National Audit Research Articles

Impact of a national audit on child and adolescent psychiatrists' prescribing practices.

A look back review of South Kerry Child and Adolescent Mental Health Services (CAMHS) in Ireland, known as the 'Maskey report' (MR), highlighted substandard prescribing practices. The aim of this 'Maskey Impact Study' (MIS) was to explore changes to child and adolescent psychiatrists' prescribing practices following the MR. The study was cross-sectional and mixed method. A study specific questionnaire was distributed electronically to psychiatrists working in CAMHS (n = 160). 102 psychiatrists participated in the study (response rate 63.8%). Perceived improvement in prescribing practices included improved medical record keeping (63.7%), consent documentation (53.9%), medication information provision (41.2%) and physical health monitoring (60.8%). However, 43.1% of psychiatrists reported a reluctance to prescribe medication even when clinically indicated and 50% were more likely to avoid off-label use. Most respondents reported increased stress levels (80.4%) with higher stress being significantly associated with reticence in prescribing (χ2 = 11.746, p < .001) and avoiding off-label use (χ2 = 15.392, p < 0.001). Thematic analysis highlighted increased medication hesitancy, enforced 'meaningless' bureaucracy and medication mistrust among families. Although improvements reported are welcomed, the increased hesitancy of medication use, avoidance of prescribing more than one medication, and avoidance of off-label use, is of concern with potential unintended adverse consequences. Reluctance in prescribing may deprive youth of access to evidence-based treatments and limit exposure of NCHDs to the safe practice of consultant-initiated psychopharmacology. Further research will be important to determine if this impacts clinical care. Continued education in psychopharmacology is essential along with increased public awareness of the evidence for medication, to help restore public confidence and trust in psychopharmacology.

Research on the National Audit Model to Promote the Strategy of Rural RevitalizationBased on the Practice Analysis of Ankang, Shaanxi

The issue of unbalanced and insufficient development in China is particularly prominent in rural areas. Therefore, the report of the 19th National Congress of the Communist Party of China proposed the implementation of the "Rural Revitalization Strategy" and pointed out that effective governance is the foundation for achieving rural revitalization. This paper, based on the comprehensive audit practice in Ankang City, Shaanxi Province, summarizes the specific practices and achievements of Ankang, analyzes its role and the problems that exist. It studies from the perspective of effective governance how national audit at the rural level can promote effective rural governance and thus achieve rural revitalization; on this basis, it proposes relevant policy recommendations from clarifying the leading position of national audit at the rural level, audit subjects, audit forces, audit methods, and the application of audit results.

Advanced life support interventions during intra-operative cardiac arrest among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists.

Few existing resuscitation guidelines include specific reference to intra-operative cardiac arrest, but its optimal treatment is likely to require some adaptation of standard protocols. We analysed data from the 7th National Audit Project of the Royal College of Anaesthetists to determine the incidence and outcome from intra-operative cardiac arrest and to summarise the advanced life support interventions reported as being used by anaesthetists. In the baseline survey, > 50% of anaesthetists responded that they would start chest compressions when the non-invasive systolic pressure was < 40-50 mmHg. Of the 881 registry patients, 548 were adult patients (aged > 18 years) having non-obstetric procedures under the care of an anaesthetist, and who had arrested during anaesthesia (from induction to emergence). Sustained return of spontaneous circulation was achieved in 425 (78%) patients and 338 (62%) were alive at the time of reporting. In the 365 patients with pulseless electrical activity or bradycardia, adrenaline was given as a 1 mg bolus in 237 (65%). A precordial thump was used in 14 (3%) patients, and although this was associated with return of spontaneous circulation at the next rhythm check in almost three-quarters of patients, in only one of these was the initial rhythm shockable. Calcium (gluconate or chloride) and 8.4% sodium bicarbonate were given to 51 (9%) and 25 (5%) patients, but there were specific indications for these treatments in less than half of the patients. A thrombolytic drug was given to 5 (1%) patients, and extracorporeal cardiopulmonary resuscitation was used in 9 (2%) of which eight occurred during cardiac procedures. The specific characteristics of intra-operative cardiac arrest imply that its optimal treatment requires modifications to standard advanced life support guidelines.

Cost-effectiveness of outpatient adherence to recommendations for monitoring of patients hospitalized for heart failure.

A set of indicators to assess the quality of care for patients hospitalized for heart failure was developed by an expert working group of the Italian Health Ministry. Because a better performance profile measured using these indicators does not necessarily translate to better outcomes, a study to validate these indicators through their relationship with measurable clinical outcomes and healthcare costs supported by the Italian National Health System was carried out. Residents of four Italian regions (Lombardy, Marche, Lazio, and Sicily) who were newly hospitalized for heart failure (irrespective of stage and New York Heart Association class) during 2014-2015 entered in the cohort and followed up until 2019. Adherence to evidence-based recommendations [i.e. renin-angiotensin-aldosterone system (RAS) inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and echocardiograms (ECCs)] experienced during the first year after index discharge was assessed. Composite clinical outcomes (cardiovascular hospital admissions and all-cause mortality) and healthcare costs (hospitalizations, drugs, and outpatient services) were assessed during the follow-up. The restricted mean survival time at 5years (denoted as the number of months free from clinical outcomes), the hazard of clinical outcomes (according to the Cox model), and average annual healthcare cost (expressed in euros per person-year) were compared between adherent and non-adherent patients. A non-parametric bootstrap method based on 1000 resamples was used to account for uncertainty in cost-effectiveness estimates. A total of 41406 patients were included in this study (46.3% males, mean age 76.9±9.4years). Adherence to RAS inhibitors, beta-blockers, MRAs, and ECCs were 64%, 57%, 62%, and 20% among the cohort members, respectively. Compared with non-adherent patients, those who adhered to ECCs, RAS inhibitors, beta-blockers, and MRAs experienced (i) a delay in the composite outcome of 1.6, 1.9, 1.6, and 0.6months and reduced risks of 9% (95% confidence interval, 2-14%), 11% (7-14%), 8% (5-11%), and 4% (-1-8%), respectively; and (ii) lower (€262, €92, and €571 per year for RAS inhibitors, beta-blockers, and MRAs, respectively) and higher costs (€511 per year for ECC). Adherence to RAS inhibitors, beta-blockers, and MRAs showed a delay in the composite outcome and a saving of costs in 98%, 84%, and 93% of the 1000 bootstrap replications, respectively. Strict monitoring of patients with heart failure through regular clinical examinations and drug therapies should be considered the cornerstone of national guidelines and audits.

Informal Institutions and Audit Pricing: Cross-Country Evidence of National Culture and Audit Fees

Synopsis The research problem In this study, we examined the effect of an important informal institution, namely, national culture, on audit fees in an international context. Motivation In recent years, extant literature has increasingly focused on country-level differences in the audit environment, as these might have a significant influence on how financial statement audits are conducted across the globe. We contribute to this stream of literature by investigating the impact of national culture on audit fees. The test hypotheses Based on the demand- and supply-side perspectives of audit fees, we hypothesized that national culture dimensions — namely, uncertainty avoidance, power distance, individualism versus collectivism, and masculinity versus femininity — affect audit fees. Target population We used a sample of 27,670 firm-year observations across 22 countries over the 2002–2019 period. Adopted methodology We used ordinary least squares (OLS) regressions as baseline technique and entropy-balanced method (EBM) and system-generalized method of moments (GMM) to address endogeneity concerns. Analyses We examined the impact of Hofstede’s four national culture dimensions — uncertainty avoidance, power distance, individualism versus collectivism, and masculinity versus femininity — on audit fees. We also tested the robustness of results using alternative measures of national culture, subsample analyses, and additional firm-level factors. Findings Consistent with our hypotheses, we find that audit fees are higher (lower) in countries with higher uncertainty avoidance, individualism, and masculinity (power distance) scores. Our further analyses reveal that earnings management proxied by abnormal accruals does not impact the relationship; however, country-level creditor rights influence audit fees in high power distance and masculine cultures. We also note that national culture influences auditor choice and audit opinion. Our main findings are robust to alternate proxies and subsample analysis, as well as to address potential endogeneity concerns. Overall, our findings offer important implications for firms operating in global markets and for the audit profession.

Abstract PO4-17-05: Patterns of care: radiotherapy after breast conserving surgery and the use of endocrine therapy for screen-detected ductal carcinoma in situ (DCIS) in the UK

Abstract Background The use of adjuvant radiotherapy (RT) and endocrine therapy (ET) in the management of pure ductal carcinoma in situ (DCIS) remains controversial. We investigate how the use of adjuvant RT after breast conserving surgery (BCS) and use of adjuvant ET (in BCS and mastectomy patients) has changed over time. Methods A prospective cohort SQL database of 11,284 patients (the Sloane Project) diagnosed 2003-2012 with screen-detected DCIS in the UK was interrogated for use of adjuvant RT and ET over time and association with factors reported to be predictive of recurrence (patient age, DCIS nuclear grade, size, comedo necrosis, resection margins), as well as institution of surgery, travel time to radiotherapy facility, Index of Multiple Deprivation and outcome (provided by the National Disease Registration Service, NDRS). RT data by site were confirmed with more recent data from the National Audit of Breast Cancer in Older Patients (NABCOP), which looked at patterns of care and outcomes for women aged 70 years and over, compared with those aged 50-64 in England and Wales. Results Among the 7,949 women (70.6%) treated by BCS, post-operative adjuvant RT was given to 4,939 (62.1%); RT use after BCS increased over time (R2 =0.92; p&amp;lt; 0.01). RT use was associated with year of diagnosis (p &amp;lt; 0.01), younger age at diagnosis (p &amp;lt; 0.01), larger DCIS size (p &amp;lt; 0.01), presence of comedo necrosis (p &amp;lt; 0.01), higher nuclear grade (p &amp;lt; 0.01) and presence of microinvasion (p &amp;lt; 0.01). Adjusted analyses showed the most significant factor for RT after BCS was the surgery institution. Travel time to RT facility, Index of Multiple Deprivation and final radial margin were not associated with RT use. When compared with the more recent data from the NABCOP, a marked variation in radiotherapy use across hospitals remains. Ipsilateral recurrence rate varied significantly by hospital, with some of the difference associated with RT utilisation. ET was prescribed in 1313 women (12%), more often following BCS than mastectomy (p &amp;lt; 0.001), with significant variation by institution and a decline in the use of ET over time. Conclusion Marked geographic variation in the use of RT and ET after surgery for DCIS persists in the UK and is likely due to physician choice rather than other factors such as travel times to RT facilities. This is contributing to geographic variation in ipsilateral recurrence rates, suggesting the need for adoption of more authoritative guidelines to support clinical decision-making. Consistent national practice could provide auditable performance standards for adjuvant therapy of screen detected DCIS and contribute to more uniform patient care. Citation Format: Karen Clements, David Dodwell, Elinor Sawyer, Ramsey Cutress, Nisha Sharma, Abeer Shaaban, Alastair Thompson. Patterns of care: radiotherapy after breast conserving surgery and the use of endocrine therapy for screen-detected ductal carcinoma in situ (DCIS) in the UK [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-17-05.

The Environmental Consequences of National Audit Governance: An Analysis Based on County-Level Data in China

Recent years have witnessed growing public concern over air pollution in China, posing a challenge to the government's environmental management efforts. Empirical evidence indicates that the digital economy contributes to mitigating environmental pollution. Given that national audits are a crucial part of the national oversight system and considering the significant role of digital technology in audit governance, it is relevant to explore how the digital economy can support national audits in enhancing China's environmental quality. This study investigates the environmental impact of national audit governance, utilizing a dataset from 1540 counties in China spanning from 2005 to 2018. The findings reveal that effective national audits contribute to reducing haze pollution (HP) levels, with the digital economy playing a moderating role. The results also demonstrate heterogeneity; national audits are particularly effective in regions characterized by high urbanization rates, severe HP, and stringent environmental regulations. The mechanism analysis suggests that industrial transformation and enhanced government governance are the key mechanisms through which national audits reduce regional HP. Additionally, reforming the audit management system can amplify the effects of national audits on reducing HP.

Local recurrence after breast conserving surgery (LRAB) national audit

Local recurrence after breast conserving surgery (LRAB) national audit

Reducing the time to activation of the emergency call system in operating theatres: effect of installing vertical red line indicators

BackgroundThe 7th National Audit Project of the Royal College of Anaesthetists (NAP7) recommended that an emergency call system be immediately accessible in all anaesthesia locations. It is essential that all theatre team members can rapidly call for help to reduce the risk of patient harm. However, the ability of staff to activate this system in a timely manner can be affected by cluttered or unfamiliar environments and cognitive overload. One proposed strategy to enable rapid identification and activation of emergency call systems is to install a red vertical painted stripe on the wall from the ceiling to the activation button. We investigated the effect of introducing this vertical red line on activation times in operating theatres in the UK and Australia. MethodsOperating theatre team members, including anaesthetists, surgeons, anaesthetic nurses, surgical and theatre nurses, operating theatre practitioners, and technicians, were approached without prior warning and asked to simulate activation of an emergency call. Vertical red lines were installed, and data collection repeated in the same operating theatres 4–12 months later. ResultsAfter installation of vertical red lines, the proportion of activations taking >10 s decreased from 31.9% (30/94) to 13.6% (17/125, P=0.001), and >20 s decreased from 19.1% (18/94) to 4.8% (6/125, P<0.001). The longest duration pre-installation was 120 s, and post-installation 35 s. ConclusionsThis simple, safe, and inexpensive design intervention should be considered as a design standard in all operating theatres to minimise delays in calling for help.

A national audit of prescribing in Child and Adolescent Mental Health Services (CAMHS)

Abstract Introduction Specialist Child and Adolescent Mental Health Services (CAMHS) provide essential support to the mental well-being of young people. Concerns regarding CAMHS delivery in Ireland have been brought to the fore since 2022 and the publication of the Maskey report; this report presented the findings from a review into the care delivered in one region of Ireland and highlighted risk of harm to children and young people due to deviation from clinical best practice.[1] Following the report’s publication, a national audit of CAMHS prescribing practice was requested by the Minister for Mental Health and Older People. Aim To conduct an audit of prescribing in CAMHS nationally and determine adherence to defined audit standards. Methods Every community CAMHS team in Ireland were requested to self-complete the audit on a random sample of 50 children under their care between 1st July 2021 and 31st December 2021, and prescribed medication during this period. An audit tool was developed by the audit team, based on issues identified in the Maskey report, and was sent electronically to each CAMHS team. The tool gathered data on demographics of children, disorders treated, medications prescribed, patient monitoring and communication. Adherence to six audit standards was evaluated. These standards were: i)involvement of a consultant in prescribing. ii)consent to medication by parent/guardian. iii)baseline physical assessment. iv)ongoing physical monitoring. v)communication with general practitioner. vi)follow-up review appointment arranged. The target for each standard was set at 95%. Data were analysed using the software STATA Version 17.0[2] Results The audit sample comprised 3528 children, representing 74 CAMHS teams nationally. More males were included in the sample (n=1955, 55.4%). The median age was 15 years, with a range of 4-17 years. -The majority of children (70.6%) were taking one medication, 24.2% were prescribed two medications and 4.6% were prescribed three medications. -54% of children were prescribed ADHD medications; 41.9% were prescribed an anti-depressant, 10.9% were prescribed an antipsychotic. -Most medications were prescribed within recommended dose ranges. -95% of prescribing was done under consultant supervision. -89% of children had consent to medication documented. -90% of children had baseline physical monitoring conducted prior to prescribing. -92% of children had ongoing physical monitoring conducted. -90% had documented communication with the child’s general practitioner. -98% of children had follow-up review appointments arranged. Conclusion This audit of 3528 children from 74 CAMHS teams is the first of its kind to highlight nationally the broad complexity in prescribing practices in CAMHS in Ireland. These data add to the limited literature on the nature of illnesses treated by CAMHS and the need for services. The work has several strengths and limitations; a key strength is that 100% compliance was achieved in terms of participation of community CAMHS teams, a limitation is that external validation of the data was not undertaken as it was not feasible in the timeframe available. Several recommendations, at national and community health organisation level, were derived from the results of this audit.

Western European Variation in the Organization of Esophageal Cancer Surgical Care.

Reasons for structural and outcome differences in esophageal cancer surgery in Western Europe remain unclear. This questionnaire study aimed to identify differences in the organization of esophageal cancer surgical care in Western Europe. A cross-sectional international questionnaire study was conducted among upper gastrointestinal (GI) surgeons from Western Europe. One surgeon per country was selected based on scientific output and active membership in the European Society for Diseases of the Esophagus or (inter)national upper GI committee. The questionnaire consisted of 51 structured questions on the structural organization of esophageal cancer surgery, surgical training, and clinical audit processes. Between October 2021 and October 2022, 16 surgeons from 16 European countries participated in this study. In 5 countries (31%), a volume threshold was present ranging from 10 to 26 annual esophagectomies, in 7 (44%) care was centralized in designated centers, and in 4 (25%) no centralizing regulations were present. The number of centers performing esophageal cancer surgery per country differed from 4 to 400, representing 0.5-4.9 centers per million inhabitants. In 4 countries (25%), esophageal cancer surgery was part of general surgical training and 8 (50%) reported the availability of upper GI surgery fellowships. A national audit for upper GI surgery was present in 8 (50%) countries. If available, all countries use the audit to monitor the quality of care. Substantial differences exist in the organization and centralization of esophageal cancer surgical care in Western Europe. The exchange of experience in the organizational aspects of care could further improve the results of esophageal cancer surgical care in Europe.

P078 United Kingdom rates and determinants of romosozumab prescriptions, a need for greater action

Abstract Background/Aims Romosozumab rapidly reduces fracture risk and has been recommended as a first-line option for post-menopausal persons with severe osteoporosis and a recent major fracture from November 2020 (Scotland) and May 2022 (England, Northern Ireland and Wales). Aim: to describe hospital-level romosozumab prescriptions and the determinants across the four nations. Methods Hospital-level romosozumab prescription data were analysed by country. Potential predictors included surrogates of local patient need (the population of women aged 50 years and over), local FLS status (none, partial, full) and, in England and Wales, the number of patient records submitted to the mandatory national audits for Fracture Liaison Service (FLSDB) and National Hip Fracture Database (NHFD) in 2021. Spearman correlations and zero-inflated Poisson models identified independent determinants of: a) any prescription and b) the number of prescriptions or romosozumab. Results 152 sites were included (England-126, N. Ireland-5, Scotland-14, and Wales-7) with 60 full and 28 partial FLSs. 63 sites recorded a least one romosozumab prescription in 2022. The proportion of hospitals with any prescription varied from 20% in Northern Ireland to 64.3% in Scotland. An estimated four million women aged 50+ lived in areas with no romosozumab delivery. No determinants of any prescription were identified. With England as the referent group, the number of prescriptions was greater in Scotland (p = 0.001) and lower in Northern Ireland (p = &amp;lt;0.001). After adjusting for the number of women aged 50 years and over (p = 0.008), a full FLS but not partial FLS predicted the number of prescriptions (Figure). In England and Wales both local NHFD (Rs = 0.19, p = 0.03) and FLSDB records (Rs = 0.25, p = 0.056) predicted the number of local prescriptions. Conclusion Even after inclusion in national guidelines, there is a care gap of at least four million women in the UK. In NHS sites that have started prescribing romosozumab, the patient numbers are significantly below expected rates. A national implementation strategy should be considered for decision makers, healthcare providers and patient groups to minimise the number of subsequent fragility fractures in the FLS setting by increasing the number of sites implementing romosozumab focusing on FLS first and matching local delivery to local population needs. Disclosure M.K. Javaid: Consultancies; MKJ has received honoraria, travel and/or subsistence expenses from: Amgen, Kyowa Kirin Hakin, UCB, Abbvie, Besin Healthcare, Sanofi. Grants/research support; MKJ has received unrestricted research grants Amgen, Kyowa Kirin Hakin, UCB. T. Jones: Corporate appointments; Employee of British and Irish BioPharma SPRL. S. Hepworth: Corporate appointments; Employee UCB BioPharma SPRL.

Program of All-Inclusive Care for the Elderly: an untapped setting for research to advance pain care in older persons.

The Program of All-Inclusive Care for the Elderly (PACE) is a community-based care model in the United States that provides comprehensive health and social services to frail, nursing home-eligible adults aged 55 years and older. PACE organizations aim to support adequate pain control in their participants, yet few evidence-based pain interventions have been adopted or integrated into this setting. This article provides a roadmap for researchers who are interested in collaborating with PACE organizations to embed and evaluate evidence-based pain tools and interventions. We situate our discussion within the Consolidated Framework for Implementation Research (CFIR), a meta-theoretical framework that considers multi-level influences to implementation and evaluation of evidence-based programs. Within each CFIR domain, we identify key factors informed by our own work that merit consideration by research teams and PACE collaborators. Inner setting components pertain to the organizational culture of each PACE organization, the type and quality of electronic health record data, and availability of staff to assist with data abstraction. Outer setting components include external policies and regulations by the National PACE Association and audits conducted by the Centers for Medicare and Medicaid Services, which have implications for research participant recruitment and enrollment. Individual-level characteristics of PACE organization leaders include their receptivity toward new innovations and perceived ability to implement them. Forming and sustaining research-PACE partnerships to deliver evidence-based pain interventions pain will require attention to multi-level factors that may influence future uptake and provides a way to improve the health and well-being of patients served by these programs.

Antipsychotic prescribing: national findings of children and adolescents attending mental health services in Ireland.

Antipsychotic prescribing trends vary internationally, albeit off-label use remains high (i.e., target symptoms). We aim to describe antipsychotic use, target conditions, target symptoms and dosing regimens in children and adolescents in Ireland. We used a sampled cohort from a national audit of children and adolescents attending mental health services with predefined inclusion and exclusion criteria from Jul-2021 to Dec-2021 who were prescribed at least one psychotropic medication and up to and including 17-years of age (n = 3528). Each service provided anonymised data. We described the frequency of antipsychotic medication, medication type, target condition, target symptom and medication doses. We used multivariable logistic regression, adjusted with available co-variates to assess the association of being prescribed an antipsychotic medication. Twelve percentage (n = 437) were prescribed an antipsychotic and 16-17-years (n = 211, 48.3%) was the most common age category. The commonest reason for prescribing an antipsychotic was target symptoms (i.e., off-label use) (n = 329; 75.%) and of these symptoms, agitation (n = 77/329; 25%) and irritability (56/239; 25%) were the most common. Quetiapine (n = 127; 29%) was the most common antipsychotic, followed by risperidone (n = 125; 28.6%), aripiprazole (n = 107; 24.5%), and olanzapine (n = 66; 15.1%). In adjusted analysis, having a psychotic disorder ((adjusted-odds-ratio) aOR: 39.63, CI 95%, 13.40-117.22), bipolar disorder (aOR: 16.96, CI 95%, 3.60-80.00), autism spectrum disorder (aOR: 3.24, CI 95%, 2.45-4.28) or aggression symptoms (aOR: 16.75, CI 95%, 7.22-38.89) was associated with prescribing an antipsychotic medication. This is the first study in children and adolescents that describes the target conditions and target symptoms for antipsychotic use in Ireland. Our results show a high proportion of antipsychotic prescribing based on target symptoms rather than target condition or diagnosis.

What are the determinants of change in walking fitness in patients with a history of depression following cardiac rehabilitation?

This study aims to investigate the demographic, clinical and service level factors determining change in walking fitness in cardiac rehabilitation (CR) patients with a history of depression following the CR programme. National Audit of Cardiac Rehabilitation (NACR) clinical data were used to identify 1476 patients with a history of depression who had their pre and post incremental shuttle walk test (ISWT) recorded between 1st Jan 2016 and 31st Jan 2020. A multiple linear regression was conducted to examine the determinants of change in walking fitness (m) following CR. Mean age was 61 (SD 10.45) and mean ISWT distance at baseline and outcome were 352.06m (SD 169.48) and 463.43m (SD 197.65), respectively. Multivariate analysis revealed that change in walking distance reduced by 1.6m for each year increase in age at baseline (P < 0.001). Females and unemployed patients had less improvement in walking fitness (23.1m and 21.5m, respectively). Having a body mass index >30 was associated with lower improvement (24.2m, p < 0.001), while physically active patients had 14.6m higher change. Higher baseline ISWT quintiles were associated with less improvement, and increased waiting time to start CR was associated with reduced change in walking fitness following CR. Older age, female gender, unemployment, higher baseline BMI, longer waiting time, and lower physical activity were associated with reduced walking fitness improvement in patients with a history of depression. Targeted intervention and prompt access to CR can optimize outcomes.

Prevention of accidental awareness under general anaesthesia: A regional service evaluation.

The United Kingdom's Fifth National Audit Project investigated the incidence and causes of accidental awareness during general anaesthesia. Subsequently, guidelines produced by the Association of Anaesthetists of Great Britain and Ireland provide key recommendations to minimise awareness. These include using processed electroencephalogram for patients receiving total intravenous anaesthesia while paralysed and using audible low end-tidal anaesthetic concentration alarms. The Southcoast Perioperative Audit and Research Collaboration undertook a five-day regional service evaluation, assessing the measures in place to minimise awareness and conducting a practitioner survey. Eight hospitals participated with 382 theatre attendances were analysed. Processed electroencephalograph monitoring for patients receiving total intravenous anaesthesia with neuromuscular blockade has been widely adopted into regional practice, from 23% of cases in the Fifth National Audit Project, to 85% in this snapshot. During volatile anaesthesia, age-adjusted low end-tidal anaesthetic concentration alarms were used in 34% cases. The range was 0-97% at different hospitals, suggesting heterogeneity in practice. Seventy-six per cent of anaesthetists rarely alter the default anaesthetic machine alarm settings. Therefore, instigating default low end-tidal anaesthetic concentration alarms could improve compliance with guidelines and reduce the risk of awareness for patients.

New development: Great expectations—whole of government accounting: An Australian perspective of its adoption, development and future use in the current environment

IMPACT While this article focuses on the Australian experience (federal and state levels), the issues/suggestions are relevant to countries that have adopted Whole of Government Accounting (WGA) or are considering doing so. A major issue is to encourage greater attention by, and involvement of, the parliament and its committees in reviewing and examining the outcomes as an important element of accountability to the general public for the use of the resources and to show trends over time. While there has been a greater focus on individual programme performance over recent years, the WGA have rated little discussion, let alone examination and questioning. For example, the finance commentary on the latest consolidated financial statements is largely a statistical examination, not an identification /analysis, of issues of concern nor of necessary action to improve financial performance. A recent initiative taken by the Australian government and the Australian National Audit Office (ANAO) is the conduct of audits of agencies’ annual performance statements. No doubt a catalyst has been the unprecedented financial difficulties being experienced by governments.

The current standard of the shoulder trauma series in Ireland – A national audit

Objectives/aimsThe primary aim of this study was to assess the current standard of shoulder radiographs in Ireland. The secondary aim of this study was to determine whether orthopaedic surgeons in Ireland are of the opinion that a national protocol is required, and what this protocol should consist of. MethodsA national audit of shoulder trauma series x-rays performed in emergency departments was conducted. The number and type of views performed was recorded. The anteroposterior (AP) and axillary or Velpeau views were assessed to determine if they met pre-defined audit criteria. Consultant orthopaedic surgeons working in public trauma hospitals were invited to participate in an online survey by email. ResultsThe number of shoulder trauma series included in this audit was 789. The majority of patients had two views performed (75.92%, n ​= ​599) and 21.17% (n ​= ​167) had an axillary or Velpeau view. The AP view met the audit criteria in 23.09% (n ​= ​181) of cases. The survey response rate was 70.8% (n ​= ​17). 88.2% (n ​= ​15) of surgeons agreed that three views should be performed for a shoulder trauma series and 94.12% (n ​= ​16) agreed that an axillary or Velpeau view should be included. The majority of surgeons surveyed (94%, n ​= ​16) are in favour of establishing a national protocol. ConclusionThe current standard shoulder trauma series in Irish hospitals consists of two views, most frequently a thoracic AP and a scapular Y view. We propose the introduction of a national protocol consisting of three views: Grashey AP, Scapular Y, and an axillary or Velpeau view.

Network analysis of stroke systems of care in Korea

BackgroundThe landscape of stroke care has shifted from stand-alone hospitals to cooperative networks among hospitals. Despite the importance of these networks, limited information exists on their characteristics and functional attributes.MethodsWe...

A service evaluation of a new regional integrated stroke service in the NHS

Background: Stroke is the UK's leading cause of disability and contributes to numerous deaths. In response, centralised stroke care is on the rise, both globally and in the UK. A local trust has formed a regional stroke centre to provide efficient and timely emergency treatment. Aims: This article evaluates hyperacute performance in a new service, identifying areas for improvement and monitoring standards. It also aims to address and minimise shortfalls in preparation for the upcoming opening of a designated stroke hub, which will admit patients directly to the stroke team, bypassing the emergency department. Methods: Data were extracted from the Sentential Stroke National Audit Programme (SSNAP) database from 26 September 2022 to 26 January 2023. Comparison was made to national quarterly SSNAP data from October 2022 to December 2022, due to the corresponding publication dates. Literature was sourced from the Cumulative Index to Nursing &amp; Allied Health database. The main targets within SSNAP based on the first 4 hours of patient care were identified and analysed. Findings: From admission, 64% of patients underwent computer tomography scanning under 1 hour from admission, compared to a national average of 56.6%; 76% of patients underwent a swallow screening under 4 hours from admission, compared to a national average of 71.5%; and 37% of patients achieved admission to the hyperacute stroke unit under 4 hours from admission, compared to a national average of 39.5%. National average data were taken directly from SSNAP national averages from the report spanning October 2022 to December 2022. Conclusion: In comparison to national averages in many areas, the current service is performing well; however, there are many areas for improvement to address. Although the outlook for stroke care looks more promising as newer technologies emerge, stroke prevalence is increasing simultaneously. Stroke continues to cost the UK upwards of 26 billion pounds per year and causes significant detriment to survivors. Therefore, healthcare has a duty of care to continue to improve standards and innovate to improve outcomes.