Serial Audits Research Articles

SURF-COPD: the recording of cardiovascular risk in patients with chronic lung disease.

Cardiovascular disease (CVD) is the leading cause of death in patients with chronic obstructive pulmonary disease (COPD) and such patients tend to carry a heavy burden of risk factors for CVD. There is little information on the documentation and management of CVD risk factors in COPD patients. To audit the recording and management of CVD risk factors in 200 COPD patients attending the respiratory out-patient clinics at two University teaching hospitals. Retrospective analysis of hospital records. While there was reasonable recording of a history of CVD risk factors such as hypertension and hyperlipidaemia, the actual recording of risk factor levels was poor-blood pressure and heart rate were recorded in less than half of subjects; lipids, waist circumference, HbA1c and height were essentially not recorded at all. Best practice guidelines and standard operating procedures for CVD risk factor recording and control require to be developed if the major cause of death in COPD subjects, CVD, is to be addressed. An outline for a standard operating procedure is presented in the Appendix. Serial audits will be required to assess the efficacy of such measures.

Optimisation of intravenous fluid prescribing: framework for changing practice through education and audits.

IntroductionIntravenous fluids are one of the most commonly prescribed drugs in the hospital setting and yet the practice continues to fall short of National Institute for Health and Care Excellence (NICE) guidelines, with significant gaps in staff knowledge exposing patients to heightened morbidity and mortality.AimFollowing the 2013 publishing of updated NICE guidelines on intravenous fluid prescribing, an intravenous fluid team was formed within the Royal Liverpool University Hospital (RLUH). Their role has been (and continues to be) to overhaul the culture of suboptimal intravenous fluid prescribing within the hospital and, ultimately, to improve patient outcomes. A framework to engender this change has been developed and is offered as an example to other Trusts within which improvement of guideline-compliant intravenous fluid prescribing remains stagnant.MethodThere have been three principal stages of the project to this point which are best demonstrated in a chronological manner. The period of 2010–2014 allowed for assessment of the issue of intravenous fluid prescribing and analysis of its causes through serial audits and a staff-wide survey. From 2015, there has been implementation of several measures (educative, managerial, administrative and technological) within the hospital to foster reproducible and positive change with regards to intravenous fluid prescribing. Finally, between 2016 and 2017, three cycles of a rolling audit based on NICE guidelines have been completed to allow measurement of improvement in intravenous fluid prescribing practice.ConclusionResults have demonstrated a significant improvement in the appropriateness of the intravenous maintenance and replacement fluids prescribed in the hospital since the March 2016 audit. Moreover, a 29-fold increase has been observed in the use of 4% dextrose/0.18% sodium chloride as maintenance fluid (gold standard as per NICE guidelines) since the staff-wide survey of 2015. Despite progress however, adherence to NICE guidelines remains below the recommended 100% and therefore further work remains to be done.

Standards of prescription writing in a long-term psychogeriatric unit: a series of clinical audits.

The aim of this study was to improve the quality of prescription writing in a long-term psychogeriatric inpatient unit by a combination of serial audits and interventions designed to address the identified deficiencies. We undertook three clinical audits of the prescription sheets used in an inpatient unit providing continuing care for residents with severe and enduring mental illness and dementia. Based on the findings of the first audit a set of prescribing guidelines was implemented into the ward. Following the second audit a new prescription sheet was developed. The format of the new prescription sheet was designed to account for the needs of the unit and to adhere to Irish and UK best practise guidelines. Two months after its introduction we undertook a third audit. Completion of the drug sensitivity box increased from 25% at audit one to 100% at audit three. Other specific aspects of prescription writing that had been poor at the beginning of the audit cycle also showed improvement: prescribing of generic psychotropic drugs increased by 69% and inclusion of the prescribers Medical Council Registration Number increased by 78%. However, some basic aspects of prescription writing remained weak such as frequency of drug administration and documentation of the stop/review date for 'as required' medication. The results of this study suggest that clinical audit and feedback can improve the quality of prescriptions in an in-patient setting.

Implementing evidence-based practice with normalisation process theory to improve nutritional care in the neonatal intensive care unit

BackgroundPostnatal growth failure is common in preterm infants, and one reason for this growth failure is that nutritional care is often variable and suboptimal. We aimed to improve the nutritional care of extremely preterm infants by implementing evidence-based practice changes and embedding these changes into routine care. Given the challenge that this represents, we used the novel sociological framework of normalisation process theory (NPT), to develop, guide, and assess the implementation process. MethodsWe developed and implemented an evidence-based, complex intervention for the nutritional care of preterm infants, including guidelines, a screening tool, and a multidisciplinary ward round. We compared nutrient intakes and growth in infants born before 30 weeks' gestation or weighing less than 1500 g during 2012 (the intervention period, n=75) with those born in 2009 (pre-intervention period, n=65). The extent to which the new practices were being embedded into routine care was assessed with a bimonthly staff questionnaire based on NPT (n=80), allowing weaknesses to be detected and addressed and making implementation a dynamic process. Serial audits of guideline compliance were also done. Primary infant outcomes were daily energy and protein intake, and mean change in standard deviation scores (SDS) for weight and head circumference between birth and discharge. Linear regression was used to compare cohorts, with adjustment for gestational age and weight at birth. FindingsMean daily energy and protein intakes as a percentage of recommended amounts improved significantly from 2009 to 2012 (energy 89·1% [SD 18·6] and protein 66·9% [20·5] vs 96·7 [18·4] and 78·2 [18·6]; p<0·05 for both). Growth also improved, with the mean change in weight SDS between birth and discharge changing from −0·90 (SD 0·78) to −0·57 (SD 0·75) (p<0·01). Head circumference did not improve significantly. During the intervention period, mean daily protein intake and mean NPT scores improved over time (r=0·88 [p=0·02] and 0·18 [p=0·01], respectively). There was a significant linear association between the mean audit score and the mean NPT score (r=0·22, p<0·01). InterpretationThe intervention succeeded in improving the nutrient intakes and growth of preterm infants. The NPT results show that these practices seem to have become part of routine care over time and suggest that measures of practice change using NPT can be related to measures of guideline compliance in the clinical setting. The findings of this study suggest that NPT offers an effective way of implementing and monitoring complex interventions. FundingNational Institute for Health Research.

Evaluation of a medication order writing standards policy in a regional health authority.

The Winnipeg Regional Health Authority (WRHA) implemented a medication order writing standards (MOWS) policy (including banned abbreviations) to improve patient safety. Widespread educational campaigns and direct prescriber feedback were implemented. We audited orders within the WRHA from 2005 to 2009 and surveyed all WRHA staff in 2011 about the policy and suggestions for improving education and compliance. Overall, orders containing banned abbreviations, acronyms or symbols numbered 2261/8565 (26.4%) preimplementation. After WRHA-wide didactic education, the proportion declined to 1358/5461 (24.9%) (p = 0.043) and then, with targeted prescriber feedback, to 1186/6198 (19.1%) (p < 0.0001). A survey of 723 employees showed frequent violations of the MOWS, despite widespread knowledge of the policy. Respondents supported ongoing efforts to enforce the policy within the WRHA. Nonprescribers were significantly more likely than prescribers to agree with statements regarding enhancing compliance by defining prescriber/transcriber responsibilities and placing sanctions on noncompliant prescribers. Education, raising general awareness and targeted feedback to prescribers alone are insufficient to ensure compliance with MOWS policies. WRHA staff supported ongoing communication, improved tools such as compliant preprinted orders and reporting and feedback about medication incidents. A surprising number of respondents supported placing sanctions on noncompliant prescribers. Serial audits and targeted interventions such as direct prescriber feedback improve prescription quality in inpatient hospital settings. Education plus direct prescriber feedback had a greater impact than education alone on improving compliance with a MOWS policy. Future efforts at the WRHA to improve compliance will require an expanded focus on incentives, resources and development of action plans that involve all affected staff, not just prescribers. Plans include continued advertising, MOWS summaries in all charts, all-staff education, reminders and exploration of sustainable interventions for targeted feedback for prescribers.

Optimizing Healthcare at the Population Level: Results of the Improving Cardiovascular Outcomes in Nova Scotia Partnership

Disease management is increasingly considered a valid strategy in the chronic care of our aging patient populations with multiple diseases. The Improving Cardiovascular Outcomes in Nova Scotia (ICONS) project examined whether a community-oriented health management partnership would lead to enhanced care and improved outcomes across an entire healthcare system. ICONS was a prospective cohort study, with baseline and repeated measurements of care and outcomes fed back to all project partners, along with other interventions aimed at optimizing care; preceding interval cohorts served as controls to post-intervention cohorts. The setting was the province of Nova Scotia, whose population is approximately 950,000. All 34,060 consecutive adult patients hospitalized in Nova Scotia with acute myocardial infarction (AMI), unstable angina (UA) or congestive heart failure (CHF) October 1997-March 2002 were included. Interventions were a combination of serial audits and feedbacks of practices and outcomes, web-based publication of findings, newsletter-based education and reminders, physician small-group workshops, pharmacy monitoring and compliance programs, care maps, algorithms, discharge forms and patient information cards. Rates of use of evidence-based marker therapies were the primary outcome measure. Secondary measures included one-year, all-cause mortality and re-hospitalization. Evidence-based prescription practices, for all target diseases, continuously and markedly improved over time. At the population level, there were no changes in one-year mortality for any disease state, although use of proven therapies predicted survival at the individual level throughout the five-year period for all disease states. Rates of re-hospitalization decreased significantly for all disease states over the course of ICONS; but most traditional positive and negative predictors of this outcome, like advanced age and use of proven therapies, respectively, were not predictive. ICONS demonstrated that provider prescribing patterns and patient re-hospitalization rates were continuously improved in three disease states and across an entire health system, through a community partnership model of disease management that was sustained over a long time. Further studies are needed to better understand the drivers and modifiers of patient outcomes at the population level.

Improving the quality of written prescriptions in a general hospital: the influence of 10 years of serial audits and targeted interventions

Poor quality prescribing has been identified as one of the leading causes of medication error and adverse drug events. The aim of this study was to improve the quality of written prescriptions in a general hospital by a combination of serial audits and interventions designed to address identified deficiencies. Inpatient medication charts were audited annually from 1998 to 2007. Charts were assessed against predetermined standards for good-quality prescribing. Initially an unacceptable proportion of medication charts failed to document adequately one or more of the following: prescriber identification (58%), legible prescriptions (14%), route of administration (14%), a dose (11%), date (11%) or adequate patient identification (8%). Only 53% of charts had any information about medication alerts and 15% contained at least one verbal order. Interventions designed to address these deficiencies included educational strategies (e.g. feedback of audit results, education sessions for doctors and nurses on prescribing and medication errors) and changes to systems (e.g. modifications to medication charts, development of hospital wide prescribing standards and an alert notification system). Serial audits showed progressive improvements in all items by 2007 including; legibility (97%), patient identification (100%), documentation of date (98%), drug dose (99%) and route (97%), use of medication alerts (98%) and the prevalence of verbal orders (<1%). Identification of prescribers remained suboptimal (81% in 2006, 53% in 2007). Serial audits of the quality of prescribing on hospital medication charts can rapidly identify the extent of deficiencies in prescribing practice, facilitate interventions specifically designed to address these and monitor their influence.

Pain relief for simple procedures in New Zealand neonatal units: Practice change over six years

Newborn infants are routinely exposed to pain. We wanted to see how practice regarding pain relief changed over a 6-year period. Serial audits were carried out of existing practice and attitudes at three points, over a 6-year span, in New Zealand neonatal units. Almost all units agreed that many commonly performed procedures were painful over the 6-year study period. The number of units using analgesia rose markedly over the same period. The fact that a simple, cheap and effective intervention (oral sucrose) has taken more than 6 years to be used routinely in New Zealand highlights the problem of turning evidence into practice.

Unread Tuberculin Tests

Serial audits of tuberculin skin testing at a community teaching hospital indicated an ongoing need for standardization and quality control.