinician results in mistrust and disinterest. This in turn leads to under-development of such data from a clinical perspective, and the cycle continues. The RCP Information Laboratory (iLab) aims to address this problem by accessing, analysing and presenting information from these central repositories concerning the activity of visiting individual consultant physicians. With support from iLab staff--an information analyst and a clinician--local data quality issues are highlighted and local solutions sought. The information obtained can be used as an objective measure of activity to support the processes of appraisal and revalidation.

Data Collection↗