Ongoing Quality Assurance Research Articles

Respiratory function testing: the impact of respiratory scientists on the training and support of primary health care providers.

In rural Australia access to doctors is limited, access to respiratory physicians even more so and these are the traditional sources of lung function testing. The aim of this study was to assess the feasibility of training and supporting existing rural primary healthcare providers in lung function testing as a screening and monitoring mechanism due to the shortage of healthcare professionals capable of providing such a service. As pharmacists are readily accessible healthcare professionals, they were trained in spirometry measurement and supported with ongoing quality assurance by respiratory scientists. Spirometers were provided to the pharmacists. People purchasing respiratory medications or responding to advertising about the service were tested after giving informed consent. Spirometic assessments were assessed for accuracy and reproducibility. Participants' spirometry results were reviewed and those with abnormal test results were referred to their doctor. Pharmacists were able to competently develop the skills necessary for providing spirometry measurement as a screening and monitoring technique. The level of competence exceeded that reported in previously published studies. Pharmacists were able to successfully identify spirometry results within the normal range. Training and supporting accessible healthcare professionals to provide lung function testing increases access in areas of need and has implications for respiratory morbidity and mortality in such settings.

Analytical and comparative testing of EnergyPlus using IEA HVAC BESTEST E100–E200 test suite

The EnergyPlus building energy simulation software has been tested using the IEA HVAC BESTEST E100–E200 series of tests. The volume 1 final report for the International Energy Agency (IEA) solar heating and cooling programme task 22 building energy simulation test and diagnostic method for heating, ventilating, and air conditioning equipment models (HVAC BESTEST) was recently published in January 2002. HVAC BESTEST is a series of steady-state tests for a single-zone DX cooling system. Cases range from dry to wet coil, low to high part load, and low to high temperatures. This published test suite includes three sets of analytical solutions and results from several other simulation programs for comparison. This test suite was initially used to test EnergyPlus beginning with beta versions prior to its official public release, and it is also applied as an ongoing quality assurance test. The application of these tests proved to be very useful in several ways: • revealed input model shortcomings, which resulted in new user inputs being added; • revealed reporting errors which were fixed; • revealed algorithmic errors which were fixed; • revealed algorithmic shortcomings which were improved or eliminated through the use of more rigorous calculations for certain components; • in later versions, caught newly introduced bugs before public release of updates. Overall, the application of this test suite has been extremely useful in debugging and verifying the DX cooling algorithms in EnergyPlus. This paper summarizes the difficulties encountered and the benefits gained in applying the tests.

Initiation of a teleradiotherapeutic network for patients in German lymphoma studies

PurposeDeviations of radiation treatment portals and dose from prospective treatment plans are unfavorable prognostic factors for lymphoma patients. Therefore, an extensive radiotherapy quality assurance program is used in the ongoing German lymphoma studies. The introduction of teleradiotherapy offered the opportunity to optimize and simplify the workflow of these quality assurance programs. The purpose of this report was to evaluate the feasibility of teleradiotherapy and to describe our experiences with these innovative tools. Methods and materialsDuring this pilot phase, five radiotherapy centers were equipped with the hardware and software that guarantees a rapid and high-quality transfer of imaging data, as well as real-time teleconferences. The workstation consists of standard PCs with Windows NT as the operating system and the commercial telemedicine software Hipax. ResultsAs a first step, imaging communication between the radiotherapy reference centers in Cologne and Homburg/Saar was established. Subsequently, three additional radiotherapy departments (Universities of Berlin, Münster, and Munich) with large numbers of lymphoma patients were connected. Other study centers delivered digital imaging on mobile data carriers or via an Integrated Services Digital Network point-to-point connection. Communication units were completed for interactive teleconferences. A facility for central online documentation was installed. Telemedical functions were integrated into the ongoing radiotherapy quality assurance program. Since the introduction of a teleradiotherapeutic workstation in the radiotherapy reference center in Cologne in January 2001, the images of 10% (n = 228 patients) of all reviewed cases of the ongoing Hodgkin's disease 10–12 trials were delivered digitally. The amount of digitally available imaging is continuously increasing. ConclusionThe introduction of teleradiotherapy improved the dialog between the radiotherapy reference centers and study centers and thus contributed toward high radiotherapy quality for lymphoma patients in Germany.

Dose adjustments are unnecessary for local reactions occurring at immunotherapy satellite clinics

Rationale Although recent reports have found that a no dose adjustment policy for local reactions does not increase systemic reaction rates, this policy has not been examined in satellite clinics outside of the allergist's office. Methods In 9 satellite clinics from Apr 2002-Jun 2003, a no dose adjustment policy was followed for immediate and late local reactions. During this 15-month period, each suspected systemic reaction following immunotherapy was documented as part of an ongoing quality assurance program. Numbers of injections and systemic reactions were reported quarterly to the allergist prescribing the immunotherapy. Results During this 15-month period, 6,338 immunotherapy injections were administered among the 9 satellite clinics. There were a total of 43 systemic reactions resulting in a 0.68% reaction rate (43/6,338). The historical systemic reaction rate in the office of the prescribing allergist under the same no dose adjustment policy was not statistically different: 0.84% (89/10,636) vs. 0.68% (p=0.26). In addition to existing patients, a total of 84 new immunotherapy prescriptions were written for the satellite clinics during this time period by the single allergist. In general, an immunotherapy maintenance dosage of 0.5 mL 1:100 w/v was used and each maintenance vial consisted of 0.5-1 mL of each antigen. Conclusions A no dose adjustment policy at immunotherapy satellite clinics does not increase systemic reaction rates. Dose adjustments for local reactions are unnecessary and may delay achievement of a therapeutic dose, lead to patient non-compliance due to increased visits, increase costs, and place patients at an increased risk for dose administration errors.

A system for symptom assessment in advanced palliative home healthcare using digital pens

Symptom control is one of the most important components of delivering effective palliative care, and adequate symptom assessment is a prerequisite for good symptom control. Patients receiving treatment in palliative home healthcare is geographically separated from the caregivers making symptom control a challenge, a challenge that could be met by the use of information and communication technology. Technologies of today offer different ways for patients to assess their symptoms at home and send the assessments to the healthcare provider. Examples are the use of a PC, a touch-tone telephone, and a digital pen, which require different kinds of infrastructure in the patient's home, and which differ in strengths and weaknesses. As part of an ongoing quality assurance work within the hospital-based home care clinic at Linköping University Hospital, the project has designed, developed and implemented an IT-support system for pain assessments for patients at home using digital pen and mobile Internet technology. A questionnaire study indicated that pain assessment using digital pens was accepted by patients and that problems mainly arose from the use of the visual-analogue scale.

The dilemma

The dilemma

Presidential address: The modern vascular specialist--surgeon, clinician, and interventionist.

Presidential address: The modern vascular specialist--surgeon, clinician, and interventionist.

Nasal bone evaluation with ultrasonography: a marker for fetal aneuploidy.

Nasal bone evaluation with ultrasonography: a marker for fetal aneuploidy.

Improving Services for Women with Depression in Primary Care Settings

Women have a higher prevalence of depressive disorders compared to men. The current system of care for women with depressive disorders provides significant financial barriers for patients with lower incomes to access mental health services. Primary care systems are used extensively by women and have the potential to diagnose patients at early stages of mental illness and to provide evidence-based treatments, but this potential is largely unfulfilled because of significant system-level barriers inherent in primary care. Recent effectiveness research provides an excellent framework for cost-effectively improving care of depression using stepped care principles and strategies effective for improving care of other chronic conditions. Psychologists have the potential to help implement stepped care models by providing training, consultation and ongoing quality assurance, as well as by delivering collaborative care models of acute-phase treatment and relapse prevention interventions.

Current calibration, treatment, and treatment planning techniques among institutions participating in the Children’s Oncology Group

Purpose : To report current technology implementation, radiation therapy physics and treatment planning practices, and results of treatment planning exercises among 261 institutions belonging to the Children’s Oncology Group (COG). Methods and Materials : The Radiation Therapy Committee of the newly formed COG mandated that each institution demonstrate basic physics and treatment planning abilities by satisfactorily completing a questionnaire and four treatment planning exercises designed by the Quality Assurance Review Center. The planning cases are ( 1) a maxillary sinus target volume (for two-dimensional planning), ( 2) a Hodgkin’s disease mantle field (for irregular-field and off-axis dose calculations), ( 3) a central axis blocked case, and ( 4) a craniospinal irradiation case. The questionnaire and treatment plans were submitted (as of 1/30/02) by 243 institutions and completed satisfactorily by 233. Data from this questionnaire and analyses of the treatment plans with monitor unit calculations are presented. Results : Of the 243 clinics responding, 54% use multileaf collimators routinely, 94% use asymmetric jaws routinely, and 13% use dynamic wedges. Nearly all institutions calibrate their linear accelerators following American Association of Physicists in Medicine protocols, currently 16% with TG-51 and 81% with TG-21 protocol. Treatment planning systems are relied on very heavily for all calculations, including monitor units. Techniques and results of each of the treatment planning exercises are presented. Conclusions : Together, these data provide a unique compilation of current (2001) radiation therapy practices in institutions treating pediatric patients. Overall, the COG facilities have the equipment and the personnel to perform high-quality radiation therapy. With ongoing quality assurance review, radiation therapy compliance with COG protocols should be high.

Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS).

Four hundred and nineteen incidents that occurred in the recovery room were extracted from the Anaesthetic Incident Monitoring Study database, representing 5% of the total database of 8372 reports. Incidents were reported mainly in daylight hours, with over 50% occurring in ASA 1-2 patients. The most common presenting problems related to respiratory/airway issues (183; 43%), cardiovascular problems (99; 24%) and drug errors (44; 11%). One hundred and twenty-two events (29%) led to a major physiological disturbance and required management in the High Dependency Unit or Intensive Care Unit. Contributing factors cited included error of judgement (77; 18%), communication failure (57; 14%) and inadequate pre-operative preparation (29; 7%), whilst factors minimising the incident included previous experience (97; 23%), detection by monitoring (72; 17%) and skilled assistance (54; 13%). Staffing and infrastructure of the recovery room needs to be supported, with ongoing education and quality assurance programmes developed to ensure that such events can be reduced in the future.

Summary findings of the fourth international radiocarbon intercomparison (FIRI)(1998–2001)

AbstractInterlaboratory comparisons have been widely used in applied radiocarbon science. These are an important part of ongoing quality assurance (QA) programmes, which are vital to the appropriate interpretation of the evidence provided by the 14C record in Quaternary applications (including climate change and environmental reconstruction). International comparisons of laboratory performance are an essential component of the quality assurance process in radiocarbon dating. If the user community is to have confidence in radiocarbon results, it needs to be assured that laboratories world wide are producing measurements that are reliable and in accordance with ‘good practice’. The findings from the most recent (completed in 2001) and extensive (more than 90 participating laboratories) radiocarbon intercomparison (FIRI) are reported here. This study was designed (i) to assess comparability, or otherwise, of the results from different laboratories and (ii) to quantify the extent and possible causes of any interlaboratory variation. The results demonstrate that there are no significant differences amongst the main measurement techniques (gas proportional counting, liquid scintillation counting and accelerator mass spectrometry (AMS)) but there is evidence of small laboratory offsets relative to known age samples for some laboratories. There is also evidence in some cases of underestimation of measurement precision. Approximately 10% of all results were classified as extreme (outliers) and these results were generated by 14% of the laboratories. Overall, the evidence supports the fact that radiocarbon laboratories are generally accurate and precise but that, notwithstanding internal QA procedures, some problems still occur, which can best be detected by participation in independent intercomparisons such as FIRI, where the results allow individual laboratories to assess their performance and to take remedial measures where necessary. The results from FIRI are significant in that they show a broad measure of agreement between measurements made in different laboratories on a wide range of materials and they also demonstrate no statistically significant difference between measurements made by radiometric or AMS techniques. Copyright © 2002 John Wiley & Sons, Ltd.

The Use of ACE‐Inhibitors after Myocardial Infarction

Background: There is good evidence that angiotensin‐converting enzyme (ACE)‐inhibitors are beneficial after myocardial infarction (MI). However, it is not known how widely this evidence is used in practice and whether all eligible patients receive this therapy.Aim: To assess the usage of ACE‐inhibitors in patients after MI in a large teaching hospital.Method: A one‐month prospective analysis, combined with a three‐month retrospective analysis, was conducted at the Royal Brisbane Hospital (RBH) in February‐March 2000. Patients admitted with an MI or who had been diagnosed with an MI during admission from November 1999 to March 2000 were identified from the coronary care unit (CCU) records. Inpatient medication charts and outpatient records were then reviewed. Information collected included: ACE‐inhibitor use, doses, reasons for prescribing/not prescribing ACE‐inhibitors, and ACE‐inhibitor prescribers (cardiologists or general physicians).Results: Forty‐four patients with an MI were included in the study, 28 of whom were prescribed ACE‐inhibitors (64%). Twenty‐four of the 28 patients on ACE‐inhibitors were prescribed perindopril. The major reason given for prescribing ACE‐inhibitors was signs of congestive cardiac failure. All ACE‐inhibitors initiated in patients after MI at RBH were ordered by cardiologists.Conclusion: ACE‐inhibitors were prescribed appropriately in 88% of patients who met criteria for their use. This high percentage of appropriate prescribing was encouraging. Re‐evaluation as part of an ongoing quality assurance activity could be used to ensure this is maintained.

Quality assurance and radiofrequency heating.

This paper proposes an inexpensive means of assessing radiofrequency (RF) power deposition in a magnet. This is particularly important at 3T where sequences approach Food and Drug Administration approved RF limits. It will also be of interest to operators at 1.5 T as part of their ongoing quality assurance programs. At 3T, we found that the RF power deposited in the magnet was less than that read by the MR power monitor.

Sequential analysis for quality control in the neonatal intensive care unit

Objective: This article describes a novel application of a statistical technique for continuous quality assurance in the NICU. Methods: We used prospective analysis of rates of survival to 28 days of life, without major IVH in ELBW infants in a single tertiary NICU, before and after the introduction of an evidence-based treatment protocol. By using the CUSUM function, each infant's results were sequentially plotted, and significant changes in outcomes were noted when the plot crossed predetermined boundary lines. Results: Significant changes in outcomes were evident with this method sooner than traditional analyses on the basis of year-end or other arbitrary intervals. The introduction of the ELBW protocol was temporally associated with significant improvement in intact short-term survival. Conclusion: Sequential analysis techniques are useful tools for ongoing quality assurance; deviations in outcomes may be detected more quickly, which should assist in the identification of improvements or decrements in performance of the NICU. (J Pediatr 2001;139:778–84)

Prehospital Resuscitative Thoracotomy for Cardiac Arrest after Penetrating Trauma: Rationale and Case Series

The purpose of this study is to present the rationale for an algorithm that describes the place of resuscitative thoracotomy in the prehospital management of a patient with penetrating chest injury, and to review a 6-year experience using this algorithm. This study was a retrospective review of all cases where a prehospital thoracotomy was performed by the medical teams of the London Helicopter Emergency Medical Service. Thirty-nine prehospital thoracotomies were performed. Four (10%) patients survived, one with long-term disability. Factors associated with survival were stab wound, single cardiac wound, cardiac tamponade, and loss of pulse in the presence of an experienced prehospital doctor. Current evidence suggests that patients who suffer a cardiac arrest more than 10 minutes away from emergency room thoracotomy are very unlikely to survive. Prehospital thoracotomy is associated with a small number of survivors. This intervention should be considered if there is an appropriately experienced, trained, and equipped doctor present, who is acting within a trauma system with ongoing training and quality assurance.

T HE E MOTIONAL C ONTENT AND C OOPERATION S CORE IN E MERGENCY M EDICAL D ISPATCHING

Background. A common belief regarding scripted-protocol-driven emergency medical dispatch is that the caller is “too hysterical” or “too uncooperative” to allow a structured interrogation or to receive and act upon dispatch life support instructions. Objectives. To examine the emotional content and cooperation scores (ECCSs) of callers in more than 6,000 cases from two communication centers and to investigate the relationships between ECCS and caller party, incident nature, time of day, and geographical location. Methods. The ECCS has five levels: 5, uncontrollable, hysterical; 4, uncooperative, not listening, yelling; 3, moderately upset but cooperative; 2; anxious but cooperative; and 1, normal conversational speech. The authors tabulated the ECCS as recorded during case review for a random sample of each center's ongoing quality assurance programs. Statistical tests were used to identify the presence of relationships between ECCS and caller party, arrest'nonarrest situations, time of day, and geographical location. Results. Regardless of the caller party, the type of call, the time of day, or the geographical location, the mean ECCS of emergency callers is extremely low, indicating that most emergency callers are, in fact, very calm. The average ECCS computed from more than 3,000 cases from British Columbia was 1.05; the average score from almost 3,500 cases from New York State was 1.21. Conclusion. While relationships between ECCS and the different parameters were noted, the differences were so small as to be of little or no use as additional information to assist with complaint triage. The low overall ECCS shows that the typical caller who requests emergency medical assistance is calm enough to be interrogated in a scripted and structured fashion, and is cooperative enough to be responsive to dispatch life support instructions.

Cardiac tamponade in the “new device” era: Evaluation of 6999 consecutive percutaneous coronary interventions

Background The incidence of cardiac perforation and pericardial tamponade appears to be increasing in the era of new coronary interventional devices compared with coronary balloon angioplasty. Methods and Results We reviewed 6999 consecutive percutaneous coronary interventions performed during 1994 to 1996 in a single urban university hospital catheterization laboratory. Data had been collected prospectively as part of an ongoing quality assurance program. Fifteen patients had cardiac tamponade within 36 hours of the procedure. Only 6 of these occurred during the interventional procedure; the others occurred 2 to 36 hours later. The median patient age was 72 years. Nine (60%) patients were female. Three patients received abciximab. Five perforations were at the target coronary artery site, 3 were caused by a guide wire tip in the distal part of the target artery, and 7 represented right ventricular perforations caused by a temporary pacemaker wire. Five of the 7 right ventricular perforations occurred during rotational atherectomy procedures. Diagnosis was aided by immediate echocardiography. Treatment was medical, including pericardiocentesis, in 6 cases. The other 9 patients required surgical drainage and repair. All patients survived the index hospitalization. At 18-month follow-up, 1 patient had died, and all others were without apparent sequelae. Conclusions Tamponade after percutaneous coronary intervention is not rare in the “new device” era (overall incidence 0.2%); tamponade after percutaneous coronary intervention is often delayed and may occur outside the catheterization suite; patients are more likely to be female and elderly; immediate echocardiography is an essential aid to diagnosis and prompt treatment; and the use of temporary right ventricular pacing catheters must be reexamined. (Am Heart J 2000;140:279-83.)

The effect of organized systems of trauma care on motor vehicle crash mortality.

Despite calls for wider national implementation of an integrated approach to trauma care, the effectiveness of this approach at a regional or state level remains unproven. To determine whether implementation of an organized system of trauma care reduces mortality due to motor vehicle crashes. Cross-sectional time-series analysis of crash mortality data collected for 1979 through 1995 from the Fatality Analysis Reporting System. All 50 US states and the District of Columbia. All front-seat passenger vehicle occupants aged 15 to 74 years. Rates of death due to motor vehicle crashes compared before and after implementation of an organized trauma care system. Estimates are based on within-state comparisons adjusted for national trends in crash mortality. Ten years following initial trauma system implementation, mortality due to traffic crashes began to decline; about 15 years following trauma system implementation, mortality was reduced by 8% (95% confidence interval [CI], 3%-12%) after adjusting for secular trends in crash mortality, age, and the introduction of traffic safety laws. Implementation of primary enforcement of restraint laws and laws deterring drunk driving resulted in reductions in crash mortality of 13% (95% CI, 11%-16%) and 5% (95% CI, 3%-7%), respectively, while relaxation of state speed limits increased mortality by 7% (95% CI, 3%-10%). Our data indicate that implementation of an organized system of trauma care reduces crash mortality. The effect does not appear for 10 years, a finding consistent with the maturation and development of trauma triage protocols, interhospital transfer agreements, organization of trauma centers, and ongoing quality assurance.

Clinical impact of dosimetry quality assurance programmes assessed by radiobiological modelling of data from the thermoluminescent dosimetry study of the European Organization for Research and Treatment of Cancer

The European Organization for Research and Treatment of Cancer (EORTC) Radiotherapy Group initiated its mailed thermoluminescence dosimetry (TLD) programme in 1986. The aim of the present study was to evaluate the clinical relevance of variations in beam output detected in the period 1993 to 1996. A total of 140 beam outputs were checked (26 for cobalt-60 units and 114 for linear accelerators) in 35 centres. Clinical dose–response data for tumour control and normal tissue morbidity were used to assess the variation in clinical outcome resulting from variability in beam output. For 75 checked beams with nominal accelerating potentials (n.a.p.) of 6 MV or less the mean ratio, ± standard deviation (S.D.) of measured to stated output was 1.004±0.020. For 65 beams with n.a.p. of 8 MV or more, the ratio was 1.009±0.021. Even with this relatively high level of precision, broad distributions of estimated tumour control or normal tissue morbidity were found. In the 10% of the beams with the most pronounced underdosage, the loss in tumour control probability was estimated at 7–8 percentage points. Likewise, in the 10% of the beams with the most pronounced overdosage, the increase in mild/moderate morbidity was 19–22 percentage points. For severe morbidity the same beams raised the estimated incidence of severe complications from 5% to 9–10%. An estimation of the loss of uncomplicated cure probability was about 1% for both high and low energy beams. Sequential mailings considerably improved the uniformity of clinical outcome. We conclude that small deviations in beam output may lead to clinically important variations in outcome. Substantial reductions in the variation between measured and stated output can be achieved by sequential mailings. Mailed TLD checks should be an integral part of a continuously ongoing quality assurance activity in radiotherapy.