Part Of Clinical Audit Research Articles

Auditing the microbiological quality of the air in operating theatres.

The critical relationship between airborne microbiological contamination in an operating theatre and surgical site infection (SSI) is well known. The aim of this annotation is to explain the scientific basis of using settle plates to audit the quality of air, and to provide information about the practicalities of using them for the purposes of clinical audit. The microbiological quality of the air in most guidance is defined by volumetric sampling, but this method is difficult for surgical departments to use on a routine basis. Settle plate sampling, which mimics the mechanism of deposition of airborne microbes onto open wounds and sterile instruments, is a good alternative method of assessing the quality of the air. Current practice is not to sample the air in an operating theatre during surgery, but to rely on testing the engineering systems which deliver the clean air. This is, however, not good practice and microbiological testing should be carried out routinely during operations as part of clinical audit.

Profile and mortality outcome of patients admitted with cryptococcal meningitis to an urban district hospital in KwaZulu-Natal, South Africa.

IntroductionCryptococcal meningitis (CCM) is one of the leading causes of early mortality among HIV-infected patients. This study was a part of clinical audit [1] aimed at improving care for patients with CCM at an urban district hospital in South Africa.MethodsClinical records of all patients (age>13 years) admitted to the hospital with a diagnosis of CCM (based on a positive India ink, positive cryptococcal latex agglutination test (CLAT) or a positive culture of Cryptococcus neoformans) between June 2011 and December 2012 were retrospectively reviewed. Descriptive statistics and Chi-square analysis were generated with Epi Info 7.1.2.0. 95% confidence intervals were reported where appropriate.ResultsOf the 127 patients admitted with CCM, only 97 (76.4%) knew their HIV status. Only 44.8% (43/96) of those who knew they were HIV positive were on antiretroviral therapy (ART). Seventeen out of 25 patients (68%) previously treated for CCM had defaulted fluconazole and only 60% (15/25) were on ART. Acute mortality (death within 14 days of CCM diagnosis) was 55.9% (71/127). The median time to death from diagnosis was four days (IQR 2–9). The association between CSF WBC count<20cells/mL and increased risk of death within 14 days was statistically significant (OR 2.2; 95% CI 1.1–4.6, p=0.03). Patients with heavy cryptococcal burden (reported as numerous yeasts seen on microscopy) at diagnosis were three times more likely to die within 14 days of diagnosis of CCM (OR 3.2; 95% CI 0.9–10.7, p=0.06). Even though a CD4 count<100cells/mm3 was associated with a 1.6 times increased acute mortality risk, the association was not statistically significant (OR 1.6; 95% CI 0.6–4.6, p=0.3). The role of elevated CSF opening pressure at diagnosis was not assessed because only two (1.6%) patients had their baseline opening pressure measured.ConclusionsAcute CCM-related mortality remains high. The number of patients who do not know their HIV status, the number of HIV positive patients not on ART, the high level of non-adherence to fluconazole and the proportion of patients not on ART after at least one previous CCM episode all point to the need of developing comprehensive strategies aimed at encouraging HIV testing and improving patient's retention in HIV care and support.

Functioning as a team? The role of NCEPOD reports in clinical risk management

Since 1990, the National Confidential Enquiry into Perioperative Deaths (NCEPOD) has published a total of 14 reports. These are intended to assist clinical staff in applying the lessons learned from the analysis of post‐operative deaths to help prevent future incidents. However, anecdotal evidence suggests that the dissemination of this information does not always take place. Access to these reports should be encouraged and perhaps considered more formally during surgical training. Their use is also advocated in the multidisciplinary setting and as part of clinical audit. Unacceptable standards of medical record keeping are frequently highlighted in the NCEPOD reports. All health‐care professionals have a responsibility to raise these standards such that clinical documentation conforms with a basic acceptable standard that does not compromise patient care. Risk managers should also make use of the NCEPOD reports in meeting the requirements of Clinical Negligence Scheme for Trusts (CNST) standards.