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PubMed1999

Myringoplasty: a prospective audit study.

Seventy-three surgeons participated in a prospective audit of myringoplasty. They returned data on 1070 individual patients. Up to 12 months follow-up information was obtained. The mean number of myringoplasties performed per consultant in 1 year (1995) was 14.7 (95% confidence intervals (CI) 12.1 17.2). The main indication for performing the operation was to achieve an intact tympanic membrane. The mean graft take rate was 82.2%. When hearing improvement was the main indication for surgery it was improved in 67%. The use, or not, of an antibiotic had no significant influence on the graft take rate or the complication rate. Most complications reported were minor in nature.

Ear Diseases↗
PubMedDate not supplied

Conducting a security audit.

Prior to conducting a full-fledged security survey in order to meet requirements of JCAHO and other agencies, it is essential to conduct an initial audit that will assess your hospital's vulnerability. The information from this audit can guide and direct the survey process. This article describes what is involved in preparing for the initial audit and includes a sample security audit report.

Data Collection↗
PubMed1995

Involving clients in clinical audits of mental health services.

Involving clients in service audits is never straightforward. In developing a new audit system for use in mental health settings a review of the literature demonstrated that the concept of satisfaction, like quality, is problematic because it is multidimensional, it is affected by expectations, and may be defined differently by professionals and clients. Furthermore, it fails to address the notion of empowerment. However, the literature provided some clear methodological guidance about involving clients in clinical audit. Clients must be involved in defining audit topics, and the most appropriate techniques of data-collection are open-ended and qualitative. Clients can also be involved in the process of audit, particularly through conducting audits in collaboration with professionals. Evidence from the literature persuaded the authors to abandon the idea of developing an audit module on patient satisfaction, and instead to develop one with a clear focus on clients' perspectives, entitled "Clients' Appraisal of Care" as part of the Newcastle Audit System, with clients involved throughout.

Data Collection↗
PubMed2003

Five-year interim comparison of the Guidant bifurcated endograft with open repair of abdominal aortic aneurysm.

OBJECTIVE: This study was undertaken to compare 1-year and 5-year results of endovascular repair of abdominal aortic aneurysm (AAA) with the Guidant/EVT bifurcated graft system with results of open repair. METHODS: This was a prospective, nonrandomized, concurrent controlled study that compared results of endovascular versus open repair of AAA. The Phase II study with the EGS delivery system included 268 patients in 18 US medical centers; and the Phase III trial with the Ancure delivery system incuded 305 patients in 21 US institutions. Data were internally and externally audited and subjected to periodic review by the US Food and Drug Administration. The control group of 111 patients were excluded from endovascular repair with a tube graft because of anatomic considerations, but were otherwise comparable to the experimental group. Patients in the control group underwent conventional open surgical repair concurrently with patients who underwent EGS repair in 18 US institutions. RESULTS: Five hundred thirty-one of 573 patients (92.7%) underwent successful implantation of the Guidant/EVT bifurcated endograft. The combined major morbidity and mortality in the endograft group was 28.8%, compared with 44.1% in the open control group. Additional benefits in the endograft group included shorter hospital stay (2 days vs 6 days), less surgical blood loss (400 mL vs 800 mL), and less intensive care unit use (33% vs 94%). These early results are reported on an intent-to-treat basis; in all patients an attempt was made to treat with the endovascular graft, including those patients in whom conversion to standard open repair was necessary during the primary procedure. Three hundred nineteen patients were selected for long-term follow-up to 5 years, on the basis of date of implantation; ie, patients with the earliest implantations were followed up for 5 years. The primary purpose of long-term follow-up was to obtain data on long-term efficacy of the graft; thus only patients in whom implantation was successful were selected. No patient has experienced an aneurysm rupture to date. Survival (Kaplan- Meier method) in the experimental group was 68.1%, compared with 77.2% in the control group (P = NS). At 60 months, 74.4% of patients (32 of 43) were free of endoleak. There were no type I or type III endoleaks remaining. Aneurysm sac diameter decreased or remained stable in 97.6% of patients (41 of 42) and increased in only 1 patient. During the course of long-term follow-up, post-procedural conversion to open repair was required in only 9 patients (2.8%). CONCLUSION: The EVT/Guidant bifurcated graft is effective in preventing AAA rupture, and long-term survival is comparable to that with open repair.

Aged↗
PubMed1991

Testing various methods of introducing health charts into medical records in family medicine units.

OBJECTIVE: To test three methods of introducing health charts into the medical records of six family medicine units. DESIGN: Quasi-experiment. PARTICIPANTS: The staff physicians and family medicine residents in all six units and the nurses in two units. INTERVENTIONS: Group 1 (minimal intervention): health charts, a user's guide and one training session. Group 2 (intermediate intervention): same intervention as for group 1 plus two feedback sessions at 3 and 6 months. Group 3 (maximum intervention): same intervention as for group 2 plus promotion of the team concept (nurses were included). The intervention phase lasted from September 1987 to August 1988. OUTCOME MEASURES: The frequency with which the health charts were used, the item scores of each preventive care activity and the overall unit scores. Data were gathered through chart audits at baseline and at the end of the intervention phase. RESULTS: The frequency with which the health charts were used varied from 3.9% to 26.9%. The greatest increases in item scores were observed in the use of mammography (20.0%), counselling on lifestyle (19.4%) and breast examination (17.2%). Although the overall improvement in the unit scores was statistically significant (p less than 0.05) the hypothesis of an increasing gradient of effect across the three intervention groups could not be tested because of the variation in scores across the units. CONCLUSION: Health charts and other similar tools are useful; however, they are not sufficient to change practice behaviours. The support of a "champion" on the health care team might well be a determining factor of success for the delivery of preventive services in primary care practice.

Adult↗
PubMed1998

Factors influencing oral cavity status during high-dose antineoplastic therapy: a secondary data analysis.

PURPOSE/OBJECTIVES: To identify factors associated with oral cavity status in patients receiving high-dose antineoplastic therapy. DESIGN: Descriptive, correlational secondary analysis. SETTING: Midwestern university oncology special care unit. SAMPLE: 50 males and females, ages 15-69. METHODS: The Oral Assessment Guide (OAG) was used to assess oral cavity status every shift throughout hospitalization. Additional data were collected by chart audit. Correlations and Cox regression analysis were performed. MAIN RESEARCH VARIABLES: Oral cavity status, absolute granulocyte count, blood urea nitrogen (BUN), creatinine, mean OAG score during the preparative regimen (prep-OAG), age, and total body irradiation (TBI). FINDINGS: Elevated BUN and creatinine, higher prep-OAG, older age, and TBI were associated with higher OAG scores. Cox analysis revealed that TBI was predictive of an OAG score > or = 16, and an OAG score > or = 18 was predictive of death by day +20. CONCLUSIONS: Patients who receive TBI and chemotherapy in combination are most likely to experience severely compromised oral cavity status. Those who are older, have poorer oral status, and have decreased renal function are at increased risk. IMPLICATIONS FOR NURSING PRACTICE: High-risk patients must be identified early, and oral assessments and care must be given consistently to decrease morbidity and potential mortality.

Adolescent↗
PubMed1996

The efficacy, applicability and side-effects of postoperative intravenous patient-controlled morphine analgesia: an audit of 1233 Chinese patients.

We analyzed data from 1233 Chinese patients of a wide age range who received patient-controlled analgesia (PCA) intravenous morphine for postoperative pain relief, during the period of January 1992 to May 1995. The analgesic regimen was standardized as follows: PCA bolus 1 to 1.5 mg; lock-out interval 5 minutes; one-hour maximum dose 0.075 to 0.1 mg.kg-1 and background infusion 0 or 0.5 mg.h-1. Most patients underwent major surgery that was broadly subclassified according to the anatomical area involved. The median verbal numerical rating scales of pain (0 to 10) at rest and while coughing for the first, second and third 24 hours were 3.0/5.0, 1.5/4.0 and 0/3.0 respectively and the corresponding demand to delivery ratios were 2.8 +/- 2.9, 2.6 +/- 2.4 and 2.4 +/- 2.6. The overall morphine consumptions in 1004 of these Chinese patients were 27.5 +/- 16.8, 17.8 +/- 16.1 and 18.1 +/- 21.0 micrograms.kg-1.h-1 during the first 16, 17 to 41 and 42 to 66 postoperative hours respectively. These figures were the same as for Caucasian patients managed in the same institution. Morphine consumption was significant higher following thoracic, upper abdominal and spinal surgery. Also it was higher in patients younger than 65 years, males, cigarette smokers and those with ASA physical status I or II. The commonest side-effects were nausea (34.5%) and vomiting (18.2%). Bradypnoea and oxygen desaturation occurred in 0.5% and 1.6% respectively. All cases were promptly detected and managed with no adverse outcomes. Most patients were satisfied (76.7% ranked "good") with their postoperative analgesia. The commonest reasons for dissatisfaction were inadequate pain relief, nausea and reluctance to self-control analgesic administration. It is concluded that PCA with intravenous morphine is effective and safe as a routine postoperative technique for Chinese surgical patients.

Aged↗
PubMedDate not supplied

Audit of feeding practices in babies<1200 g or 30 weeks gestation during the first month of life.

AIM: In 2002, the composition of the breast milk fortifier used in our hospital changed, giving increased protein and energy. We therefore decided to prospectively audit nutritional management in our unit and to compare nutritional intake and growth in our babies with published data. METHODS: Data were prospectively collected over a 3-month period on infants<1200 g or 30 weeks gestation. Prescribed and delivered volumes of all parenteral and enteral fluids were recorded. Babies were weighed as per unit protocol. RESULTS: Thirty-four infants met the audit criteria. Data are median (range). After the first week of life, energy and protein intakes were 147 (78-174) kcal/kg/day and 3.9 (2.1-4.8) g/kg/day respectively. Daily weight gain was 17 (-3.2-35.4) g/kg and was significantly associated with both energy and protein intakes (P<0.001). However, standard deviation scores for weight fell from 0.15 (-1.9-2.0) at birth to -1.0 (-2.9-0.8) by 36 weeks corrected age. Time to commencing enteral feeds was 1 (1-3) day and to full enteral feeds was 8 (5-28) days. One infant was diagnosed with necrotising enterocolitis and eight with chronic lung disease. Mean protein intake was significantly lower in babies with chronic lung disease (P=0.005). CONCLUSION: Overall, nutritional intakes and weight gain in this cohort of babies lie within the recommended ranges, although protein intakes in the smallest babies are at the lower end of the range. Enteral feeds are introduced early and advanced rapidly, but we have a low incidence of necrotising enterocolitis. However, babies still fell across weight centiles, suggesting that actual intakes for these tiny babies may be inadequate.

Enteral Nutrition↗
PubMed1999

The delivery of clinical preventive services: acute care intervention.

BACKGROUND: . Evidence-based clinical preventive services are underutilized. We explored the major factors associated with delivery of these services in a large physician-owned community-based group practice that provided care for both fee-for-service (FFS) and health maintenance organization (HMO) patient populations. METHODS: We performed a cross-sectional audit of the computerized billing data of all adult outpatients seen at least once by any primary care provider in 1995 (N = 75,621). Delivery of preventive services was stratified by age, sex, visit frequency, insurance status (FFS or HMO), and visit type (acute care only or scheduled preventive visit). RESULTS: Insurance status and visit type were the strongest predictors of clinical preventive service delivery. Patients with FFS coverage received 6% to 13% (absolute difference) fewer of these services than HMO patients. Acute-care-only patients received 9% to 45% fewer services than patients who scheduled preventive visits. The combination of these factors was associated with profound differences. CONCLUSIONS: Having insurance to pay for preventive services is an important factor in the delivery of such care. Encouraging all patients to schedule preventive visits has been suggested as a strategy for increasing delivery, but that is not practical in this setting. Assessing the need for preventive services and offering them during acute care visits has equal potential for increasing delivery.

Adult↗
PubMed1994

Risk factors associated with having a pressure ulcer: a secondary data analysis.

Data obtained through five hospital-wide pressure ulcer audits were pooled for exploratory analysis. The purpose of this secondary data analysis was (1) to delineate the association of various risk factors and the presence of pressure ulcers and (2) to generate specific, testable hypotheses. Risk factors studied included fecal incontinence, urinary incontinence, malnutrition, impaired mobility, decreased mental status, diabetes mellitus, peripheral vascular disease, spinal cord injury, multiple sclerosis, and metastatic carcinoma. Stepwise logistic regression resulted in a best-fitting model that included fecal incontinence, impaired mobility, malnutrition, decreased mental status, and an interaction effect between fecal incontinence and impaired mobility. This model suggested that the odds of having a pressure ulcer were 22 times greater for hospitalized adult patients with fecal incontinence compared to hospitalized adult patients without fecal incontinence.

Adolescent↗
PubMed1994

Primary bone tumours of the shoulder: an audit of the Leeds Regional Bone Tumour Registry.

An audit of the prospectively gathered data of the Leeds Regional Bone Tumour Registry found that primary bone tumours of the shoulder constituted 145 of 2039 cases (7%). Seventy-five per cent of these occurred in the proximal humerus, 20% in the scapula and 5% in the outer half of the clavicle. Malignant and benign tumours were of equal overall frequency (73 vs 72) but the malignant lesions tended to occur in an older population (mean ages 43 years and 17 years respectively). Simple bone cyst was the commonest diagnosis in children, chondrosarcoma in the middle age group and osteosarcoma in the over-60s. Presenting symptoms were a poor guide to whether the lesion was malignant or not and the correct preoperative diagnosis was made only in a minority of cases. In 134 cases the diagnosis made by the referring pathologist was confirmed by the Bone Tumour Registry but in 11 cases, the diagnosis was changed by the Tumour Registry and differed with important clinical implications. Bone tumour registries provide a valuable source of cumulative information about uncommon tumours and facilitate accurate diagnosis, teaching and research.

Adolescent↗
PubMedDate not supplied

Successful implementation of universal woman abuse inquiry.

OBJECTIVE: This study investigated a year-long professional development strategy to improve Public Health Nurse (PHN) documented abuse inquiry among low-risk postpartum women. Strategies included workshops and small group work at regular intervals. DESIGN: A retrospective chart audit of cross-sectional data collected as part of the Healthy Babies/Healthy Children Program was conducted 1 year before and after the introduction of the Routine Universal Comprehensive Screening (RUCS) Program. SAMPLE: Charts of all postpartum women who lived in one Ontario county (Canada) and who received a PHN home visit were reviewed (pre-RUCS, n=1,151; post-RUCS, n=1,193). MEASUREMENT: Information regarding mother's age group and parity, month of PHN visit, abuse inquiry, and whether or not the woman was a single parent was abstracted. RESULTS: Originally, there was documentation of abuse inquiry on only 0.8% of low-risk postpartum client charts. Women aged <20 years and single parents were significantly (p<.001) more likely to be asked, suggesting case-finding among PHNs. Post-RUCS abuse inquiry increased to 20.5% with no demographic differences between those groups asked. CONCLUSION: Policy changes providing specific expectations and documentation cues can improve routine abuse inquiry. New policies can be effectively combined with existing programs and infrastructure, facilitating the longer term success of new initiatives.

Algorithms↗
PubMed2004

Case mix, outcome and length of stay for admissions to adult, general critical care units in England, Wales and Northern Ireland: the Intensive Care National Audit & Research Centre Case Mix Programme Database.

INTRODUCTION: The present paper describes the methods of data collection and validation employed in the Intensive Care National Audit & Research Centre Case Mix Programme (CMP), a national comparative audit of outcome for adult, critical care admissions. The paper also describes the case mix, outcome and activity of the admissions in the Case Mix Programme Database (CMPD). METHODS: The CMP collects data on consecutive admissions to adult, general critical care units in England, Wales and Northern Ireland. Explicit steps are taken to ensure the accuracy of the data, including use of a dataset specification, of initial and refresher training courses, and of local and central validation of submitted data for incomplete, illogical and inconsistent values. Criteria for evaluating clinical databases developed by the Directory of Clinical Databases were applied to the CMPD. The case mix, outcome and activity for all admissions were briefly summarised. RESULTS: The mean quality level achieved by the CMPD for the 10 Directory of Clinical Databases criteria was 3.4 (on a scale of 1 = worst to 4 = best). The CMPD contained validated data on 129,647 admissions to 128 units. The median age was 63 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. Mortality was 20.3% in the CMP unit and was 30.8% at ultimate discharge from hospital. Nonsurvivors stayed longer in intensive care than did survivors (median 2.0 days versus 1.7 days in the CMP unit) but had a shorter total hospital length of stay (9 days versus 16 days). Results for the CMPD were comparable with results from other published reports of UK critical care admissions. CONCLUSIONS: The CMP uses rigorous methods to ensure data are complete, valid and reliable. The CMP scores well against published criteria for high-quality clinical databases.

Adult↗
PubMed1993

Sudden unexpected death in epilepsy: a local audit.

Sudden unexpected death in epilepsy (SUDE) remains an under-investigated area. Little progress has been made in prospective evaluation of its incidence and causes. We report an audit of Cardiff Epilepsy Unit data that identified 14 cases of SUDE within a time period of 7000 patient-treatment years. These data suggest that SUDE occurs in 1 in 500 of our patients per year. Males were affected twice as often as females. The mean age of affected patients was 35 years, and most were in the 20-40 year age bracket. Eleven had epilepsy for more than 6 years, 12 were taking one or two antiepileptic drugs, and nine had been experiencing four or fewer seizures per month. Ten patients had idiopathic generalized seizures, and only one patient did not experience tonic-clonic seizures. Antiepileptic drug usage favoured carbamazepine. Most patients were not living alone but 11 of 14 (79%) were either unmarried, separated or widowed. In comparison with other patients attending the Epilepsy Unit (more than 1820 patients), SUDE patients were significantly (chi 2 < 0.05) more likely to be male, to have idiopathic generalized tonic-clonic seizures, or to be taking carbamazepine (monotherapy or in combination with another drug). There were no statistically significant differences in age, duration of epilepsy, number of drugs, or seizure frequency between the SUDE patients and our other patients. Correct case identification, and controlled, prospective, ante-mortem studies are needed so that the true incidence, associated risk factors and causes of sudden unexpected death in epilepsy can be accurately ascertained.

Adult↗
PubMed2003

Lost productive time and cost due to common pain conditions in the US workforce.

CONTEXT: Common pain conditions appear to have an adverse effect on work, but no comprehensive estimates exist on the amount of productive time lost in the US workforce due to pain. OBJECTIVE: To measure lost productive time (absence and reduced performance due to common pain conditions) during a 2-week period. DESIGN AND SETTING: Cross-sectional study using survey data from the American Productivity Audit (a telephone survey that uses the Work and Health Interview) of working adults between August 1, 2001, and July 30, 2002. PARTICIPANTS: Random sample of 28 902 working adults in the United States. MAIN OUTCOME MEASURES: Lost productive time due to common pain conditions (arthritis, back, headache, and other musculoskeletal) expressed in hours per worker per week and calculated in US dollars. RESULTS: Thirteen percent of the total workforce experienced a loss in productive time during a 2-week period due to a common pain condition. Headache was the most common (5.4%) pain condition resulting in lost productive time. It was followed by back pain (3.2%), arthritis pain (2.0%), and other musculoskeletal pain (2.0%). Workers who experienced lost productive time from a pain condition lost a mean (SE) of 4.6 (0.09) h/wk. Workers who had a headache had a mean (SE) loss in productive time of 3.5 (0.1) h/wk. Workers who reported arthritis or back pain had mean (SE) lost productive times of 5.2 (0.25) h/wk. Other common pain conditions resulted in a mean (SE) loss in productive time of 5.5 (0.22) h/wk. Lost productive time from common pain conditions among active workers costs an estimated 61.2 billion dollars per year. The majority (76.6%) of the lost productive time was explained by reduced performance while at work and not work absence. CONCLUSIONS: Pain is an inordinately common and disabling condition in the US workforce. Most of the pain-related lost productive time occurs while employees are at work and is in the form of reduced performance.

Absenteeism↗
PubMed1992

Clinical audit in intensive care--the Meath Intensive Care Audit.

Audit is now recognised as being an essential component of clinical practice. We report on the first year of the Meath Intensive Care Audit (MICA). This audit was instituted to investigate the activity of the unit, to assess the feasibility of continuous audit in our ICU and to provide data for future development of ICU facilities. Two hundred and fifty four patients were admitted between July 1st 1990 and June 30th 1991. The mean age at admission was 58 years and the mean length of stay 5.2 days. The mean APACHE II score was 16. Thirty four patients (13.4%) died in the ICU and 17 patients died in hospital following discharge from the unit bringing the hospital mortality rate to 20%. The audit proved feasible to implement and data collection is now accepted as a routine part of our ICU work.

Cause of Death↗