Case Note Audit Research Articles

EMERGENCY NEUROMUSCULAR ADMISSIONS ARE AVOIDABLE: A REGIONAL AUDIT OF UNPLANNED HOSPITAL ADMISSIONS OF NEUROMUSCULAR PATIENTS 2009–2011: FINAL RESULTS AND RECOMMENDATIONS

IntroductionNeuromuscular diseases (NMD) require long–term multi–disciplinary care. In 2010–11 there were 5.3 million emergency admissions of which 213,000 related to neurological disorders. 13% of these (∼28,000) were secondary to NMD....

Post-operative steroids in the management of capsulitis following TMJ arthroscopy

Post-operative steroids in the management of capsulitis following TMJ arthroscopy

Investigation of the Alcohol, Smoking, and Substance Involvement Screening Test (the ASSIST) Version 3.0 in Pregnancy

Objectives: To investigate the utility of the World Health Organization’s Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) Version (V) 3.0 for identifying substance use disorders in pregnancy. Methods: ASSIST V3.0’s performance was assessed, focussed on nicotine, alcohol, and cannabis, using a 2-pronged harm categorization: risk to the woman as an individual and risk to the fetus. For the former, risk levels concordant with general population cut-points were utilized. A total of 104 substance users in an Australian public maternity hospital were identified by case-note audit. The ASSIST V3.0 scores were appraised against the scores for established tools—tobacco: the Revised Fagerstrom Tolerance Questionnaire, alcohol: the tolerance, annoyed, cut down, eye-opener, and cannabis: the Timeline FollowBack. Results: Kappa analyses of Specific Substance Involvement Scores for ASSIST V3.0 did not support changing cut-points for the woman as an individual; however, receiver operating characteristics curves delineated an Specific Substance Involvement Scores of 4 as indicative of fetal risk for both alcohol and cannabis. All nicotine users (98 of the 104 participants) were “at high risk”; hence a cut-point indicative of fetal risk for nicotine could not be determined. Conclusions: The role of the ASSIST V3.0 is uncertain for this population. Given the predominance of nicotine use, nicotine use screening could be the primary focus, with follow-up screening for alcohol and other substances if tobacco use were identified; there may be a place for a restructured ASSIST in that context. Positive screening results should be followed by ongoing counseling support throughout pregnancy, with the intensity dictated by the severity of use.

RAPID AND COST EFFECTIVE INTERVENTIONS IN THE NUTRITIONAL MANAGEMENT OF PATIENTS AT A LARGE DISTRICT GENERAL HOSPITAL LEAD TO SIGNIFICANT IMPROVEMENTS IN SERVICE AND PATIENT CARE

IntroductionWe anecdotally observed a lack of good practice amongst healthcare staff in identifying and managing patients at risk of nutritional deficiency admitted to the Gloucestershire Royal Hospital.Aims/BackgroundWe aimed to assess...

Congenital diaphragmatic hernia in Northern Queensland

To investigate the survival of non-syndromic live born infants diagnosed in Northern Queensland with congenital diaphragmatic hernia (CDH). Case note audit was completed of all live born newborns with a diagnosis of CDH admitted between February 1987 and December 2010. Demographic and clinical data were extracted. Overall survival to time of discharge for all infants was 67.3% (n = 35/52). For infants born before 2003 survival was 59.5% and for those born in 2003 and onwards was 86.7% (P = 0.10, OR 4.4, 95% confidence interval (CI) 0.87-22.55). Infants born prior to 2003, compared to those born from 2003 onwards, were less likely to survive with an isolated defect (P = 0.04, OR 8.0, 95% CI 0.93-68.62). Isolated congenital diaphragmatic hernia survival since 2003 was 92.3%. A significant difference was found in the time to surgery with those born in 2003 onwards having surgery significantly later, median 134 h, compared to the earlier cohorts median time to surgery of 83 h (P < 0.005, 95% CI 32.61-167.09). Premature infants had poorer survival (46.7%) compared to term infants (75.7%) (P < 0.0001 OR 3.6, 95% CI 1.99-6.68). Univariate analysis identified low birthweight was associated with poorer survival. Survival to discharge in our cohort equals other reported rates in Australia and around the world, including centres with tertiary paediatric services. The current management strategies used for these infants have seen a significant improvement in outcomes over time.

PM.28 Audit on Care and Outcome of Pregnancy in Women with Morbid Obesity

Background Obesity is one of the biggest challenges facing maternity services today. Women with obesity have significant higher complication rates and these can potentially be reduced with good quality clinical...

PF.70 Prenatal Diagnosis, Maintaining High Standards: Reflections on 200 Consecutive Procedures

AimsTo assess the local compliance for CVS and Amniocentesis, with RCOG Green-top standards1. Additionally, examine the indications for prenatal diagnosis, results and outcomes.Background1:20 pregnant women in the UK are offered...

Obstetric and neonatal outcomes of pregnant women with severe mental illness at a specialist antenatal clinic.

To evaluate the obstetric and neonatal outcomes of pregnant women with severe mental illness (SMI) who attended a specialist multidisciplinary antenatal clinic in Perth, Western Australia. A retrospective case-note audit of outcomes from the Childbirth and Mental Illness Antenatal Clinic (CAMI clinic) at King Edward Memorial Hospital for pregnant women with severe mental illness (SMI), aged 18-41 years, who gave birth between December 2007 and April 2011, and their babies. Obstetric and neonatal outcomes for 138 women and newborns from singleton live births. Data were compared between three diagnostic groups (schizophrenia, bipolar and non-psychotic SMI), and with WA obstetric and perinatal statistics for 2008. 44 women with schizophrenia, 56 with bipolar disorder and 38 with non-psychotic SMI attended antenatal care for an average of 7.7 (SD, 3.3) visits. The proportion of women who smoked tobacco was significantly higher than that in the WA antenatal population (46% v 15%; P < 0.0001). Alcohol use, illicit substance use and psychotropic medication exposure during pregnancy were high. The women were at increased risk of developing gestational diabetes mellitus (15% v 4%; P < 0.0001) and pre-eclampsia (9% v 3%; P < 0.0001), and birth complications were more common. Babies born to CAMI clinic women were less likely to have Apgar scores ≥ 8 at 1 minute and 5 minutes. Pregnant women with schizophrenia had more psychiatric relapses during pregnancy, and had more statutory child welfare involvement. Gestational age at birth and infant birth weights were similar for the pregnant women with SMI and the WA population in 2008. Women attending our specialist clinic had increased rates of obstetric and neonatal complications compared with the general population, and were exposed to a cluster of risk factors. We report encouraging trends in antenatal attendance, gestational age at birth, and birth weights. Managing pregnant women with SMI will require a comprehensive approach aimed at early detection of obstetric complications and psychosocial difficulties, as well as neonatal monitoring. Optimising prepregnancy maternal health and welfare may also be of benefit.

Sexual and reproductive health in a UK cohort of young adults perinatally infected with HIV

ObjectivesTo assess sexual health and behaviour outcomes of young adults with perinatally acquired HIV-1 (PaHIV), and audit sexual health interventions against published standards of care.MethodsRetrospective case note audit of 16–25-year-olds...

Presenting Visual Acuity and Ocular Comorbidity in Patients with Primary Open Angle Glaucoma in a Private Tertiary Eye Center in Nigeria.

ABSTRACTPurpose: To determine the presenting visual acuity (VA) of patients with primary open angle glaucoma (POAG) and the relationship to ocular comorbidity.Materials and methods: A retrospective case note audit was undertaken in Eye Foundation Hospital, Calabar, between 1st January 2010 and 31st June 2011. The case notes of all newly presenting patients diagnosed with POAG were retrieved and data were extracted for analysis. Inclusion criteria for glaucoma was defined.Results: Out of a total of 320 new patients, 88 patients were diagnosed with POAG, with a prevalence of 27.5% (95% CI: 22.7-32.7). The mean age for males is 57.1 ± 8.8 while that of females is 52.6 ± 11.2 and the total mean of 55.8 ± 9.7. Of the 88 patients, there were 84 self referrals [95.5% (95% CI: 88.8-98.7)], of these, 45, 53.6% (95% CI: 42.4-64.5) were for second opinion. There was no statistical significance between the gender, education and occupation and the level of VA seen on presentation.The best corrected visual acuity (BCVA ) in the right and left eye respectively, was significantly (p < 0.0001) related to the cup disk ratio. Ocular comorbid conditions were seen in 19 (22%) patients in the study. The presenting BCVA was significantly related to the presence of ocular comorbidity in the best eye. Comorbidity was not strongly related to the age of the patients.Conclusion: The course of glaucomatous progression is highly variable, identifying factors that not only predict progression but influence the VA and ocular health of the eye can help to guide clinical practice and patient treatment and monitoring.How to cite this article: Duke R, Akinye A, Ameh S. Presenting Visual Acuity and Ocular Comorbidity in Patients with Primary Open Angle Glaucoma in a Private Tertiary Eye Center in Nigeria. J Current Glau Prac 2013;7(1):6-10.

Ten-year Audit of Kawasaki Disease in a District General Hospital

Background: This audit aimed to evaluate the cases Kawasaki disease (KD) seen in the pediatric department of a community hospital over a 10-year-period. In particular, length of time to diagnosis and variations in treatment were reviewed. Possible effects of these factors on patient outcome in the acute and chronic phase of KD were analyzed. Methods: Data were obtained from the hospital information and coding departments. The following parameters were studied: demographic characteristics, presenting signs and symptoms, duration and peak of fever, hemoglobin and platelet count, coagulation times, C-reactive protein, urine dipstick analysis, length of hospital admission and cardiovascular abnormalities. The data were compared using standard computer software. Results: Eleven patients were identified. Seven of them were male, and the mean age was 35 months. Mean length of hospital stay was 5 days. Mean time from admission to diagnosis was 4 days. All but one patient were given one course of immunoglobulin upon diagnosis. Two developed coronary artery aneurysms and were still receiving aspirin therapy at the time of the audit. Eight of the 11 patients were treated with antibiotics during their time in hospital, all prescribed to treat suspected infections. Once KD had been confirmed antibiotics were stopped. Conclusion: A retrospective case note audit was performed which found that delay in diagnosis may be associated with cardiac complications. The data analyzed highlight the importance of early diagnosis and adequate treatment of KD. It is likely that new genetic tests will help clinicians achieve these goals in the near future.

P44 How Long is short term Oxygen Therapy? Home Oxygen Prescriptions Post Hospitalisation

Introduction Long-term oxygen therapy (LTOT) has been shown to improve survival in some patients with chronic obstructive pulmonary disease (COPD); generalisation to other groups of hypoxic patients is less clear. The British Thoracic Society recommend LTOT should be prescribed to hypoxic patients after appropriate assessment during a period of clinical stability.¹ In practise LTOT is frequently prescribed following hospitalisation. This form of oxygen therapy has been termed short-term oxygen therapy (STOT). We sought to audit our practise of prescribing home oxygen therapy to hypoxic patients following hospital admission with an exacerbation of a respiratory disorder. Method We performed a retrospective case note audit of 30 patients [13 male] commenced on home oxygen therapy at discharge over a 6 month period recording patient demographics, smoking status, underlying diagnosis, compliance with BTS oxygen prescribing guidelines and the outcome of follow-up. Results The mean age was 71 years (48–91yrs); 17% current smokers, 73% ex-smokers. COPD was the most common diagnosis in 80% (24/30); the mean FEV1 1.1L (52% predicted). No definitive diagnosis was documented in 10% (3/30) with 10% diagnosed with sarcoidosis, idiopathic pulmonary fibrosis or lung cancer. 64% (19/30) of patients met BTS LTOT criteria, (80% (19/24) with COPD), 33% (10/30) did not and 3% (1/30) were prescribed palliative oxygen. 93% of patients (27/29) were followed up at 3 months. The mean oxygen flow rate required was 1.4L/min; oxygen flow rate was altered in 63%. The overwhelming majority of our patients, 90% (26/29), continued with LTOT after reassessment at 3 months and 79% (23/29) at 6 months. Conclusion Our audit shows that the majority of patients commenced on oxygen therapy post hospitalisation met the criteria for LTOT and continued to require oxygen at 3 and 6 months; this is a higher figure than quoted in the majority of the literature. This suggests our patients are presenting late with underlying chronic lung disease; we need to strive to identify these patients earlier. There is still a lack of evidence-based guidelines for STOT and further research in this area is needed. References BTS Home Oxygen Service in England and Wales. January 2006.

Guillain–Barre´ syndrome patient's satisfaction with physiotherapy: A two-part observational study

The purpose of this observational study was to assess Guillain–Barre´ syndrome (GBS) patients' satisfaction with physiotherapy in the acute and sub-acute setting, and provide an overview of inpatient case management, including the number of complications. Twenty-seven patients admitted to Sir Charles Gairdner Hospital (SCGH) with GBS between 1 May 2005 and 30 April 2010 were considered for inclusion. Nineteen patients consented and a waiver of consent was granted for four other patients. Data were collected from case-note audit (n = 23) and telephone survey (n = 19) during June and July 2011. Participants receiving physiotherapy (n = 16) reported they were satisfied with management (87%), treatment frequency (88%), duration (94%), and timetabling (81%) of treatment and the professionalism and rapport (100%) of physiotherapists. Median length of hospital stay was 20 days (range 5–198) for 23 participants. Physiotherapists documented patient assessment within 2 days from admission (range 1–5). First functional improvements were documented on day 6 (median, range 2–34). Physiotherapists were most commonly first to mobilize patients to sit, stand, transfer, and walk (83%, 82%, 81%, and 90%, respectively). Twenty patients (87%) developed complications during their hospital stay, the most common being low back pain (61%). This study has demonstrated that GBS patients were satisfied with care provided by physiotherapy.

AVOIDING UNPLANNED HOSPITAL ADMISSIONS IN PATIENTS WITH NEUROMUSCULAR DISEASES: A REGIONAL COLLABORATIVE AUDIT OF HOSPITAL ADMISSIONS

BackgroundNeuromuscular diseases require long-term multi-disciplinary care. In 2010, there were 5368 unplanned admissions for metabolic and neuromuscular conditions in England (Hospital Episodes Statistics 2007–2008). Unplanned admissions are those that occur...

Estimating the potential of tissue donation in Scotland

The Scottish National Blood Transfusion Service became the preferred provider of tissues in 2000. At that time, the only tissues procured were heart valves and some tendons from multiorgan donors. These sources and the range of tissues were not enough to provide for the clinical needs of Scottish patients. A systematic review was undertaken using the International Classification of Disease codes to assess what the potential pool of tissue donors would be by region, hospital and hospital department. Such data would enable us to focus our limited resources to maximize the yield of tissues to meet clinical demand. The data from this study were validated by a case-note audit in one hospital in Edinburgh. It was shown that the maximum tissue donor potential of approximately 48.5 per million population was in the central belt of Scotland in hospitals with large emergency medicine departments.

Real-life experience of managing vulval erosive lichen planus: a case-based review and U.K. multicentre case note audit

There is a lack of published evidence for treatment and outcome measures for vulval erosive lichen planus (ELPV). To conduct a multicentre case note review to examine real-life management of ELPV comparing current U.K. practice against an agreed audit standard. Criteria for standards of care for which to evaluate current service provision were set following communication with experts from the British Society for the Study of Vulval Disease. Participants from 10 U.K. centres included nine dermatologists and one gynaecologist who run specialist vulval clinics. Standards examined the documentation of disease severity/impact measures, the use of diagnostic biopsies, treatments used and assessment of treatment response. Audit data were collected from 172 patients. Documentation of symptoms/clinical findings was excellent (99%, 170/172). A schematic diagram was present in the notes of 87% (150/172). Patient-related disease impact measures including Dermatology Life Quality Index (3%, 6/172) or visual analogue scales (1%, 2/172) were less well documented. Biopsies were performed in 78% (135/172); 71% (96/135) showed histological features consistent with erosive lichen planus. Squamous cell carcinoma developed in four patients (two vulval, two oral) and vulval intraepithelial neoplasia in two further patients. Recommended first-line treatment with a very potent topical steroid was used in 75% (129/172) with improvement in 66% (85/129). Significant variation in second-line therapy was seen. Wide variation in U.K. practice demonstrates the absence of standardized guidance for treating ELPV and the need for vulval-specific outcomes. This audit should act as a framework towards improving ELPV management and to plan future research in this area.

An audit against current guideline for the management of children born to VDRL+ mothers

Background and aimsUntreated maternal syphilis results in perinatal loss/morbidity. Congenital infection results in deafness, bone, teeth and eye abnormalities. Children have serology at birth (maternal pairing) and are followed up...

Does the assessment of young people attending hospital with self harm meet national standards?

Aims To determine whether young people who self harm are being assessed according to national guidance. Methods A multi-centre retrospective case note audit was undertaken of a random sample of young people (12-18 years) presenting during a six-month period (1st Jan 2010-July 31st 2010) with any form of self harm to a District General and tertiary Children9s Hospital. Standards were derived from NICE guidance CG16: Self Harm and included a comprehensive risk and needs assessments, admission rates and waiting times for mental health assessment. Results 167 episodes (in 160 young people) of self harm were audited - 57% resulted in admission and most patients were female (79%). Mean age was 15.3 years (12-18) with 79 episodes in patients under 16 years. Self poisoning (77%) was the most common method, with cutting seen less often (14%) and both methods were documented in Information about substance use, smoking and education status was rarely recorded and 35% did not have a past medical or social history recorded. Evidence of planning and future intent to self harm was not documented in 12% and 17% of patient episodes respectively. Four young people were assessed as presenting a significant risk to themselves or others. Of those not admitted, 7 were under 16 years with only two being offered admission. 69% of those admitted were seen within 24 hours by mental health services, compared with 61% of those discharged. Waiting times were not clear in 14%, and 16% of patients were not referred for a full mental health assessment. Conclusions The audit shows the assessment of young people with self harm is not meeting national standards. Documentation of adolescent psychosocial factors was often incomplete and not all young people under 16 years were offered admission. Assessment by mental health services was often delayed beyond recommended timescales, and in a small but significant number no referral was made.

Hypoglycaemia and infectious gastroenteritis: the risk of sugar-free fluids

Background The National Institute of Health and Clinical Excellence has made recommendations regarding the management of children under five with infectious gastroenteritis. This includes the use of sugar-free fluids such as water for rehydration. A local audit has demonstrated a marked increase in the incidence of hypoglycaemia in such children in recent years. Aims To determine if provision of only sugar-free fluids to children To compare the clinical characteristics of such children with and without hypoglycaemia. Patients and methods Retrospective casenote audit of acute admissions to a district general hospital between April 2010 - May 2011. 67 children (28 hypoglycaemic) Results Stated as mean[range]: Age of the hypoglycaemic children was 1.5 [0.1-3.4] years and 1.6 [0.2-4.5] years in the non-hypoglycaemic group. Vomiting as a presenting symptom was associated with hypoglycaemia. Duration of illness was not. Clinical features associated with hypoglycaemia were drowsiness and subjective assessment of looking ‘unwell’. Dry mucous membranes, reduced skin turgor, tachycardia, sweatiness and pallor were not associated with hypoglycaemia. In twenty cases, stool culture and virology were sent. Six were positive for rotavirus: all were hypoglycaemic. Three were positive for campylobacter: none were hypoglycaemic. Of the other eleven, only two were hypoglycaemic. The fluids given at home were documented in 40/67 cases (60%). There was an association between giving only sugar-free fluids at home and documented hypoglycaemia (p=0.05). When only children with a measured sugar were considered, 1/11 (9%) of normoglycaemic children had sugar-free fluids compared with 6/15 (40%) of those who were hypoglycaemic, but this difference did not reach statistical significance. Conclusion Provision of only sugar-free drinks at home was associated with hypoglycaemia at presentation, as was the presence of vomiting. Longer duration of illness was not. Hypoglycaemia at presentation was associated with rotavirus infection.

Audit of diagnosis and management of placenta praevia

ObjectiveAssess performance in diagnosis and management of placenta praevia.SettingTertiary referral hospital (6000 deliveries per annum)MethodRetrospective case note audit of all cases of placenta praevia at delivery over a 12 month...