Repeat Audit Research Articles

226 Staff Knowledge of Orthostatic Hypotension

Abstract Background The prevalence of orthostatic hypotension increases with age(1). The aim of this audit was to assess healthcare provider’s knowledge of identifying and measuring orthostatic hypotension (OH) in the acute setting. Early identification and management of OH is an important step to prevent adverse outcomes and improve patient’s overall functional performance. Methods Fifty-one questionnaires were distributed to a random selection of non-consultant doctors and nurses in our hospital. The questionnaires included questions regarding basic knowledge of OH and its measurement. Questions were based on international guidelines on the appropriate measurement and assessment of OH(1). An education session was then offered to junior doctors and nurses, and subsequently carried out by a senior nurse. Staff were educated on OH and how to correctly assess it. Doctors and nurses were subsequently reassessed using the same questionnaire. Results Initial results showed that many of the respondents were interns (37%) and nurses (35%). 94% of respondents had never received formal training in the evaluation of OH. 51% knew that a patient should lie supine for 5 minutes prior to initial BP assessment. 61% knew to take the BP at 1-minute post standing, and 45% knew that the BP should again be taken at 3 minutes. 71% knew to take the pulse alongside the BP checks. The education sessions and repeat audit are ongoing. Conclusion Many of the hospital staff who assess for OH have not received specific training on how to evaluate and diagnose OH. It is our aim to educate front line staff as to the importance of looking for OH and how to diagnose it.

Reassessing standards of vascular access device care: a follow-up audit.

This article reports on the findings of a repeat audit of vascular access devices (VADs) in a district general hospital undertaken 4 years after a previous audit. The first demonstrated poor standards of care and low compliance with evidence-based guidelines, indicating that a change in practice was necessary. A strategy of training, education and standardisation for intravenous devices was introduced, with the goal of transforming practice to raise standards and improve compliance. The findings of the follow-up audit show that the strategy has been successful in raising standards of care and reducing infections.

An Audit to Verify a Key Performance Indicator: Secondary Prevention Medication Prescription: Registry Versus Real-World Rates Post-Acute Coronary Syndromes

Background: The proportion of patients with acute coronary syndromes (ACS) in Waikato District Health Board (WDHB) in 2018 who met the Composite Post-ACS Secondary Prevention Medication indicator (Meds Indicator) was observed on the All New Zealand Acute Coronary Syndrome Quality Improvement [ANZACS-QI] registry to be 64.9% (n = 314/484). The purpose of this audit was to investigate the difference between the registry-reported rates and key performance indicator target rates (>85%) for Meds Indicator adherence. Method: A retrospective analysis of those not meeting the Meds Indicator in the ACS Registry was conducted for all patients with ACS domiciled in WDHB between 1 January and 31 December 2018 (as recorded by ANZACS-QI) and who initially presented to any WDHB hospital (Taumaranui, Te Kuiti, Tokoroa, Thames, and Waikato). Results: After excluding deceased patients and repeat entries, the adjusted Meds Indicator compliance rate was 64.3% (n = 304/473). After the remaining 169 patient discharge summaries and primary care records had been audited, 57 patients were found to have been incorrectly captured, giving a corrected compliance rate of 76.3% (n = 361/473). Conclusion: This audit demonstrates the difference between registry and real-world rates of post-ACS secondary prevention medication prescription at WDHB in 2018. Although the corrected compliance rate is much better than initially reported it still falls short of the recommended target. A repeat audit will be undertaken after a review of processes influencing the quality of captured data and instigating a more rigorous discharge process including implementation of a post-ACS checklist.

THUR 156 Safe prescribing of immunosuppression: quality improvement project

BackgroundThe use of immunosuppression therapies in Neurology has extended exponentially since they were first used in the 1970s for myasthenia gravis. However there are no NICE or neurology specific guidelines in this area for Neurologists to refer to in their clinical practice.Method and resultsThis 2014 retrospective case notes audit compared medical documentation to ‘10 key statements’ pertaining to the safe use and monitoring of immunosuppression therapies. This is a framework for clinical practice that was first published by The British Association of Rheumatology and The British Association of Dermatology in 2008.A number of key areas of poor documentation around drug safety, pregnancy and vaccinations were identified and in response generic and drug specific safety ‘check-lists’ and guidelines were produced, to be filled out with all patients, prior to starting therapies.In 2016 following the implementation of the quality improvement project, a repeat audit of patient’s medical notes showed a clear improvement in documentation.ConclusionsDrug specific guidelines led to an improvement in documentation and we believe that this also reflects safer prescribing and improved clinical practice. We are now in the process of developing guidelines to be used throughout the entire Northern Deanery.

The use of radiological tests for the assessment of biliary tree disease at Wye Valley NHS Trust – repeat audit

Category: GI/GU

A repeat audit of primary care management of group A streptococcal pharyngitis in Northland, New Zealand 2016.

INTRODUCTION One of the New Zealand Government's Better Public Services targets was to reduce the rate of acute rheumatic fever (ARF) nationally by two-thirds by 2017. Māori children and young people are disproportionately affected by ARF in the Northland District Health Board region. General practice contributes to ARF prevention in detecting and appropriately treating group A streptococcal (GAS) pharyngitis. An audit in 2012 suggested improvements in adherence to national guidelines were needed. AIM The aim was to reassess general practice adherence to national guidelines for the management of GAS pharyngitis in Northland, New Zealand, following implementation of the national Rheumatic Fever Prevention Programme. METHODS Throat swab and dispensing data were obtained and analysed for children and young people aged 3-20 years who attended general practice in Northland between 1 April and 31 July 2016 and had laboratory-proven GAS pharyngitis. RESULTS Between 2012 and 2016, the number of throat swabs carried out in general practice more than doubled, and amoxicillin was more commonly prescribed. The proportion of GAS pharyngitis patients in general practice not receiving recommended antibiotics, or receiving an inadequate length of treatment or no prescription, has not reduced. There are significant differences in the management of care for Māori and non-Māori patients, with much higher risk of ARF for Māori. Discussion The management of GAS pharyngitis by general practice in Northland remains substandard. Implicit bias may contribute to inequity. Focused engagement with identified subgroups of general practices and practitioners who disproportionately contribute to non-guideline prescribing should be further investigated.

Auditing stillbirths at Lower Umfolozi War Memorial Regional Hospital: A 12-month review.

Although the total number of stillbirths worldwide was estimated at 2.6 million in 2009, there is currently a dearth of literature on stillbirths in developing countries and rural settings, where the majority of such births occur. The 'Hands Up' Mortality and Morbidity Extraction Tool (HUMMET), developed at Lower Umfolozi War Memorial Regional Hospital (LUWMRH) in 2010, outlines a systematic approach to summarising individual cases of adverse perinatal outcomes. To depict the HUMMET form by describing the detailed demographic and obstetric profile of patients who delivered a stillborn infant at LUWMRH, as well as risk factors associated with these stillbirths between 1 April 2014 and 31 March 2015. The findings add to a global initiative advanced by the Lancet series on stillbirths, aimed at raising awareness of stillbirth statistics in low- and middle-income countries. A total of 310 detailed stillbirth case summaries of 305 patients were collected during the study period, representing 90% of the total number of stillborn infants delivered at LUWMRH. A retrospective audit of the HUMMET forms was conducted and the cases were further summarised in a Microsoft Excel spreadsheet that allowed for a univariate analysis of the variables. The stillbirth rate at LUWMRH is much higher than that at other regional hospitals owing to the number of at-risk referrals and emergency cases from surrounding clinics and district hospitals. Referrals were from local clinics (49%) and district hospitals (45%), 35% of stillbirths were due to abruptio placentae and a large proportion were associated with gestational hypertension, pre-eclampsia and/or eclampsia. Avoidable factors were predominantly a late patient response to reduced fetal movements and delays in transfer to hospital. Twenty percent of stillbirths were associated with inappropriate monitoring or management of the obstetric condition at the district hospital. The HUMMET form provides a systematic approach to analysing cases of perinatal morbidity and mortality in line with the requirements of the Perinatal Problem Identification Programme database, but provides more details on the circumstances and contributing factors. A repeat audit is recommended to determine whether interventions have been effective.

Use of audit, feedback and education increased guideline implementation in a multidisciplinary stroke unit

BackgroundThe audit-feedback cycle is a behaviour change intervention used to reduce evidence-practice gaps. In this study, repeat audits, feedback, education and training were used to change practice and increase compliance...

Creating an integrated tracheostomy care pathway for patients in an Irish regional hospital setting - the feasibility and effectiveness of a dedicated tracheostomy team

Introduction: Temporary tracheostomy is increasingly used earlier in the management of the general critical care population. With rising numbers of temporary tracheostomies, more patient are being transferred from the Intensive Care Unit (ICU) to general wards, so the care pathway for inpatients has to be considered in both ICU and ward environments (Paul, 2010). International guidelines emphasise that the timely involvement of the multidisciplinary team (MDT) is essential for the good aftercare of patients with a tracheostomy (Global Tracheostomy Collaborative). A number of studies have documented the benefits of a dedicated or outreach tracheostomy MDT to support patient care and weaning from tracheostomy. Reduction in length of stay, time to decannulation, and incidence of adverse events have been reported. Impacts on quality of patient care have not been well documented (Garruba, Turner & Grieveson, 2009). In the Irish context, dedicated tracheostomy teams are less common in regional hospital settings. Little is known about their potential to improve patient outcomes. Objectives: The aim of this project was to: 1. Explore the feasibility of creating a dedicated tracheostomy team in an Irish regional hospital setting 2. Examine the potential for this team to improve outcomes and experience for patients with temporary tracheostomy in a regional hospital setting Method: With the support of a local quality improvement forum, a process mapping exercise was completed examining the journey for the patient with a temporary tracheostomy in a regional hospital setting. An audit of patient charts was completed, and outcomes at various stages of the patient journey were documented. Potential points for co-ordination of MDT care along the patient journey were identified, based on a comparison with international guidelines. A dedicated tracheostomy team was convened, based on need identified from audit findings, and staff resources available. The team consisted of Consultant Intensivist, Physiotherapy, Speech & Language Therapy, Intensive Care Nursing, and Respiratory Nursing. A once weekly MDT tracheostomy ward round was established. Repeat audit of patient charts was completed to evaluate the impact of above. Results: It is feasible to create and maintain a dedicated tracheostomy team in this regional hospital setting. Challenges were encountered, particularly in relation to availability of staff, but these can be addressed through planning and flexibility. The implementation of the team and ward rounds led to improvements in: - clarity of plan for weaning and decannulation - cuff management - time to assessment for basic communication support - time to assessment for speaking valve - time to swallow assessment Conclusion: A dedicated tracheostomy team can contribute to improvements in quality of care for the patient with temporary tracheostomy in a regional hospital setting. Due to the heterogenity of this clinical population, a larger sample size is required to explore its effectiveness, with regards to reducing length of hospital and ICU stay. Process mapping is a useful form of clinical audit. In this instance, multiple potential points for co-ordination of MDT care along the patient journey were identified, which could be addressed with further quality measures going forward.

P004 Prospective comparison of charcoal swabs versus near-patient direct culture plate inoculation for the culture of gonorrhoea in high-risk patients. a repeat audit

IntroductionGonorrhoea culture is required to monitor antibiotic resistance and is recommended for all patients known or suspected to be infected. In July 2016 a retrospective comparison of near-patient direct plating and transported charcoal swabs found that the culture positive rate was 24% lower for charcoal swabs. Since this audit, the laboratory service implemented an urgent transport system for charcoal swabs, in order to improve the reliability of this method.MethodsBetween July 2016 and January 2017 all patients who had a positive GC NAAT or were otherwise at high risk had two culture swab specimens taken from the infected site (cervical, male urethra, rectum, pharynx): 1. a charcoal swab sent to the laboratory for plating within two hours and 2. specimen directly plated onto VCAT GC selective agar.ResultsOf 139 positive NAATs across all sites, 47 were followed by both direct plating and charcoal swab. Of these 47 pairs of cultures, there were only 2 discrepancies between culture types (one with direct plating positive, charcoal negative, the other vice-versa).Abstract P004 Table 1Culture +ve rate by method and siteSiteCervixUrethraPharynxRectumTotalNo. of positive NAATs28503625139No. of patients in whom both methods of culture/transport used5249947No. (%) +ve by direct plate4 (80%)21 (88%)2 (22%)7 (77%)34 (72%)No. (%) +ve charcoal swab4 (80%)21 (88%)2 (22%)7 (77%)34 (72%)DiscussionWith the implementation of the new urgent transport system, there is no difference in the culture positive rates of direct plating versus charcoal swabs for GC culture. Provided the same high standards of transport are maintained, a change in practice, moving to charcoal swabs transported to the lab for GC culture and stopping direct plating, is recommended.

Breast magnetic resonance imaging: are those who need it getting it?

Indications for breast magnetic resonance imaging (mri), a very sensitive but less-specific tool for breast investigation, remain controversial, and accessibility is limited. The purposes of our study were to determine the proportion of breast mri exams performed for various clinical indications, to assess the wait times for breast mri, and to create a list of evidence-based indications for breast mri. The indications for breast mri exams performed in September 2013 at our academic centre were audited. A multidisciplinary meeting held in May 2014 established a list of evidence-based indications for breast mri, after which, in September 2014 and 2015, breast mri exams were re-audited for clinical indications, and pending requests were calculated. In September 2013, surveillance of women with a prior diagnosis of breast cancer represented 21% of breast mri exams (24 of 113), with preoperative staging representing 18% of exams (20 of 113) and high-risk screening representing 12% (13 of 113). Of pending mri requests, 230 were within the recommended delay period, and 457 exceeded the recommended delay. After elaboration of evidence-based guidelines, repeat audits in September 2014 and September 2015 showed that mri performed for women with a prior breast cancer diagnosis represented 23% (33 of 141) and 7% (10 of 143) of exams respectively, with preoperative staging having declined to 9% (13 of 141) and 11% (16 of 143) of exams, and high-risk screening having increased to 36% (51 of 141) and 46% (66 of 143) of exams. Overall, wait times were improved for all breast mri indications. Through multidisciplinary discussion, we actualized a list of breast mri indications, prioritized requests more adequately, and improved wait times.

P2.07-010 Hospital Readmission Rates within 30 Days Following Thoracic Oncology Surgery: Topic: Research, Audits

Readmission after thoracic surgery is not well documented. It impacts on patients’ physical and psychological wellbeing, whilst also increasing healthcare costs. The Thoracic Enhanced Recovery programme at Papworth Hospital (a regional cardio-thoracic centre) has reduced average length of stay from 12 days (2010) to 5 days (2014). The lung cancer nurse specialists (LCNS) were concerned that a shorter length of stay may increase the incidence of readmission. An audit was undertaken to determine the number of thoracic oncology surgical patients readmitted within 30-days of discharge. From 1st April 2015 to 31st July 2015 all surgical patients were contacted by a LCNS 30 days following discharge. A formic questionnaire including demographic, socioeconomic, surgical factors and readmission details (if appropriate) was completed. 74 patients underwent surgery, 68 (92%) completed the questionnaire. Of these 11 (16%) were never smokers, 45 (66%) ex-smokers, 12 (18%) current smokers. Lobectomy was the most common operation 45 (66%). Video-Assisted Thoracoscopy (VATS) accounted for 72% of all operations. 60/66 (91%) felt ready for discharge, 9/68 (13%) were discharged home with a pleural drainage system, 40/64 (63%) were aware to contact LCNS for advice. Average length of stay 6.6 days, thoracotomy 7.5 days, current smokers 9 days, patients readmitted 10 days. 30-day readmission rate was 13/68 (19%) of these 9 (69%) were readmitted within 7 days. Initially our concern was that a shorter length of stay may increase the incidence of readmission. However our findings showed that a longer length of stay (and current smoking status) was associated with an increased risk of readmission. This audit therefore suggests that enhanced recovery at Papworth Hospital is a safe and effective practice. Recommendations:•Review patient education / encourage patient self-referral for advice.•Improve discharge planning / communication with the community.•Establish a smoking cessation clinic / telephone service.•Implement a thoracoscore to accurately identify and target the highest risk patients.•Repeat audit over a longer period.

Improving the management of acute coronary syndrome for Aboriginal and non‐Aboriginal patients in a regional hospital

ObjectivesTo determine inequities in clinical adherence to national diagnostic and management guidelines for acute coronary syndrome (ACS) for Aboriginal and non‐Aboriginal ACS patients at a regional hospital. MethodsCovering two study periods (2011–12; 2013–14), records of Aboriginal (n=276) and a random selection of non‐Aboriginal patients (n=333) presenting to the Emergency Department with chest pain were retrospectively reviewed using an audit protocol. Groups were compared using logistic regression, controlling for age, sex and comorbidity. ResultsPathway utilisation improved overall, but risk stratification improved only for non‐Aboriginal patients (OR=3.34, 95%CI 1.88–5.94). Performance of two troponin measurements increased to 88% for both Aboriginal and non‐Aboriginal presentations. Although initially higher for non‐Aboriginal presentations, the likelihood of admission was found to be similar in the repeat audit (75.6% vs 78.6%; p=0.60), reflecting a rise in Aboriginal presentations being admitted (OR=2.30, 95%CI 1.27–4.15). There was no significant difference in proportions transferred, receiving angiograms or for ST Elevation Acute Coronary Syndrome (a severe form of Acute Coronary Syndrome) being thrombolysed. Discharge against medical advice remained higher among Aboriginal presentations (OR=4.22, 95%CI 0.88–20.29). Conclusions and implicationsAlthough there was a general improvement in adherence to the chest pain pathway and a reduction in inequity in the treatment of Aboriginal people, there is continuing need for improvement in adherence to guidelines to optimise the management of ACS in this regional setting.

Monitoring antipsychotic side effects: a competed audit cycle conducted in a secure hospital

Purpose – The purpose of this paper is to describe a completed audit cycle of the assessment and documentation of antipsychotic side effects reported by patients in a secure hospital setting. Design/methodology/approach – The initial audit was carried out in 2012. As a result of the findings clinicians were recommended to use a brief structured side effect monitoring guide (the Glasgow Antipsychotic Side-Effect Scale (GASS-m)). The audit was repeated in 2015. Findings – Of the 41 patients notes included in the initial audit, for only one (2.4 per cent) was there evidence of a systematic and structured approach to monitoring antipsychotic side effects. In the repeat audit this figure (and use of the GASS-m) had increased to 21/45 (46.7 per cent). For all patients where the GASS-m had been used (n=21) the overall severity of side effects was in the “mild” range (0-21). Research limitations/implications – Sample size was modest and the study was conducted in an independent secure hospital so may not be generalisable to the NHS. Practical implications – Use of structured tools/guides to monitor patients’ side effects is recommended so that emergent side effects can be readily recognised, tracked and managed and, relapses made less likely through improved compliance and thus patients’ quality of life improved. This is very important for forensic patients since relapses are likely to increase risk to others. Originality/value – Previous audits have addressed physical health monitoring of patients on antipsychotics but not by asking them about side effects.

PWE-145 Incorporating Screening for Poor Prognosis Into Inpatient Management of Decompensated Cirrhosis

Introduction The Lancet standing commission on liver disease recently highlighted the importance of palliative care in advanced liver disease. The end of life care strategy (DoH, 2008) noted many patients do not die in a place of their choosing, and that difficulties exist amongst physicians in identifying the dying process. Optimal provision and co-ordination of palliative care relies on timely recognition of poor prognosis. 90% of patients who die from liver disease are admitted to hospital at least once in the previous year. Hospital admission presents an important opportunity to assess prognosis and explore patients’ understanding of their risk of dying and preferences for care. This quality improvement project aimed to create a clinical framework through which screening for poor prognosis could be integrated into the routine inpatient management of patients with decompensated cirrhosis. Methods An inpatient Poor Prognosis Screening Tool (PPST - incorporating assessment of disease severity, WHO performance status, frequency of admission, and suitability for transplantation) was developed at University Hospitals Bristol in 2013. Based on retrospective data, a positive PPST screen predicted death at 1 year with a sensitivity of 81%. Initial audit identified infrequent use of the existing PPST (18.1%). A series of 5 quality improvement cycles (plan-do-study-act) were completed with input from consultants, junior medical and nursing staff at each stage. Ease of use and incorporation into routine practice were used as primary objectives. Results The weekly ward MDT was identified as a point where the PPST could be routinely incorporated. Following feedback from junior staff the PPST was simplified and embedded into a weekly written MDT proforma. Guidance for completion were streamlined and made accessible by printing on the reverse of the proforma. Following feedback from nursing staff the proforma sheet was coloured, allowing key discussions and decisions to be easily identified on subsequent admissions. Consultants chairing the MDT incorporated the PPST into the standard weekly discussion of each patient. Repeat audits demonstrated that PPST use had become routine with completion rates of 66–94% for patients with decompensated cirrhosis. Conclusion Assuming MDT agreement, a positive PPST screen triggers a consultant led poor prognosis discussion with the patient, a poor prognosis letter to the GP, and involvement of the palliative medicine team to assist with symptom control and advance care planning. Through incorporation of the PPST into the routine care of patients with decompensation, identification of patients with end-stage disease has improved. Better access to appropriate services and support, and improved co-ordination of community care can be subsequently afforded to appropriate patients. Disclosure of Interest None Declared

SU‐F‐T‐237: The Imaging and Radiation Oncology Core (IROC) Cooperatives Activities Supporting the NCI's National Clinical Trial Network

Purpose:The Imaging and Radiation Oncology Core (IROC) Cooperative has been active for the past two years supporting the National Clinical Trial Network and the details of that support are reported.Methods:There are six QA centers (Houston, Ohio, Philadelphia‐RT, Philadelphia‐DI, Rhode Island, St. Louis) providing an integrated RT and DI quality control program in support of the NCI's clinical trials. The QA Center's efforts are focused on assuring high quality data for clinical trials designed to improve the clinical outcomes for cancer patients worldwide. This program is administered through five core services: site qualification, trial design support, credentialing, data management, and case review.Results:IROC currently provides core support for 172 NCTN trials with RT, DI and RT/DI components. Many of these trials were legacy trial from the previous cooperative group program. IROC monitors nearly 1800 RT photon and 20 proton institutions. Over 28,000 beams outputs were monitored with 8% of the sites requiring repeat audits due to beam out of criteria. As part of credentialing, 950 QA phantoms have been irradiated, 515 imaging modalities evaluated and almost 4000 credentialing letters have been issued. In just year 2, 5290 RT and 4934 DI patient datasets were received (many using TRIAD) by IROC QA Centers to be prepared for review. During the past 2 years, a total of 6300 RT cases and 19,000 DI image sets were reviewed by IROC technical staff. To date, IROC has published 36 manuscripts.Conclusion:The QA services provided by IROC are numerous and are continually being evaluated for effectiveness, harmonized across all NCTN Groups and administered in an efficient and timely manner to enhance accurate and per protocol trial data submission. These efforts increase each NCTN Group's ability to derive meaningful outcomes from their clinical trials.This work was supported by DHHS NIH grant 5U24CA180803

Bringing provincial improvements to oral chemotherapy prescribing through co-ordinated regional initiatives.

107 Background: Oral chemotherapy delivery is complex, making safe medication practices a high priority. Cancer Care Ontario, the provincial government agency responsible for continually improving cancer services in Ontario, undertook a jurisdiction-wide quality improvement initiative to ensure that all oral chemotherapy drugs are prescribed using Computerized Prescriber Order Entry (CPOE) or standardized Pre-printed Orders (PPO). The initiative was further enabled by changes to the provincial funding approach that flows facility funding for oral chemotherapy delivery. Methods: All 35 facilities prescribing chemotherapy in Ontario across 14 regions implemented strategies to work towards the common aim of reducing handwritten/verbal oral chemotherapy prescribing to zero by June 30th, 2015. Baseline audits were completed between Sept-Nov 2014; repeat audits were performed between Mar-May 2015. Each facility reported the number of patients that received an oral chemotherapy prescription, and the method of prescribing. Results: At baseline, 30% of audited prescriptions across the province were handwritten or verbal, which decreased to 9% by June 2015. Improvements were seen in thirteen of the 14 regions. Thirteen out of 35 facilities met the aim of 0 handwritten/verbal orders, with an additional 16 facilities seeing an improvement. Alignment with funding mechanisms, an early physician engagement strategy, and education of key stakeholders on CPOE systems were identified as key enablers to implementation. Conclusions: Though the goal of zero handwritten/verbal prescriptions was not met by all facilities, the initiative encouraged a change in implementing safe prescribing practices for oral chemotherapy. Further audits will assess that the gain was sustained and that the provincial goal is achieved. This initiative is part of a larger strategy to standardize care for systemic treatment patients and promote a culture of safety in hospitals. [Table: see text]

Classification and rates of adverse events in a Malawi male circumcision program: impact of quality improvement training.

BackgroundAssessing safety outcomes is critical to inform optimal scale-up of voluntary medical male circumcision (VMMC) programs. Clinical trials demonstrated adverse event (AE) rates from 1.5 to 8 %, but we have limited data on AEs from VMMC programs.MethodsA group problem-solving, quality improvement (QI) project involving retrospective chart audits, case-conference AE classification, and provider training was conducted at a VMMC clinic in Malawi. For each identified potential AE, the timing, assessment, treatment, and resolution was recorded, then a clinical team classified each event for type and severity. During group discussions, VMMC providers were queried regarding lessons learned and challenges in providing care. After baseline evaluation, clinicians and managers initiated a QI plan to improve AE assessment and management. A repeat audit 6 months later used similar methods to assess the proportions and severity of AEs after the QI intervention.ResultsBaseline audits of 3000 charts identified 418 possible AEs (13.9 %), including 152 (5.1 %) excluded after determination of provider misclassification. Of the 266 remaining AEs, the team concluded that 257 were procedure-related (8.6 AEs per 100 VMMC procedures), including 6 (0.2 %) classified as mild, 218 (7.3 %) moderate, and 33 (1.1 %) severe. Structural factors found to contribute to AE rates and misclassification included: provider management of post-operative inflammation was consistent with national guidelines for urethral discharge; available antibiotics were from the STI formulary; providers felt well-trained in surgical skills but insecure in post-operative assessment and care. After implementation of the QI plan, a repeat process evaluating 2540 cases identified 115 procedure-related AEs (4.5 AEs per 100 VMMC procedures), including 67 (2.6 %) classified as mild, 28 (1.1 %) moderate, and 20 (0.8 %) severe. Reports of AEs decreased by 48 % (from 8.6 to 4.5 per 100 VMMC procedures, p < 0.001). Reports of moderate-plus-severe (program-reportable) AEs decreased by 75 % (from 8.4 to 1.9 per 100 VMMC procedures, p < 0.001).ConclusionsAE rates from our VMMC program implementation site were within the range of clinical trial experiences. A group problem-solving QI intervention improved post-operative assessment, clinical management, and AE reporting. Our QI process significantly improved clinical outcomes and led to more accurate reporting of overall and program-reportable AEs.

Audits show that specialist paediatric training programmes are sensitive to medical, staffing and economic changes.

In Finland, specialist paediatrics training is led by university hospitals, but half of it is carried out in regional central hospitals. We audited the training provided by four regional central hospitals in the tertiary care area covered by Tampere University Hospital, in 2003, 2008 and 2015. The audits comprised hospital visits and discussions with the chief doctor of the paediatric clinic, the trainees and the specialists who trained them. A modified version of the European Union of Medical Specialists 1997 protocol was used, and the key areas that performed poorly in the audits were followed up. In 2008 and 2015, most of the key follow-up issues had improved, but two main areas in need of further development were identified in 2015. These were that educational objectives should be clarified, and their implementation systemically followed up, and that trainees should spend more time working in outpatient settings. Since 2003, a marked improvement had taken place in the paediatric training provided by regional central hospitals, partly because of the increase in paediatric specialist resources. This study underlines the importance of repeat audits and the need for co-opera-tion between the university hospital and regional hospitals, including regular visits.

The Effectiveness of Clinician Education on the Adequate Completion of Laboratory Test Request Forms at a Tertiary Hospital.

Background:Inadequately completed laboratory test request forms contribute to preanalytical errors and limit the advice of pathologists when interpreting laboratory test results. Educating clinicians about this has been proposed by several studies as a strategy to reduce the occurrence.Aim:We aimed to determine the effectiveness of such education on the prevalence of adequately completed laboratory test request forms.Subjects and Methods:This was a quasi-experimental study conducted at the chemical pathology laboratory of the Lagos University Teaching Hospital, Nigeria. Incoming laboratory request forms were audited for a period of 1 month looking out for eight data variables. Subsequently, intensive clinician education was undertaken via seminars, publications, and orientation programs on 670 clinicians for 6 weeks duration. After that, a repeat audit for the same data variables was conducted for another period of 1 month. A Z-test of significance for the comparison of independent proportions was conducted for form errors pre- and post-intervention.Results:Error rates for missing variables pre- and post-clinician education were: Name pre = 0 (0%), post = 0 (0%); age pre = 330 (21.6%), post = 28 (1.9%), P < 0.001; gender pre = 64 (4.2%), post = 53 (3.6%), P = 0.37; hospital number pre = 848 (55.6%), post = 524 (35.3%), P < 0.001; clinician name pre = 165 (10.8%), post = 64 (4.3%), P < 0.001; ward/clinic pre = 311 (20.4%), post = 235 (15.8%), P < 0.01; clinical diagnosis pre = 220 (14.4%), post = 33 (2.2%), P < 0.001; specimen type pre = 169 (11.1%), post = 116 (7.8%), P < 0.01, respectively.Conclusion:There was an improvement in the inadequate completion of laboratory request forms after clinicians were educated on proper completion using various interactive media, showing that it is an effective strategy. However, further studies are required to identify which educational strategy is most effective in reducing error rates in laboratory test request forms.