Departmental Audit Research Articles

Preparation of the colon for double-contrast barium enema: Comparison of picolax, picolax with cleansing enema and citramag (2 sachets) — A randomized prospective trial

A randomized prospective trial was undertaken on 196 consecutive patients referred for double-contrast barium enema examination to assess the relative efficacy of three colon cleansing regimes: Citramag (2 sachets), Picolax and Picolax with a preliminary cleansing enema. Each of the regimes was preceded by a 5 day low residue diet. The radiographs from the examinations were assessed on a double-blind basis. The quality of bowel preparation was significantly poorer (P < 0.001) in the group receiving the preliminary cleansing enema, notably with respect to mucosal coating, compared with the other two groups. The quality of the preparation was slightly better in the group receiving Picolax alone than in the Citramag group (P < 0.01), the difference being most apparent in the proximal colon. The laxatives were equally well tolerated. The study has formed the basis of a departmental audit. As a result, the bowel preparation has been standardized to a 5 day period of dietary restriction followed by 2 Picolax sachets. This measure has improved efficiency within the department with no sacrifice in quality.

Depth of central venous catheterization: an audit of practice in a cardiac surgical unit.

Central venous catheter (CVC) depth relative to the cephalic limit of the pericardial reflection (CLPR) was assessed retrospectively in 100 adult patients from chest radiographs taken after admission to the intensive care unit. A well known landmark proved to be considerably influenced by parallax; therefore we located the CLPR by a new landmark, the junction of the azygos vein and the superior vena cava, identified by the angle of the right main bronchus and the trachea. The majority (58) of CVC tips lay below the pericardial reflection on the first chest radiograph (CXR). Of these only two had been corrected by the time of the next routine CXR. No case of cardiac tamponade secondary to erosion by a CVC could be remembered, or identified from records of routine departmental audit meetings, for the last ten years. Nevertheless, reported incidents of this complication have often been fatal and vigilance is necessary in any patient with a CVC.

A district audit on the management of polymyalgia rheumatica and giant cell arteritis.

Twenty-one hospital consultants, representing 20% of the hospital specialists and 54 general practitioners representing 22% of the general practitioners in the Norwich Health District were circulated a questionnaire on the management of polymyalgia rheumatica and giant cell arteritis, as part of a departmental audit. The wide variations in the diagnosis and treatment of these two common conditions are shown in this study. Appropriate recommendations have been made for these two common conditions in the hope of providing a useful guideline for more uniform and effective therapy. We intend to repeat this study at a later date to assess if any of the recommendations have been undertaken successfully.

A study of patients referred from A&amp;E for coroners post-mortem.

A review of 179 autopsies was undertaken over a 1-year period to determine if clinically useful information was obtainable from coroners post mortems performed on patients referred from the A&E department. Fifty-six patients had undergone unsuccessful resuscitation. The leading causes of death were heart disease and trauma. Discrepancies between the diagnosis made during resuscitation and the cause of death found at autopsy were revealed especially in those dying from noncardiac causes. Iatrogenic trauma from resuscitation attempts occurred in a significant number of cases. It is suggested that review of selected Coroners post mortems should be part of departmental audit, with a view to improving clinical skills.

Departmental Audit in Histopathology

Audit is now part of any laboratory service. Histopathology is no exception, and we have set up a system which allows us to review 4% of our specimens. These specimens are identified using a random number generator and reviewed by a consultant pathologist. Both slides and wet specimens are reviewed and graded according to a set scheme. The results from the first year of operation (1990) show a high rate of accuracy with no serious diagnostic disagreements between the auditor and the reporting pathologist. However, some errors which we would wish to prevent were detected and the audit has allowed us to take corrective measures. In our opinion, this form of audit is useful and necessary to maintain good clinical practice. The cost is considerable--histopathology is by its nature labour intensive. Recognition of this fact by health boards is essential if such systems are to continue.

Audit in action: significant reduction of double-contrast barium enema screening time with no loss of examination quality.

The double-contrast barium enema is an examination of high radiation exposure to the patient. As part of a departmental audit, our own fluoroscopic screening times were being recorded. A study was undertaken to see if a determined effort could reduce the screening time without having a detrimental effect on the quality of the examinations. Methods of screening time reduction were identified and then implemented by two radiologists. In the period before the study the average screening time for radiologists A and B was 2.6 min and 3.2 min, respectively (over 56 examinations). After implementation of the changes, the average screening time for both was 0.9 min (over 50 examinations). This is a statistically significant reduction (p less than 0.01). The examinations were assessed independently by a gastroradiologist. No difference in the quality of the examinations was identified. We conclude that a significant reduction of screening time for the double-contrast barium enema can be achieved without loss of examination quality.

Computerised database for pre-prosthetic surgery

A system has been implemented using a commercial database management program and a microcomputer for computerising pre-prosthetic surgery. Using selection criteria, clinical records can be added, edited/deleted, searched for, displayed on screen, generate consultation summaries and operative discharge letters to the referring consultant, general medical and general dental practitioners together with a synopsis of the clinical assessment and surgical admission. Surgical audit may be conducted on the records. This progam will hold 30 000 clinical records. Such a system is beneficial for personal and departmental audit, epidemiological studies and research into the prevalence of surgical treatment and postoperative morbidity.

Regional Profile Data as Basis for Social Work Audit

Profile data obtained in a regional survey of social work practice have been used by one social work department of a general hospital to identify three problem areas of practice with patients whose discharges are delayed beyond medical necessity. The authors describe the department's analysis of the data, its identification of a topic of concern, and the subsequent steps taken in a departmental audit.

The Clinical Audit in a Psychiatric Setting: Is Big Brother Watching You?

This paper summarizes five methods for clinical auditing that are carried out concurrently at the London Psychiatric Hospital. The first type of audit is carried out by the Medical Records Department and consists of a check-off list of items that for accreditation purposes must be included in the record. The second and third types of audit compare the content of the records from samples of similarly diagnosed or treated patients to criteria previously specified by a committee of professionals. The fourth type of audit is really a collection of audits in which each of the clinical departments: Nursing, Social Work, Occupational Therapy, and Psychology, check random samples of files on a monthly basis for the contribution to the record made by their own departmental members. These files are checked against specific questions laid out on a departmental audit form, and feedback is given directly to the departmental member. The four preceding types of audits all have the advantage of large-scale “screening” of charts. They, however, do not allow for crosschecking recorded data with the condition of the actual patient. The fifth type of audit, the “in-depth single patient care audit” corrects this deficit, and allows for more dialogue with the treatment team. The detailed form that is used for this audit procedure is described in the text. The audit is carried out by a senior clinician from the Department of Medicine in conjunction with a senior member of another discipline. The physician interviews the patient before reading and checking the chart. Both the physician and the senior member of the other clinical department then discuss the charting and the case with the entire treatment team. This last method of auditing has helped considerably in re-designing a system for charting at London Psychiatric Hospital. The chief drawback of the audit, time consumption, is far outweighed by the advantages that accrue. The procedure affords the unit staff and the auditors opportunities for an ongoing educational experience.

Brain damage in dogs immediately following pulsatile and non-pulsatile blood flows in extracorporeal circulation.

<h3>Background</h3> COVID-19 management guidelines are constantly evolving, making them difficult to implement practically. <i>Ronapreve</i> was a neutralising monoclonal antibody introduced into UK COVID-19 guidelines in 2021. It reduces mortality in seronegative patients infected with non-omicron variants. Antibody testing on admission is therefore vital in ensuring patients could be considered for <i>Ronapreve</i> as inpatients. <h3>Local problem</h3> We found that on our COVID-19 ward, 31.4% of patients were not having anti-S tests despite fulfilling the other criteria to be eligible for <i>Ronapreve</i>. This was identified as an important target to improve; by not requesting anti-S tests, we were forgoing the opportunity to use an intervention that could improve outcomes. <h3>Methods</h3> We analysed patient records for patients with COVID-19 admitted to our ward over 4 months to observe if awareness of the need to request anti-S increased through conducting plan–do–study–act (PDSA) cycles. <h3>Interventions</h3> Our first intervention was an multidisciplinary team (MDT) discussion at our departmental audit meeting highlighting our baseline findings and the importance of anti-S requesting. Our second intervention was to hang printed posters in both the doctors’ room and the ward as a visual reminder to staff. Our final intervention was trust-wide communications of updated local COVID-19 guidance that included instructions for anti-S requesting on admission. <h3>Results</h3> Our baseline data showed that only 68.6% of patients with symptomatic COVID-19 were having anti-S antibody tests requested. This increased to 95.0% following our three interventions. There was also a reduction in the amount of anti-S requests being ‘added on’, from 57.1% to 15.8%. <h3>Conclusions</h3> COVID-19 guidelines are constantly evolving and require interventions that can be quickly and easily implemented to improve adherence. Sustained reminders through different approaches allowed a continued increase in requesting. This agrees with research that suggests a mixture of educational sessions and visual reminders of guidelines increase their application in clinical practice.