Audit Period Research Articles

Prevention of postoperative atrial fibrillation in cardiac surgery: a quality improvement project

PurposePostoperative atrial fibrillation (POAF) has an incidence of 20–60% in cardiac surgery. The Society of Cardiovascular Anesthesiologists and the European Association of Cardiothoracic Anaesthesiology Practice Advisory have recommended postoperative beta blockers and amiodarone for the prevention of POAF. By employing quality improvement (QI) strategies, we sought to increase the use of these agents and to reduce the incidence of POAF among our patients undergoing cardiac surgery.MethodsThis single-centre QI initiative followed the traditional Plan, Do, Study, Act (PDSA) cycle scientific methodology. A POAF risk score was developed to categorize all patients undergoing cardiac surgery as either normal or elevated risk. Risk stratification was incorporated into a preprinted prescribing guide, which recommended postoperative beta blockade for all patients and a postoperative amiodarone protocol for patients with elevated risk starting on postoperative day one (POD1). A longitudinal audit of all patients undergoing cardiac surgery was conducted over 11 months to track the use of prophylactic medications and the incidence of POAF.ResultsFive hundred and sixty patients undergoing surgery were included in the QI initiative from 1 December 2020 to 1 November 2021. The baseline rate of POAF across all surgical subtypes was 39% (198/560). The use of prophylactic amiodarone in high-risk patients increased from 13% (1/8) at the start of the project to 41% (48/116) at the end of the audit period. The percentage of patients receiving a beta blocker on POD1 did fluctuate, but remained essentially unchanged throughout the audit (34.8% in December 2020 vs 46.7% in October 2021). After 11 months, the overall incidence of POAF was 29% (24.9% relative reduction). Notable reductions in the incidence of POAF were observed in more complex surgical subtypes by the end of the audit, including multiple valve replacement (89% vs 56%), aortic repair (50% vs 33%), and mitral valve surgery (45% vs 33%).ConclusionsThis single-centre QI intervention increased the use of prophylactic amiodarone by 28% for patients at elevated risk of POAF, with no change in the early postoperative initiation of beta blockers (46.7% of patients by POD1). There was a notable reduction in the incidence of POAF in patients at elevated risk undergoing surgery.

THE EFFECT OF AUDITOR CHARACTERISTICS AND GENDER DIVERSITY ON FRAUD DETECTION

Accounting fraud can occur in any company and must be detected to reduce it. This research aims at empirically investigating the effects of auditor characteristics and gender diversity on fraud detection. The population used mining companies listed on the Indonesia Stock Exchange for 2016-2020 with 205 observation data. The data analysis technique used was the Panel Data Regression Model. The results showed that auditor independence and audit report lag had a positive effect, and audit tenure and gender diversity harmed fraud detection. Additionally, auditor rotation, auditor industry specialization, and audit firm size also had not. The auditor’s independence and adequate audit period would allow the auditor to be more effective in fraud detection.

Audit in surgical histopathology at Wadia hospitals - Study of pre-analytical, analytical, and post-analytical phase

Objectives: This audit of surgical histopathology aims to verify conformance to required processes, assess their implementation, and define the targets of quality control with appropriate changes in the existing system by evaluating pre-analytical, analytical, and post-analytical phases of histopathology. Material and Methods: This study was an observational retrospective study done over a year, from March 15, 2022 to February 28, 2023. Small biopsies, large organ resections, and second opinion samples like paraffin blocks or slides received in the surgical histopathology department were categorized as I, II and III respectively. Samples were also segregated as per the department it was received from, namely, gastroenterology, neurology, pulmonology, nephrology, orthopedics, gynepathology, and others. Manual audit was done as a pre-analytical phase including adequacy of clinical information and grossing adequacy, analytical phase to study the turn around time (TAT) and tissue section quality, and the post-analytical phase in the form of report verification, approval and dispatch, and amendment if any, were studied. Results: During this audit period, 1752 surgical histopathology samples were received of which 80% were small biopsies (category I), 19.6% were large organ resection samples (category II) and 0.4% samples were received for second opinion (category III). General pediatrics (n = 798) and Gynepathology (n = 569) were the main departments from which the samples were received. Incomplete request forms, errors in sample fixation, wrong payment/barcode were some of the pre-analytical errors. Training of staff on one to one basis was done. In the analytical phase errors such as nicks, folds or air bubbles in the mounted sample were seen. Histotechnical staff were retrained to reduce errors. In the post analytical phase, the turnaround time was achieved as per the hospital quality process indicator, feedback from cases on second opinion was received only in 25% of samples. Conclusions: In this surgical histopathology audit of 1752 samples, quality indicators were achieved as per external quality assurance system (EQAS). Remedial actions were carried out to prevent errors.

1162 Management of Acute Gallstone Disease at an Urban Acute Trust During the Pandemic – Closed-Loop Audit

Abstract Aim Acute gallstone disease is a surgical emergency with emphasis on early surgery (Laparoscopic Cholecystectomy (LC)) to improve outcomes. Method Patients presenting with acute cholecystitis, biliary colic, and gallstone pancreatitis between September and December 2021 were retrospectively audited. We measured re-admission rates, emergency and elective cholecystectomies performed, and interval between operation and initial admission. This revealed a need for improvement in the service provided at this trust. An intervention was implemented with the Hot Cholecystectomy list being available for other surgeons as well as encouraging acute LC on the Emergency theatre list. A follow-up retrospective audit was carried out between July and September 2022 using the same criteria as per the initial data collection. Results 240 patients were admitted with acute gallstone disease during the initial audit period. At the end of audit period, 49 patients underwent LC, of which only 20% were performed acutely. However, 70% of acute operations were performed during re-admissions. During the re-audit, 109 patients were admitted with acute gallstone disease. Within the three months, 21% of patients underwent LC, out of which 52% were acute operations. 50% of the emergency operations were in re-admission patients. Patients from the initial audit were followed up which revealed average waiting time of 118.5 days from admission to LC Conclusions There was almost a 3-fold increase in the rate of Emergency LC post intervention. While there is an increase, provision of emergency cholecystectomies does not comply with national guidelines. Resources need to be allocated nationwide for timely treatment of acute gallstone disease.

802 Are Patients with Malignant Melanoma Operated on Within National Cancer Waiting Time Standards?

Abstract Aim This audit evaluated the performance of the local melanoma referral pathway against national cancer wait times, to identify limiting factors and find solutions to deliver service in a safe and streamlined manner. Method Patients with malignant melanoma referred to general surgeons between March and June 2022 were identified retrospectively. Patients with other skin cancers, concurrent malignancy, metastatic melanoma, or those declining surgery were excluded. The date of each step of the referral pathway was noted for each patient using Microsoft Excel, and the difference between the dates was calculated. The percentage of compliance with the 31-day and 62-day wait was compared against the national operational standard. Results During the audit period, 59 patients with malignant melanoma were referred to the general surgeons, 22 of these were excluded for the aforementioned reasons. Of the remaining 37 patients, 65% were male and the average age was 66 years old. 83% of patients received their first treatment from diagnosis within 31 days, falling short of the 96% target. Only 60% of patients received surgery within the following 31 days. On average it took 56.8 days from diagnosis to surgical treatment, with wait time to operation varying from 15 days to 101 days. Conclusions Overall, the average time to surgery for patients with malignant melanoma was less than the target 62 days, however there was notable variation in the number of days patients waited for their operation. Further detailed analysis of cases with long wait times is required to reduce the risk of delaying vital cancer treatment.

Risk of post-vasectomy infections in 133,044 vasectomies from four international vasectomy practices.

To estimate the risk of post-vasectomy infections in various settings and across various surgical techniques and sanitization practices. Retrospective review of the records of 133,044 vasectomized patients from four large practices/network of practices using the no-scalpel vasectomy (NSV) technique in Canada (2011-2021), Colombia (2015-2020), New Zealand (2018-2021), and the United Kingdom (2006-2019). We defined infection as any mention in medical records of any antibiotics prescribed for a genital or urinary condition following vasectomy. Post-vasectomy infection risks were 0.8% (219 infections/26,809 procedures), 2.1% (390/18,490), 1.0% (100/10,506), and 1.3% (1,007/77,239) in Canada, Colombia, New Zealand, and the UK, respectively. Audit period comparison suggests a limited effect on the risk of infection of excising a short vas segment, applying topical antibiotic on scrotal opening, wearing a surgical mask in Canada, type of skin disinfectant, and use of non-sterile gloves in New Zealand. Risk of infection was lower in Colombia when mucosal cautery and fascial interposition [FI] were used for vas occlusion compared to ligation, excision, and FI (0.9% vs. 2.1%, p<0.00001). Low level of infection certainty in 56% to 60% of patients who received antibiotics indicates that the true risk might be overestimated. Lack of information in medical records and patients not consulting their vasectomy providers might have led to underestimation of the risk. Risk of infection after vasectomy is low, about 1%, among international high-volume vasectomy practices performing NSV and various occlusion techniques. Apart from vasectomy occlusion technique, no other factor modified the risk of post-vasectomy infection.

An audit of psychology risk screen completion across five time points and consideration of risk content

This paper describes an audit of completion of psychology risk-screens by psychology staff across a 20-month period, taken at five time-points, in a single North London Borough. A dramatic improvement in completion rate was observed over this period. For the final audit period (May, 2022) the extent of co-occurrence of self-harm/self-injury (SIB) and aggression was assessed and a strong positive association was observed.Easy to read summaryIn our learning disabilities team we need to make sure the people we meet are safe. We ask people if they hurt themselves or other people. We need to keep a note of this so we can try to help. This is called a risk assessment. We had a look at our notes to see if we were good at doing risk assessments. To start with we noticed that we were not doing many. We tried harder. Every few months for nearly two years we checked. In the end we had got a lot better at doing risk assessments. We also found that if someone hurts themself it is more likely that they might try to hurt someone else, even if they do not do this on purpose.

11-years of a nurse-led follow-up service for patients who have undergone percutaneous coronary intervention

Abstract Funding Acknowledgements Type of funding sources: None. Background The nurse-led follow-up service for patients who have undergone percutaneous coronary intervention (PCI) was established in 2001 to standardise post procedural care for this patient group. The appointment focusses on symptom assessment, medication review and optimisation, and risk factor modification and secondary prevention. Timing of appointments is dependent on the procedure the patient has undergone (primary/elective PCI) and the format of the service has changed several times since its inception in response to changes in the PCI service within the hospital. Clinic appointments were carried out face to face or via the telephone until 2020, when all clinics changed to virtual appointments (video or telephone). Methods Data for all patients reviewed in the clinic was collected prospectively and retrospectively analysed. This report covers the period 2010-2021. Results A total of 21,465 appointments were carried out in the above audit period. Most appointments were carried out in the first-year post PCI in accordance with the follow-up protocol (81.7%). Patients reviewed after 1-year were usually referred to the clinic by their GP due to recurrence of symptoms. 71.3% of patients reviewed within the first year were free of any symptoms of angina or had no limitation to physical activity, and 71.2% were not limited by breathlessness at any follow-up appointment. 33.6% patients reviewed within the first year were either attending or had attended a cardiac rehabilitation programme, with fewer patients declining referral in more recent years. 19.3% patients reviewed within the first year were diabetic, with 5.4% diagnosed on admission. 8.5% patients were still smoking, 41.0% had stopped smoking, and less than 1.0% patients had restarted smoking within the first year. 49.2% patients reviewed within the first year had a systolic blood pressure below 140mmHg, and 56.0% patients had a diastolic blood pressure below 90mmHg, however this data was not available for all patients. The data suggests that lipid management has improved within recent years with more patients achieving LDL levels below 2.0mmol/L, however, this data is also incomplete. Over 92.0% patients were taking Aspirin at 1-month and 1-year, with 95.0% patients taking a second antiplatelet agent at 1 month, and 76.6% at 1-year. Beta blocker, ACE inhibitor and statin use has been relatively consistent at 71.6%, 66.1% and 82.5% respectively at all appointment times. Conclusion This nurse-led follow-up service provides consistency of care for patients who have undergone PCI. The nurses in the clinic are able to optimise risk factors and medication, although further work needs to be done to achieve guideline directed targets. Collaboration with primary care is required to ensure secondary prevention is continued.

The impact of rurality on patient experience and diagnostic pathway intervals in Scotland’s cancer patients: Further results from a national cancer diagnosis audit

BackgroundIn Scotland 17 % of the population reside rurally and previous research has demonstrated worse cancer outcomes in this group. The underlying reason for this is unclear. This study aims to determine whether patient presenting factors, GP consultation factors or the diagnostic pathways differ between urban and rural patients within Scotland. MethodsThis study combined two Scottish National Cancer Diagnosis Audits. Participating GPs collected data on the diagnostic pathway from primary to secondary care for cancer patients diagnosed during the audit period. Using the Scottish Government Urban Rural Classification, patients were designated as rural or urban dwellers and compared in descriptive analyses. Key cancer intervals (primary, diagnostic, secondary and treatment interval) were compared between urban and rural dwellers with an additional adjusted analysis for the main cancer sites. ResultsA total of 4309 cancer diagnoses were included in the study; 22 % were in patients from rural locations. Rural patients had significantly more consultations and investigations prior to referral than their urban counterparts. There was no difference in prolonged cancer pathways between the two groups except in lung cancer patients where rural patients had a significantly increased odds of a diagnostic interval of >90 days. ConclusionOur findings suggest differences in the interaction between patients and GPs prior to referral in urban and rural settings. However, this does not appear to lead to prolonged patient pathways, except in lung cancer. Further research is needed to determine whether this delay is clinically significant and contributing to poorer outcomes in Scottish rural dwellers with lung cancer.

Predictors of severe and recurrent adult anaphylaxis, and gaps in the cascade of care: a retrospective, single-centre study 2009-2018.

Anaphylaxis is a severe, potentially fatal, systemic allergic reaction. Understanding predictors of recurrent and severe anaphylaxis in adults, and identifying gaps in ongoing anaphylaxis care, is needed to minimise its impact. To evaluate the risk factors in adults with severe and recurrent anaphylaxis presentations and to evaluate the management of patients in regard to the recommended cascade of care. We completed a retrospective audit of adults with confirmed anaphylaxis who presented to an inner-city emergency department from 1 January 2009 through 31 December 2018. Data recorded included demographics, background history, medication use, severity, co-factors, triggers, management, discharge disposition and referral for follow-up. Data were managed in REDCap and analysed using Stata. Associations were assessed through odds ratios (ORs) and t tests. Six hundred sixteen individuals had 689 episodes of anaphylaxis over the audit period. Age over 65 (OR: 5.4 (95% confidence interval, CI: 2.3-13.2), P < 0.0001) and history of asthma (OR: 1.6 (95% CI: 1.03-2.5), P = 0.03) were independent risk factors for severe anaphylaxis. History of food allergy (P < 0.001) and food as the trigger were associated with recurrent presentations (OR: 2.1, 95% CI: 1.1-3.9, P = 0.01). Only 19% of patients met the recommended cascade of care, with post-adrenaline monitoring and recommending follow-up with an allergy specialist demonstrating the largest gaps. There were increased presentations with time but no difference in triggers or severity. Increased age and asthma were identified as risk factors for severe presentations. History of food allergy was a risk factor for recurrent presentations. Further research is needed on the gaps in care for adults with anaphylaxis to identify the reasons why, so we can better care for these patients.

Potentially avoidable mortality after endoscopic retrograde cholangiopancreatography in Australia: an 8-year qualitative analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure worldwide. The aim of this study was to examine cases of mortality after ERCP to identify clinical incidents that are potentially preventable, to improve patient safety. The Australian and New Zealand Audit of Surgical Mortality provides an independent and externally peer-reviewed audit of surgical mortality pertaining to potentially avoidable issues. A retrospective review of prospectively collected data within this database was performed for the 8-year audit period from 1 January 2009 to 31 December 2016. Clinical incidents were identified by assessors through first- or second-line review, and thematically coded into periprocedural stages. These themes were then qualitatively analysed. There were 58 potentially avoidable deaths following ERCP, with 85 clinical incidents. Preprocedural incidents were most common (n = 37), followed by postprocedural (n = 32) and then intraprocedural (n = 8). Communication issues occurred across the periprocedural period (n = 8). Preprocedural incidents included delay to procedure, inadequate resuscitative management, decision to perform procedure and inadequate assessment. Intraprocedural incidents comprised technical factors and inadequate support. Postprocedural incidents involved inappropriate treatment, delay in definitive surgical treatment or in recognizing complications, inappropriate second-line intervention and inadequate assessment. Communication incidents comprised inadequate documentation, failure to escalate care and poor inter-clinician communication. Causes of mortality following ERCP are wide-ranging, and reviewing clinical incidents associated with potentially avoidable mortality can serve to inform and educate practitioners. In collating a subset of cases in which procedure-related mortality was deemed avoidable, a series of cautionary tales about ERCP is presented that may provide cues to practitioners on improving patient safety and inform future surgical practice.

Psychotropic Medication Prescribing to Patients with Dementia Admitted to Acute Hospitals in Ireland.

Psychotropic medications are commonly prescribed to people with dementia (PwD) for non-cognitive symptoms of dementia (NCSD), but have significant risks. A national audit was performed in acute hospitals in the Republic of Ireland (ROI) to establish baseline practice prior to the launch and implementation of a National Clinical Guideline on the appropriate prescribing of psychotropic medications for NCSD. The objective of this study was to analyse psychotropic prescribing patterns and compare these with international data and with existing (limited) data from a previous audit round. The pooled anonymous dataset from the second round of the Irish National Audit of Dementia Care (INAD-2) was analysed. The audit had collected retrospective data from 30 random healthcare records from each of 30 acute hospitals in 2019. Inclusion criteria were a clinical diagnosis of dementia of any type, hospital stay of 72 hours or more, and discharge or death within the audit period. Most hospitals (87%) self-audited their healthcare records, but a random sample of six healthcare records (20%) from each hospital were re-audited by a highly trained healthcare auditor. The audit tool was based on a tool used in the England and Wales National Audit of Dementia audit rounds (Royal College of Psychiatrists), adapted to the Irish healthcare setting and national priorities. In total, 893 cases were included, as one hospital could not retrieve 30 cases even within a more prolonged audit period. The sample comprised 55% females and 45% males; the median age was 84 years (interquartile range 79-88 years) and the majority (89.6%) were >75 years of age. Only 52% of healthcare records specified the type of dementia; within these, the most common diagnosis was Alzheimer's disease (45%). Most PwD (83%) were receiving psychotropic medication on admission; 40% were prescribed new or increased psychotropic medication during admission, mainly for medical indications, including end-of-life care and delirium. Anticonvulsants or cognitive enhancers were rarely prescribed for NCSD in hospital. However, new/increased antipsychotic medication was prescribed for NCSD in 11.8-17.6% of the total cohort, while 4.5-7.7% were prescribed a benzodiazepine for anxiety or NCSD. Overall, there was poor documentation of risk/benefit, or of discussion with the patient/family, and apparently inadequate review for efficacy and tolerability. Concurrently, acetylcholinesterase inhibitors appeared to be underused for cognitive impairment in the community. This audit provides baseline data on psychotropic medication prescription for NCSD in Irish hospitals prior to a specific Irish guideline on this topic. Reflecting this, most PwD were receiving psychotropic medications on admission, and many were prescribed new/increased psychotropic medication in hospital, often without evidence of appropriate decision making and prescribing processes.

Waste heat recovery and utilization of cement rotary kiln based on biomass energy

A rotary kiln is a central piece of equipment for the calcination of clinker in the production of cement. Biomass energy has been applied to rotary kilns, and solar energy has been introduced to assist the energy supply. Coupled optimization results for biomass energy and solar energy applications are compared to the single fossil energy used in the base period. A field survey and statistical analysis and integration of cement clinker production sites in China’s Central Plains Economic Zone revealed a negative linear correlation between the consumption of raw coal in the cement production process and the environmental temperature and humidity parameters of the production lines. The energy consumption is large and the energy utilization of the system is low, with goodness of fit of R=0.962. Coupled solar and biomass energy use in the audit period and single energy use in the base period comparison revealed a 19.5% reduction in electricity consumption, a 25.4% reduction in coal consumption and a 4.39% increase in heavy oil consumption. From 2017 to 2020, the average annual consumption cost of electricity and raw coal decreased, while the average annual consumption cost of heavy fuel oil slowly increased. After verification during the audit period, compared with the base period, the total production cost of the case enterprise can be reduced approximately 5.17%, in which the energy cost decreased 0.9%.

N30 Understanding Inflammatory Bowel Disease Emergency Department Admissions in a Tertiary Referral Inflammatory Bowel Disease Centre in England: A quality Improvement project

Abstract Background In February and March 2022, the emergency department (ED) affiliated to a tertiary referral inflammatory bowel disease (IBD) centre in England undertook an audit of ED attendances as part of an IBD-related admission quality improvement project (QUIP). Quality standards recommend review within 5 days of a flare. Patients presenting to ED may reflect failure of urgent GP access or to the IBD advice line a marker of poor-quality care. Methods Patients with suspected IBD presenting to ED during the audit period were identified the initial results generated further questions for the IBD team. A excel data base was created and the electronic patient record for each patient was retrospectively reviewed. Data relating to previous contact with the IBD team, how patients were referred to ED and confirmation of an IBD diagnosis was collected. Descriptive statistical analysis was used to present the data. Results There were N=48 ED attendances with a suspected diagnosis of IBD between February and March 2022. From the N=48 attendances from n=41 patients, n=29 (60.42%) admissions occurred for these patients. n=19 (39.58%) episodes resulted in discharge with five of these being self-discharges. of the n=41 patients n=4(9.76%) did not have a diagnosis of IBD n=1 (2.44%) with a diagnosis of IBD was not known to the IBD interdisciplinary team. Additionally, n=2 (4.88%) were new patients neither were known to the IBD team and n=2 (4.88%) were suspect diagnosis. multiple attendances occurred and n=1 (2.44%) patient attended four times and n=4 (9.76%) patients attended twice each meaning n=5 (12.2%) of the patients were responsible for n=12 (25%) of attendances. Of the original N=48 attendances, n=32 (66.67%) attendances occurred with no contact to the IBD advice line and n=19 (46.34%) of the n=41 patients responsible for these attendances. The outcomes are summarised in Table 1. Conclusion The original QUIP data was incomplete, and the actual IBD ED attendance rate was 66.66% of the original quoted figure, raising the importance of data cleaning and quality in QUIP. Focusing in on the 32 attendances where patients did not call the advice line, improvements to the messaging that IBD advice line service is available has become a priority as has utilising advanced nurse practitioner and specialist registrar skills to support patients therefore avoiding some of this ED attendance in the future. So far, adding advice line details to clinic letters, advertising in clinic, and setting up rapid access flare clinic led by Advanced Nurse Practitioners from the IBD Nursing team have been implemented. There are plans to review the attendance at IBD patients in ED in the same period in 2023.

Determinants of Audit Quality in Companies That Conduct Initial Public Offerings

This research aims to investigate factors that affect quality control, including audit period, auditor reputation, accounting firm size, and audit fees. The population of this study consisted of 54 companies that participated in the Initial Public Offering (IPO) and were listed on the Indonesia Stock Exchange (IDX) in 2021. The sample was taken using the purposive sampling method to obtain a sample of 42 companies. This study uses quantitative data analysis techniques. SPSS version 20 is used for statistical analysis in data analysis. From the results of this study, audit tenure, Public Accounting Firm size, and audit fees do not affect audit quality; partial research confirms that auditor reputation significantly impacts audit quality. The results of this study can be used as a reference for auditors to improve audit quality for companies conducting IPO.

The Effects of Audit Firm Size, Audit Tenure, and Audit Rotation on Audit Quality

This study examines the effect of audit firm size, audit period, and audit rotation on audit quality. The data come from annual reports of infrastructure, utilities and transportation companies listed on the Indonesia Stock Exchange (IDX) from 2016 to 2020. The sampling method used is purposive sampling. A sample of 267 companies was obtained based on the purposive sampling method. The analysis technique used is logistic regression analysis with SPSS software. This study's results confirm agency theory's role in explaining the relationship between parties with different interests. The research findings reveal that the role of audit professional services performed by audit firms can minimize agency problems that arise. Empirically, study findings show that the size of an audit firm and its audit period positively affect audit quality. Conversely, audit rotation does not affect audit quality. The study results provide a practical contribution so that non-big-4 audit firms can improve audit quality as big-4. Audit firms should also pay attention to sufficient audit tenure, short enough or too long, to produce good audit quality.

Implementation of point-of-care INR testing to improve effectiveness of anticoagulation clinic

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Oral Vitamin K antagonist (VKA) is still widely used for anticoagulation. Anticoagulation clinics are set up to monitor patients’ INR and adjust their VKA doses accordingly. Anticoagulation clinic in our centre introduced point-of-care (POC) INR testing in June 2021 to improve the effectiveness of the clinic. Purpose This audit was done to evaluate the effectiveness of anticoagulation since the introduction of the POC INR test into the clinic workflow. Methods This was a retrospective, cross-sectional, cohort audit study. The study period was from 1st June 2021 to 31st July 2022. List of patients who attended the clinic from 1st – 31st January 2022 was taken from the clinic log and their electronic medical records were reviewed for the study period. Only patients who have been established on VKA for at least 3 months were included in the audit. The data collected included their basic demographics, indication for VKA, any complications / death during the study period and if their VKA had been stopped and why and serial INRs from the POC INR test during the study period. The time in therapeutic range (TTR) is calculated by Rosendaal method and all the results analysed on Microsoft Excel. The audit standard for safe and effective anticoagulation was a TTR ≥ 70%. Results were compared to an audit done previously for the centre’s anticoagulation clinic done in 2020. Results 207 patients were included in this audit. Male patients accounted for 53.6% of the study population. Their ages ranged from 22 years to 102 years with a median age of 67 years. Majority of the patients were on VKA as stroke prevention for their atrial fibrillation (AF) (79.7%), followed by metallic valve replacement (13%). The median TTR for patients with AF had improved from 40.8% in 2020 to 51.05% in 2020-21 study period and this difference is significant (p = 0.017). Patients getting effective anticoagulation also improved from 23.26% in 2020 to 26.79% during this audit period. 13% of the study population developed complications on VKA in which 2.9% of patients developed gastrointestinal bleed and 1% developed intracranial haemorrhage. There were 4 fatalities, none were from gastrointestinal bleeding, intracranial haemorrhage or stroke. 10% of patients had their VKA changed to a novel oral anticoagulant (NOAC) as they were identified to have poor TTR during clinic review. Conclusions The introduction of POC INR test has proven to make significant improvement in patient’s median TTR for patients with AF. However, more efforts need to be made to further improve effectiveness of anticoagulation in our patients such as converting them to a NOAC if eligible or more thorough counselling and more frequent INR checks.

Seasonal affective disorder and audit quality

This paper investigates whether seasonal affective disorder (SAD) influences audit quality. On the one hand, a SAD‐induced negative mood can render auditors risk‐averse in auditing. On the other hand, SAD can lower their cognitive ability and efficiency at work. Our results show that absolute discretionary accruals and the likelihood of restatements are lower when the level of SAD is higher during the audit period, thus suggesting that SAD lowers auditors' willingness to accept aggressive reporting. Other tests show that the relationship between SAD and audit quality is not significantly different between the fall and winter or between industry expert and non‐industry expert auditors. We also find that the association between SAD and audit quality is more pronounced for auditors located in northern states than southern states. Lastly, our results hold after controlling for management reporting choices, auditor busy season, auditor locality and other robustness tests. Overall, this paper contributes to the auditing literature by highlighting the effect of environmental factors on auditors' professional judgement from a psychological perspective.

Sodium Citrate Versus Heparin Locking Solutions for Tunneled Hemodialysis Catheters

Introduction: Hemodialysis catheter dysfunction compromises dialysis adequacy and may limit catheter survival. Strategies to prevent hemodialysis catheter dysfunction include catheter locks, generally either with heparin or citrate. Methods: Our hemodialysis unit converted to locking all central venous hemodialysis catheters with sodium citrate 4% instead of heparin 5000 U/mL. A retrospective analysis compared the outcomes of the 6 months prior and after the conversion. The compared outcomes were incidence of catheter thrombosis, catheter-related infection, flow-related catheter exchange rate, dialysis efficiency measured by Kt/V and catheter dysfunction. Results: Twenty-three patients were included. Between the two audit periods, the rate of catheter thrombosis was 0 (0 per 1000 catheter days) and 7 (2.78 per 1000 catheter days) during the heparin and citrate period respectively (p=0.109). The number of catheter exchanges due to catheter dysfunction was 0 (0 per 1000 catheter days) during the heparin period and just 1 (0.39 per 1000 catheter days) during the citrate period (p=0.317). Dialysis adequacy measured by KT/V was 1.54 (0.39) in the heparin group and 1.54 (0.35) in the citrate group (p=0.465). Catheter dysfunction was recorded in 146 sessions (12.3%) in the heparin period and in 159 sessions (14,7%) in the citrate period (p=0.234). There were no catheter related infections in either group. Conclusion: There was a 58% cost reduction associated with catheter-locking therapy between the heparin period and the citrate period. This cost reduction included the costs associated with alteplase use. Besides the financial advantages in switching to citrate locking, there are other potential advantages, namely the minimization of heparin related side effects or limitations.

Податкові перевірки як спосіб здійснення податкового контролю

The article examines tax audits as one of the ways of exercising tax control. The purpose of the study is to substantiate the theoretical provisions of tax audits and determine their role and place in the control process. The study was based on the application of general scientific methods: systematisation, logical and analytical methods, induction, deduction, as well as methods of theoretical generalisation, classification and grouping. The graphic method was used to illustrate the results of the research. The study emphasises that tax audits are a way of exercising tax control in Ukraine. Based on the digital data from the official portals of the State Tax Service, the efficiency and effectiveness of tax audits conducted during 2021-2022 are proved. The authors emphasise the restrictions on tax audits in Ukraine during the period of martial law, which mostly concerned documentary audits. The types of tax audits: in-house, documentary and factual were defined. The authors compare the subject matter of documentary and factual audits, and as a result, it is found that the same issues may be subject to different types of audits. The authors summarise organisational features of certain types of tax audits in the following areas: place of conduct, grounds for conducting, frequency of conduct, duration, conditions for starting an audit, and extension of the audit period. The presented study will be useful for employees of the State Tax Service and other fiscal authorities, customs authorities, auditors and practitioners of the accounting and controlling staff of enterprises, institutions, organisations, etc. We see prospects for further research in the development of a scientifically based classification of tax audits, development of methodological approaches to the implementation of various types of tax audits for certain types of national and local taxes and fees.