Audit Data Research Articles

What can be done to improve diagnosis of aortic dissection?

Aortic dissection (AD) is rare. Missed AD is a common reason for coronial investigations and civil claims for medical negligence. Recommendations include improved education, supervision and information transfer, reminders in chest pain pathways and higher rates of investigation for AD. Higher investigation rates pose risks to patients and the health system which may not be in balance with the likelihood of AD. The appropriate diagnostic yield of investigation to balance risk and benefit has not been defined. The AD detection risk score pathway has been proposed as a useful diagnostic tool but concerns about its derivation, validation and utility remain. In this paper, we try to draw together published literature and local audit data to develop recommendations about what might be done to reduce the number of missed AD cases in EDs and what the impact of higher investigation rates might be.

Are We Following iRefer Guidelines From the Royal College of Radiology When Requesting Abdominal X-rays?

Background Abdominal radiography is one of the most routinely performed radiological investigations in hospitals. It is one of the initial investigations done in hospitals. Numerous studies have shown that abdominal X-rays have low sensitivity in several conditions such as acute abdominal pain. Methodology This study aims to first identify whether the Royal College of Radiology guidelines are being adhered to while requesting abdominal X-rays and, second, to identify the number of unnecessary requests made in the Betsi Cadwaladr health board. This is a retrospective audit of abdominal X-ray request data collected between the 1st and 23rd of August 2022. Data were collected from the electronic radiology record system. iRefer guidelines by the Royal College of Radiology were used as a reference to compare the requests made, and data were then analysed accordingly. Data are reported descriptively using percentages. Data analysis was done using SPSS version 20 (IBM Corp., Armonk, NY, USA). Results Of the total 242 abdominal X-rays noted, 89.67% of requests were according to the iRefer guidelines while 10.33% of requests were not. A total of 73.14% of cases were suspected to have an intestinal obstruction, and the positivity rate for the same was only 12.39%. Conclusions The majority of the requests followed the guidelines. However, there is an urgent need to develop local guidelines to reduce needless abdominal X-rays.

Evaluation of timeliness and models of transporting critically ill children for intensive care: the DEPICT mixed-methods study

Background Centralisation of paediatric intensive care has increased the need for specialist critical care transport teams to transfer sick children from general hospitals to tertiary centres. National audit data show variation in how quickly transport teams reach the patient’s bedside and in the models of care provided during transport; however, the impact of this variation on clinical outcomes and the experience of patients, families and clinicians is unknown. Objectives We aimed to understand if and how clinical outcomes and experience of children transported for intensive care are affected by timeliness of access to a transport team and different models of transport care. Methods We used a mixed-methods approach with a convergent triangulation study design. There were four study workstreams: a retrospective analysis of linked national clinical audit data (2014–16) (workstream A), a prospective questionnaire study to collect experience data from parents of transported children and qualitative analysis of interviews with patients, families and clinicians (workstream B), health economic evaluation of paediatric transport services (workstream C) and mathematical modelling evaluating the potential impact of alternative service configurations (workstream D). Results Transport data from over 9000 children were analysed in workstream A. Transport teams reached the patient bedside within 3 hours of accepting the referral in > 85% of transports, and there was no apparent association between time to bedside and 30-day mortality. Similarly, the grade of the transport team leader or stabilisation approach did not appear to affect mortality. Patient-related critical incidents were associated with higher mortality (adjusted odds ratio 3.07, 95% confidence interval 1.48 to 6.35). In workstream B, 2133 parents completed experience questionnaires pertaining to 2084 unique transports of 1998 children. Interviews were conducted with 30 parents and 48 staff. Regardless of the actual time to bedside, parent satisfaction was higher when parents were kept informed about the team’s arrival time and when their expectation matched the actual arrival time. Satisfaction was lower when parents were unsure who the team leader was or when they were not told who the team leader was. Staff confidence, rather than seniority, and the choice for parents to travel with their child in the ambulance were identified as key factors associated with a positive experience. The health economic evaluation found that team composition was variable between transport teams, but not significantly associated with cost and outcome measures. Modelling showed marginal benefit in changing current transport team locations, some benefit in reallocating existing teams and suggested where additional transport teams could be allocated in winter to cope with the expected surge in demand. Limitations Our analysis plans were limited by the impact of the pandemic. Unmeasured confounding may have affected workstream A findings. Conclusions There is no evidence that reducing the current 3-hour time-to-bedside target for transport teams will improve patient outcomes, although timeliness is an important consideration for parents and staff. Improving communication during transport and providing parents the choice to travel in the ambulance with their child are two key service changes to enhance patient/family experience. Future work More research is needed to develop suitable risk-adjustment tools for paediatric transport and to validate the short patient-related experience measure developed in this study. Trial registration This trial is registered as ClinicalTrials.gov NCT03520192. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 34. See the NIHR Journals Library website for further project information.

Assessing the quality of immunization data from administrative data in Enugu State, South-East Nigeria: A cross-sectional study.

Studies evaluating immunization data quality and its determinants in low- and middle-income countries are scarce. Therefore, this study assessed the accuracy of routine immunization data and its associated factors in Enugu State, South-East Nigeria. This was a descriptive cross-sectional, mixed-method study. A multi-stage sampling technique was used to select 60 out of 180 primary health facilities in six local government areas (LGAs). Routine data on Bacillus Calmette Guerin (BCG), pentavalent vaccine dose3 (Penta3), and Measles2 vaccinations in tallied registers, facility reports, and District Health Information System II (DHIS2) in 2020 were abstracted using a questionnaire. The dependent variables were the accuracy ratios of the facility and DHIS2 reports. We collected data on the independent variables including LGAs, type of location, facility type, tool availability, tool use, frequency of supervision, defaulter tracing, and vaccine tracking. Additionally, semi-structured, in-depth interviews were conducted with 35 purposively selected actors on factors affecting the data quality. The proportions of facilities with normal, under-, or over-reporting were summarized in percentages. The median accuracy ratios and interquartile range (IQR) were also reported. Differences in median accuracy ratios were tested using the independent sample median test. We tested the predictive model using a generalized linear model. Statistical significance was set at P < 0.05. The qualitative data were analyzed using content analysis. The accuracy of facility reports ranged from 38% to 68% (normal), 17-30% (under-reporting), and 15-35% (over-reporting) of health facilities. In DHIS2, the accuracy ranged from 5% to 10% (normal), 37-42% (under-reporting), and 53-63% (over-reporting) of health facilities. The median (IQR) accuracy ratios of facility reports were 100.0% (98.3-103.2%), 100.0% (98.5-103.6%), and 100.0% (81.6-110.2%) for BCG, Penta3, and Measles2, respectively. The median (IQR) accuracy ratios of DHIS2 reports were 83.6% (43.3-192.7%), 88.4% (37.8-200.8%), and 46.2% (10.7-202.7%) for BCG, Penta3, and Measles2, correspondingly. No facility characteristic predicted the accuracy of routine immunization reports. Reasons for inaccurate data include untimely recording, wrong counting, delayed reporting, infrequent supervision, lack of data audits, resource constraints, and high workload. Routine immunization data are not always accurate in Enugu state. Continuous efforts to improve the data monitoring system, supervision, data audits, funding, and staffing are warranted.

Diabetes in the public healthcare sector of four South African provinces: A comparative analysis.

The growing burden of diabetes has long been under the radar in developing countries such as South Africa (SA). In recent years, there has been an unprecedented and exponential increase in recorded and undiagnosed diabetes mellitus (DM) cases. Unreliable data collection, overburdened health systems and poor infrastructure have all proved to be barriers to achieving optimum disease management. The District Health Information System (DHIS) serves as the data collection tool for the SA public healthcare sector. It is used in all nine SA provinces to gather data without individual patient identifiers. To analyse and compare the DM data collected by the DHIS in the Western Cape (WC), Eastern Cape (EC), KwaZulu-Natal (KZN) and Gauteng provinces of SA. An audit of diabetes-related data from the DHIS for 2016 was conducted. The data were then analysed using Excel. Time-series and cross-sectional analyses were made possible using pivot tables. Graphics were designed using Thinkcell software. Of the four provinces surveyed, Gauteng recorded the highest incidence of DM, 67% higher than the reported global DM incidence estimate, while the WC had the lowest incidence. A similar pattern was also noted regarding the incidence of DM in people aged <18 years, with Gauteng having the highest and WC the lowest prevalence results. When comparing the number of DM-related consultations conducted in each province, the metropolitan districts were highlighted as hotspots of activity for DM care. This study found a moderate inversely proportional relationship between the incidence of DM in all provinces and education deprivation (p<0.05). Among the provinces that collected data on screening (excluding EC), KZN recorded the highest number of diabetic screenings. Metropolitan areas were highlighted as areas to be targeted, further reinforcing the current connection observed between urbanisation and DM in SA. The presence and recording of screening efforts is an excellent step in the right direction for the SA public healthcare sector and the DHIS. With improved interprovincial co-ordination regarding standardisation of the criteria and specifications of data collection fields, and enhanced training for data officers and primary collection agents, good quality and rich data is a very close possibility.

DEVELOPMENT OF THE PATIENT-IMPORTANT OUTCOMES NATIONAL DATA REPOSITORY (PIONEER) FOR HEREDITARY ANGIOEDEMA (HAE)

<h3>Introduction</h3> Here we describe the development and general characteristics of PIONEER-HAE, an enhanced database combining electronic medical data with insight from chart review, for the purpose of informing future studies. <h3>Methods</h3> Data source: Continuity of care documents (CCD), EMR (labs, procedures, treatment), and visit notes specific to patients in care by the Consortium of Independent Immunology Clinics (CIIC). Data extraction/collection process. [FIGURE] Unstructured data were extracted into electronic forms by clinically-trained scribes and included attack details, on demand treatment, symptoms onset and diagnosis, family history, and comorbidities. Form data were subjected to logical checks, random audit (1-2%), and tertiary data review after combining with CCD and EMR data. Inferred HAE diagnosis, based on treatment, ICD10 D84.1, and/or SNOMED 24743004, was confirmed or corrected by source physicians. <h3>Results</h3> As of Jun 2022, PIONEER-HAE contained data for 480 HAE-confirmed patients in care at 12 practices across 11 US states. Population characteristics: female 68% (327), mean (median) age 43 (42) years with 65% ≤50 years. Scribes reviewed visit notes for 265 patients and 1957 visits representing 1024 patient-years. For this subset, 83% (221/265) and 56% (148/265) patients had a visit in the last 36 or 12 months, respectively. HAE attacks were documented for 93% (246/265) patients at 69% (1358/1957) visits. Attack details included number/frequency (41%; 804/1358 visits), body location (74%; 1008/1358 visits), on-demand medication (72%, 971/1358 visits), and severity/resolution (90%; 1227/1358 visits). <h3>Conclusion</h3> PIONEER-HAE combines visit information with fielded data residing in EMR/CCD to enable better understanding of patient-important outcomes.

Differences in contraceptive prices between and within family planning outlets in urban and semiurban Nigeria: a prospective cohort study

BACKGROUNDThere is a lack of comprehensive evidence assessing variability and volatility in contraceptive prices. Improved understanding of contraceptive pricing, both between and within public and private service delivery points situated within complex, mixed health systems, may improve understanding of contraceptive access from the perspective of the consumer. OBJECTIVETo describe variability and volatility in contraceptive method prices within localized urban and semiurban markets in Nigeria. STUDY DESIGNWe used product audit data from a complete census and longitudinal cohort of family planning vendors within 4 urban and semiurban study sites in Nigeria. Differences in outlet-level minimum prices by outlet type were assessed using generalized estimating equations. We presented descriptive summaries of within-outlet changes in minimum price over time. RESULTSAmong 672 family planning vendors, outlet-level minimum prices were significantly higher in private facilities/outlets than in public facilities. The outlet-level minimum price was $9.4 (95% confidence interval, $5.7–$13.2) higher for implants in private vs public facilities. We observed high availability of free contraceptive products in the public sector (79%–100%), moderate levels for specific contraceptive product types among community health workers and private facilities (28%–62% for male condoms), and low prevalence among private nonfacility outlets (0%–3%). Variability in contraceptive prices was high within private facilities and nonfacility outlets: standard deviations in the distribution of long-acting reversible contraceptive products ranged from $9.7 for implants to $13.1 for intrauterine devices in the private sector. Changes in minimum prices by contraceptive method type were common within the same outlets over time in the private sector. CONCLUSIONWe observed high variability between and within contraceptive vendors in selected Nigerian family planning markets. Further research assessing the impact of price variability is critical for understanding contraceptive access and decision-making from the consumer's perspective.

Hyperglycaemia in patients with Acute Coronary syndromes (ACS): Retrospective audit data from Barnsley Hospital NHS Foundation Trust

Hyperglycaemia in patients with Acute Coronary syndromes (ACS): Retrospective audit data from Barnsley Hospital NHS Foundation Trust

Effect of lean implementation on team psychological safety and learning

PurposeFrontline teams are at the centre of lean transformations, but the teams also transform as they implement lean. This study examines these changes and seeks to understand how lean relates to team psychological safety and learning.Design/methodology/approachThis research setting is the Romanian division of a leading European energy company. The authors collected team-level audit and survey data, which the authors used to test the effect of lean implementation on team psychological safety and learning. The authors’ team-level data are complemented with qualitative interviews conducted with team members and headquarters leaders.FindingsThe results of the regression analyses show that leanness is positively associated with team psychological safety, which is in turn positively associated with learning. Thus, this research provides evidence that leanness – mediated by team psychological safety – increases team learning.Practical implicationsLean changes team dynamics and learning positively by ensuring and promoting an emotionally sound work environment with clear team structures, an appropriate level of autonomy, and strong leadership.Originality/valueThis paper contributes evidence of important psychological mechanisms that characterise team-level lean implementation. Particularly, the authors highlight how team psychological safety mediates the relationship between leanness and team learning.

109 FRAILTY CARE BUNDLE EAT WALK TALK: MAKING GERIATRIC ATTUNED CARE EVERYONE'S BUSINESS

Abstract Background Older adults living with frailty are predisposed to functional decline, worsening malnutrition and delirium when admitted to the acute hospital. EAT, WALK and TALK is a comprehensive framework that promotes optimal nutrition and hydration, supports functional recovery and helps prevent delirium [1]. Comprehensive geriatric assessment and interdisciplinary care on an older adult ward can improve outcomes for older adults [2]. However, not all older adults receive care on specialist wards. The frailty care bundle framework could be utilised on general medical wards to apply older adult attuned principles of good care. Methods A quality improvement initiative using PDSA was undertaken. Engagement with stakeholders was made through the Quality and Patient Safety Committee. The overall aim was to prevent hospital associated functional decline by increasing mobility, improving nutrition and cognitive engagement on general medical wards. The blue plate initiative, patient mobility and delirium screening was audited. Results The audit showed a 13.3% reduction in patients screening positive for delirium and a 100% increase in the use of delirium care plans. Nutritional intake had improved by 50% with the addition of blue crockery. Baseline mobility audit showed gaps in communication between health professionals. Whiteboards were introduced to address this. Conclusion The EAT WALK and TALK care bundle prioritises the critical components of good care for the older person living with frailty. The audit data shows improvement in care processes and outcome measurements.

VBlock: A Blockchain-Based Tamper-Proofing Data Protection Model for Internet of Vehicle Networks.

The rapid advancement of the Internet of Vehicles (IoV) has led to a massive growth in data received from IoV networks. The cloud storage has been a timely service that provides a vast range of data storage for IoV networks. However, existing data storage and access models used to manage and protect data in IoV networks have proven to be insufficient. They are centralized and usually accompanied by a lack of trust, transparency, security, immutability, and provenance. In this paper, we propose VBlock, a blockchain-based system that addresses the issues of illegal modification of outsourced vehicular data for smart city management and improvement. We introduce a novel collusion-resistant model for outsourcing data to cloud storage that ensures the network remains tamper-proof, has good data provenance and auditing, and solves the centralized problems prone to the single point of failure. We introduced a key revocation mechanism to secure the network from malicious nodes. We formally define the system model of VBlock in the setting of a consortium blockchain. Our simulation results and security analysis show that the proposed model provides a strong security guarantee with high efficiency and is practicable in the IoV environment.

Distinct components of alert fatigue in physicians' responses to a noninterruptive clinical decision support alert.

Clinical decision support (CDS) alerts may improve health care quality but "alert fatigue" can reduce provider responsiveness. We analyzed how the introduction of competing alerts affected provider adherence to a single depression screening alert. We analyzed the audit data from all occurrences of a CDS alert at a large academic health system. For patients who screen positive for depression during ambulatory visits, a noninterruptive alert was presented, offering a number of relevant documentation actions. Alert adherence was defined as the selection of any option offered within the alert. We assessed the effect of competing clinical guidance alerts presented during the same encounter and the total of all CDS alerts that the same provider had seen in the prior 90 days, on the probability of depression screen alert adherence, adjusting for physician and patient characteristics. The depression alert fired during 55649 office visits involving 418 physicians and 40474 patients over 41 months. After adjustment, physicians who had seen the most alerts in the prior 90 days were much less likely to respond (adjusted OR highest-lowest quartile, 0.38; 95% CI 0.35-0.42; P < .001). Competing alerts in the same visit further reduced the likelihood of adherence only among physicians in the middle two quartiles of alert exposure in the prior 90 days. Adherence to a noninterruptive depression alert was strongly associated with the provider's cumulative alert exposure over the past quarter. Health systems should monitor providers' recent alert exposure as a measure of alert fatigue.

Optimizing Temporal Capital: How Big Tech Imagines Time as Auditable

The belief that technology can be profitably employed to control and manage time has a long history. In this article we show how electronic calendaring systems have become emblematic of the contemporary vision of mastering time, codifying a distinctive quantitative orientation to time. Drawing on interviews with calendar designers at four prominent software development companies, we explore the quest among knowledge workers in Silicon Valley to embed a culture of temporal optimization through the use of calendaring software. Their collective response to this issue reveals that there is a specific kind of technoscientific world being developed: one fixated with solving the problem of time scarcity in contexts organized around maximizing productivity. Furthermore, this world is increasingly embracing the power of predictive data analytics and artificial intelligence. Yet, rather than being the progressive act that many Silicon Valley designers believe they are engaging in, this move toward automating time is the latest in a series of long-standing moral attempts to subject time to a particular brand of rationalization. This orientation to, and valorization of, the fast-paced, full life requires incessant performance on our part and the relentless pursuit of self-enhancement. In other words, positing that time has now become fodder for pattern recognition, we argue that calendaring software configures time events as auditable data that is ripe for accounting in the service of both old and new forms of socially-constructed optimization. We conclude by drawing out the implications of treating time as auditable data, most importantly, that it reinforces asymmetrical relations of power and devalues relations of care.

Quality assurance in the polytechnic of health, ministry of health

This research aims to see the strengths and weaknesses, differences and similarities of SPME standards, and build a hypothetical integration of quality assurance systems. This research type is evaluative research with a qualitative approach. The instrument is an interview guide, observation guide, and documentation. The data analysis used is a SWOT analysis, Mind Mapping, and CIPP. The results are the weaknesses are seen from multiple assignments, different assessment indicators, teamwork, implementation of the MOU has not been optimal, and the assessment period and data are not yet integrated. The threats are inconsistent regulations, different standards, and global competition. This is the first study that evaluated five accreditation quality assurance systems, ISO 9001: 2015, PDDikti, SAKIP, and ZI. The formulation of a hypothetical model provides SPMI data for the requirement of the SPME. The recommendation from this study is to coordinate the quality assurance center to synchronize the data and integrate data audit instruments in a quality assurance application.

Blockchain Adoption in Aviation: Opportunities and Challenges

In the world of aviation, current evidence suggests that data management systems are majorly centralized and at the same time suffer some noted shortfalls. Whereas, under this system of operation, it is hard to guarantee trust, especially data provenance, in addition to other shortfalls. More so, there are issues of lack of sufficient governance of data immutability, transparency, auditability, and traceability; which present debilitating drawbacks to the current regime of centralized data management systems in aviation industries. Blockchain as a new normal disruptive technology promises potency and reliability in data trust, traceability, transparency, auditability, and immutability. Blockchain further emphasizes immutability for stored and exchanged data, in transaction environments, in a decentralized and secure manner. That is, in a manner whereby a trusted third-party involvement is not required. For this reason, this paper discusses and highlights the key characteristics that differentiate and denominate Blockchain. It dwells more upon Blockchain application in aviation, in its several sectors such as passenger verification, In-flight Entertainment (IFE) Monetization, Smart Contract, Digital Identity, Distribution, Payment, and so on. Also, the paper did not conclude without pointing out areas of inconclusive research in Blockchain technology to stimulate further research studies leading to new understanding, knowledge, ideation, and idea incubation.

Quality of endodontic record-keeping and root canal obturation performed by final year undergraduate dental students: An audit during the COVID-19 pandemic.

To assess the quality of endodontic record-keeping and root canal obturation performed by undergraduate final year dental students during the COVID-19 pandemic. Dental records and dental radiographs of patients who received endodontic treatments between March 2020 and March 2022 by undergraduate students during the COVID-19 pandemic were included. The audit data were collected based on the European Society of Endodontology guidelines retrospectively via assessing the patient's clinical records and intraoral periapical radiograph. Root canal obturation quality was evaluated based on the following parameters: adaptation, length, taper, and mishap. A root filling is defined as satisfactory only when all four parameters were graded as acceptable. Subsequently, the data were recorded and analysed using Chi-Square test with the level of significance set at p = 0.05. A total of 111 patient records with 111 root canal-treated teeth were evaluated. The highest percentage of documented evidence was noted in the patient's general records, while the endodontic treatment records showed the lowest percentage of documented evidence. 78 (70.3%) of root canal-treated teeth were deemed satisfactory with acceptable adaptation, length, taper, and absence of mishap. Moreover, no statistical significance in terms of root canal filling quality was noted between anterior and posterior teeth, and between maxillary and mandibular arch. Although patient records and root canal fillings quality were deemed satisfactory in most cases, strict documentation requirements and continuing dental education in audit training are necessary for quality assurance.

Using simulation and machine learning to maximise the benefit of intravenous thrombolysis in acute stroke in England and Wales: the SAMueL modelling and qualitative study

BackgroundStroke is a common cause of adult disability. Expert opinion is that about 20% of patients should receive thrombolysis to break up a clot causing the stroke. Currently, 11–12% of patients in England and Wales receive this treatment, ranging between 2% and 24% between hospitals.ObjectivesWe sought to enhance the national stroke audit by providing further analysis of the key sources of inter-hospital variation to determine how a target of 20% of stroke patients receiving thrombolysis may be reached.DesignWe modelled three aspects of the thrombolysis pathway, using machine learning and clinical pathway simulation. In addition, the project had a qualitative research arm, with the objective of understanding clinicians’ attitudes to use of modelling and machine learning applied to the national stroke audit.Participants and data sourceAnonymised data were collected for 246,676 emergency stroke admissions to acute stroke teams in England and Wales between 2016 and 2018, obtained from the Sentinel Stroke National Audit Programme.ResultsUse of thrombolysis could be predicted with 85% accuracy for those patients with a chance of receiving thrombolysis (i.e. those arriving within 4 hours of stroke onset). Machine learning models allowed prediction of likely treatment choice for each patient at all hospitals. A clinical pathway simulation predicted hospital thrombolysis use with an average absolute error of 0.5 percentage points. We found that about half of the inter-hospital variation in thrombolysis use came from differences in local patient populations, and half from in-hospital processes and decision-making. Three changes were applied to all hospitals in the model: (1) arrival to treatment in 30 minutes, (2) proportion of patients with determined stroke onset times set to at least the national upper quartile and (3) thrombolysis decisions made based on majority vote of a benchmark set of 30 hospitals. Any single change alone was predicted to increase national thrombolysis use from 11.6% to between 12.3% and 14.5% (with clinical decision-making having the most effect). Combined, these changes would be expected to increase thrombolysis to 18.3% (and to double the clinical benefit of thrombolysis, as speed increases also improve clinical benefit independently of the proportion of patients receiving thrombolysis); however, there would still be significant variation between hospitals depending on local patient population. For each hospital, the effect of each change could be predicted alone or in combination. Qualitative research with 19 clinicians showed that engagement with, and trust in, the model was greatest in physicians from units with higher thrombolysis rates. Physicians also wanted to see a machine learning model predicting outcome with probability of adverse effect of thrombolysis to counter a fear that driving thrombolysis use up may cause more harm than good.LimitationsModels may be built using data available in the Sentinel Stroke National Audit Programme only. Not all factors affecting use of thrombolysis are contained in Sentinel Stroke National Audit Programme data and the model, therefore, provides information on patterns of thrombolysis use in hospitals, but is not suitable for, or intended as, a decision aid to thrombolysis.ConclusionsMachine learning and clinical pathway simulation may be applied at scale to national audit data, allowing extended use and analysis of audit data. Stroke thrombolysis rates of at least 18% look achievable in England and Wales, but each hospital should have its own target.Future workFuture studies should extend machine learning modelling to predict the patient-level outcome and probability of adverse effects of thrombolysis, and apply co-production techniques, with clinicians and other stakeholders, to communicate model outputs.FundingThis project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full inHealth and Social Care Delivery Research; Vol. 10, No. 31. See the NIHR Journals Library website for further project information.

Quantifying antibiotic use in typhoid fever in India: a cross-sectional analysis of private sector medical audit data, 2013–2015

ObjectivesTo estimate the antibiotic prescription rates for typhoid in India.DesignCross-sectional study.SettingPrivate sector primary care clinicians in India.ParticipantsThe data came from prescriptions of a panel of 4600 private sector primary care...

Perioperative oral paracetamol: kicking the intravenous habit to promote sustainable healthcare

Background: The NHS is a significant contributor to the UK’s carbon footprint and has committed to net zero carbon emissions by 2040.1 Oral (p.o.) paracetamol is more sustainable than intravenous (i.v.), producing less waste whilst maintaining analgesic efficacy.2 We proposed that patients presenting for elective surgery should be premedicated with p.o. paracetamol to reduce plastic waste and financial costs. We aimed to develop a quality improvement project to achieve this. Methods: Strategies to assess local attitudes and consider potential impact of paracetamol prescribing changes were initially devised. An online survey was distributed to anaesthetists in the North West of England, and educational material highlighting the environmental benefit and efficacy of p.o. paracetamol disseminated. A local audit was performed to assess i.v. paracetamol use and estimate potential financial savings, with results presented at a local audit meeting for discussion and review. A perioperative paracetamol infographic was produced and distributed on anaesthetic carts and in theatres, with an embedded QR code for continual monitoring of feedback. Results: Our survey of 147 anaesthetists at 12 hospitals demonstrated frequent i.v. paracetamol use, with a willingness to alter prescribing: 91% of respondents reported routine administration of i.v. paracetamol to elective patients, with 67% suggesting intent to change this practice after review of educational material. Local audit data estimated potential annual savings of £7166 with 384 kg less plastic waste for a single local hospital site. The produced infographic (Fig. 13) was rolled out in January 2022. Monitoring of prescribing habits is ongoing. Conclusions: P.O. paracetamol is equally effective as i.v. pre- and postoperatively in patients undergoing many elective surgical procedures; however, current anaesthetic behaviours favour i.v. administration. The switch to p.o. paracetamol would reduce the environmental costs of healthcare delivery, lowering plastic waste and associated carbon emissions. 1.Karliner J, et al. HCCP 2019; Paper 1: 6–482.Mallama M, Valencia A, Rijs K, Rietdijk W, Klimek M, Espana JC. Anaesthesia 2021; 76: 270–6

Association between practice coding of chronic kidney disease (CKD) in primary care and subsequent hospitalisations and death: a cohort analysis using national audit data

ObjectiveTo examine the association between practice percentage coding of chronic kidney disease (CKD) in primary care with risk of subsequent hospitalisations and death.DesignRetrospective cohort study using linked electronic healthcare records.Setting637...