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AIM Benefits of mothers' own milk (MOM) for premature and sick neonates are well documented. To increase access, many neonatal units have a lactation consultant (LC) on staff. This study aimed to assess the impact of a permanent LC on (i) maternal access to LC support; (ii) staff confidence in providing Breast Feeding (BF) education and (iii) provision of MOM. METHODS Study included a staff survey and chart audit. Questions provided feedback on access to lactation support and meeting maternal needs. Audit data included: gestational age, birthweight, intention to breastfeed, documentation of LC appointment, provision of MOM at 12 hours, days 3, 7, 28 and discharge. Student's t-tests were used for numerical data and chi-squared tests for categorical variables. RESULTS Ninety-one staff surveys were returned, (pre 35/75 (47%), post 56/85 (66%) with staff reporting organising an LC appointment was significantly easier (P

The prevalence of security guards in health care settings is growing worldwide. There is a need to explore and understand their role and actions to inform policy and training and support least restrictive practices in health care. The aim of this study was to conduct a retrospective chart audit of security guard logs to investigate security guard involvement in Code Blacks, called in emergency situations of personal threats including patient and/or visitor violence, in medical and surgical wards in a large metropolitan health network in South Australia. Security guards attended 1664 Code Blacks (0.63% of admissions) over the 2.5-year study period. Events were more frequently reported in medical than surgical wards. The most common reasons for security guard attendance were patients threatening/harming staff and patients threatening/harming themselves. The most frequent security guard actions were "Attend only/standby," "Physical restraint," and "Patient located and returned to the ward." The most frequent outcomes were physical restraint, chemical restraint, and de-escalation respectively. Results highlight the imperative that health services maintain and increase efforts to support least restrictive practice through policy directives and staff training.

BACKGROUND Clozapine is the most effective in treatment-resistant schizophrenia. Neutropenia is an adverse effect of the drug requiring treatment discontinuation. This study related treatment continuation with little or no interruption after a neutropenia episode. The study contrasted from rechallenge studies after an extended treatment interruption. METHODS This retrospective chart audit examined 37 patients with an episode of neutropenia. It described characteristics of patients continuing treatment with minimal interruption. FINDINGS Thirty-one patients continued treatment after an initial treatment interruption for less than 3 days. A probable cause for neutropenia other than clozapine was identified in 14 patients. Twelve patients continued treatment with a change in the absolute neutrophil counts threshold to 1000/μL to determine treatment cessation. Most patients recovered from the index episode of neutropenia within 2 days. They also frequently presented with recurring benign episodes of low neutrophil cell counts during treatment than a comparative group. IMPLICATIONS The study recommends modifying clozapine treatment protocol absolute neutrophil count thresholds to less than 1000/μL to determine treatment cessation. Consideration of other probable causes for neutropenia, diurnal variations in cell counts, and laboratory errors reduced preemptive discontinuation of treatment. A risk-benefit approach supports continuing clozapine treatment after an episode of neutropenia.

To improve nurses' comfort in helping laboring woman void on a bedpan after initiation of epidural analgesia, to increase the frequency of bedpan use in the labor and birth unit, and to decrease the use of continuous indwelling Foley catheters during the intrapartum period.Quality improvement project.A single large, midwestern U.S. hospital (3,000 births annually), where bedpans are infrequently used after epidural placement.Registered nurses on a labor and birth unit.A 20-minute educational presentation that included current urinary catheter evidence-based practice, preferential use of bedpans, and methods to help women void successfully was taught to all registered nurses in the author's labor unit. Nurses rated on a scale of 0 (not comfortable at all) to 10 (extremely comfortable) their comfort level at helping a woman with a bedpan. Primary data were collected through a convenience sample of anonymous surveys (n = 52) completed by registered nurses regarding their experience with bedpan and catheter use during labor and their comfort level helping women be successful with voiding. This was followed by a retrospective chart audit for women with term, singleton pregnancies who labored with epidural analgesia.Nurses' comfort levels increased from an average of 5.7 to 7.2 (p = .067). Postepidural bedpan use increased from 5.5% (n = 12) to 19% overall (n = 20; p .001), with five women using bedpans exclusively. When assisted with bedpan use, 38% (n = 12) of women were able to void 34 of the 53 times it was offered (64%). Use of continuous indwelling Foley catheters decreased from 61.7% (n = 137) to 54.7% (n = 58), and use of intermittent catheterization increased from 30.6% (n = 68) to 37.7% (n = 40).When assisted by nurses educated in and comfortable with different voiding techniques, women may be able to avoid medically unnecessary use of urinary catheters during labor.

Objective: To examine the impact of a clinical toxicology service on toxicology patients admitted to an intensive care departmentMethods: The authors performed a retrospective chart audit of all pa...

This study described psychotropic prescription patterns among adults referred to a psychiatric outpatient clinic for individuals with intellectual disability and determined demographic, clinical, and organization-level predictors of receipt of three or more psychotropic medications concurrently (psychotropic polypharmacy).To identify predictors of psychotropic polypharmacy, a retrospective chart audit was conducted for patients with intellectual disability referred (N=517) to a specialized psychiatric outpatient clinic between 2005 and 2013.Seventy percent of patients were prescribed at least one psychotropic medication, and 22% received psychotropic polypharmacy. Women, those living in supervised residential settings, and those with a psychiatric diagnosis in two or more diagnostic categories were more likely to receive psychotropic polypharmacy.Polypharmacy is a significant concern for adults with intellectual disability seeking specialized psychiatric services, with multiple contributors to prescribing practices. Both psychiatrists and family physicians can play a role in the judicious use of medications for this vulnerable population.

INTRODUCTION Specialists in a Maintenance of Certification program are required to participate in assessment activities, such as chart audit, simulation, knowledge assessment, and multisource feedback. This study examined data from five different specialties to identify variation in participation in assessment activities, examine differences in the learning stimulated by assessment, assess the frequency and type of planned changes, and assess the association between learning, discussion, and planned changes. METHODS E-portfolio data were categorized and analyzed descriptively. Chi-squared tests examined associations. RESULTS A total of 2854 anatomical pathologists, cardiologists, gastroenterologists, ophthalmologists, and orthopedic surgeons provided data about 6063 assessment activities. Although there were differences in the role that learning played by discipline and assessment type, the most common activities documented across all specialties were self-assessment programs (n = 2122), feedback on teaching (n = 1078), personal practice assessments which the physician did themselves (n = 751), annual reviews (n = 682), and reviews by third parties (n = 661). Learning occurred for 93% of the activities and was associated with change. For 2126 activities, there were planned changes. Activities in which there was a discussion with a peer or supervisor were more likely to result in a change. CONCLUSIONS AND DISCUSSION Although specialists engaged in many types of assessment activities to meet the Maintenance of Certification program requirements, there was variability in how assessment stimulated learning and planned changes. It seems that peer discussion may be an important component in fostering practice change and forming plans for improvement which bears further study.

Objective To better understand the impact of alcohol consumption on the clinical management of chronic diseases in a regional general practice setting. Methods A retrospective chart audit was undertaken of individual patient records at two large group general practices in Townsville, a regional Australian city. Three common indicator chronic diseases were selected that have clear management guidelines for general practice: type 2 diabetes; chronic obstructive pulmonary disease; and chronic kidney disease. The audits were analysed using SPSS software to examine the association between alcohol consumption on acquisition of clinical management targets and primary disease intermediate outcomes (haemoglobin A1c fraction; per cent of normal forced expiratory volume at one second; and estimated glomerular filtration rate). Results A total of 457 records were audited. Higher‐risk alcohol consumption is associated with reduced ability of patients to reach management targets (F[3,453]=3.68; p=0.012) and decreased standardised primary disease outcome (F[3,403]=2.86; p=0.037). Conclusion Higher‐risk alcohol consumption is associated with reduced attainment of chronic disease management targets and worse chronic disease outcomes. Implications for public health Alcohol consumption should be assessed frequently in people with chronic disease, especially when there is difficulty acquiring management targets or worsening of disease outcomes without a clear explanation. Better education about the potential associations between alcohol use and chronic disease would benefit those managing these complex conditions, both clinicians and patients.

Background: The majority of individuals who have had a mild stroke are discharged home from acute care. Yet, the proportion who are assessed for driving ability and given related recommendations is unknown. Objective: To describe acute care practice related to driving among individuals whose discharge location is home. Methods: A secondary analysis of data from a chart audit was realized in the Province of Quebec, Canada. Data were retrieved from the charts by trained extractors. Evaluation practice was described according to whether the driving assessment was specific or nonspecific to driving (cognitive, perceptual and visual functions). Descriptive statistics were used. Results: The sample consisted of 419 charts of individuals with a mean age of 70.5 ± 13.3 years old. Mean length of hospital stay was 10.3 ± 13.3 days. Specific driving assessment was documented among 26/419 (6.2%) charts while for seven of these, the assessment was considered full. Meanwhile, 92/419 (22.0%) were considered as problematic for driving a vehicle. Nonspecific driving assessment was documented among 70/419 (16.7%), 43/419 (10.3%) and 33/419 (7.9%) of charts for cognitive, perceptual and visual functions, respectively. Charts were characterized by several missing data relating to driving. Conclusion: The proportion of charts documenting driving restriction post-stroke in acute care was very low. Assuming that all driving discussions and referrals were captured in the charts (which may not be the case), our results would indicate an important gap in acute care practice as compared to best practices relating to driving post-stroke.

BackgroundOral dextrose gel is an evidence-based treatment that has been shown to reduce NICU admissions and support exclusive breastfeeding.PurposeWe summarize a knowledge translation project to introduce dextrose 40 percent oral gel to treat hypoglycemia or hyperglycemia. Implementation took place during the months of May, June, and July 2017.ResultsThrough chart audit, rates for NICU admissions and exclusive breastfeeding were measured for a three-month period before implementation and the three-month period after implementation.There were 234 doses indicated, 128 doses given, 93 doses missed, and 13 doses declined by parents in the first three months of implementation. Admission rates to the NICU for the groups audited were 13 percent in 2016 and 6 percent in 2017.Principles of knowledge translation were used to successfully introduce this change. Centers providing maternal newborn care should consider similar projects to enable introduction.

Objective To educate nurses and physicians on changing practice from visual estimation of blood loss to quantification of blood loss (QBL) and to replace estimation of blood loss with QBL for at least 85% of vaginal births during a 3-month period. Design Quality improvement project. Setting/Local Problem A midwestern U.S. urban community hospital with 1,200 annual births, where postpartum blood loss was being measured by using visual estimation. Participants A convenience sample of 43 intrapartum nurses and 17 physicians. Intervention/Measurements A goal was set to use the QBL method for at least 85% of vaginal births for 3 consecutive months. Study participants were surveyed at baseline to assess their knowledge of the QBL method; they then received a 10-minute educational presentation by the clinical nurse specialist (CNS) on QBL. The CNS attended births on both 12-hour shifts to give support, evaluate correct use of the new drapes, and answer questions. Midway through the project, a brief survey was distributed to participants for their feedback. The CNS conducted a chart audit to determine the compliance rate for the QBL process. Results Data analysis indicated an average 89% compliance rate with the QBL process for the time period studied. Conclusion Education on the QBL method increased nurses’ and physicians’ awareness of the importance of using this method as the new standard of care for assessment of postpartum blood loss. Accuracy of postpartum blood loss measurement is critical to help prevent maternal morbidity and mortality. Nurses play a key role in the development and implementation of practice changes to use QBL measurement.

Objective To describe referral source, meal ordering patterns and the nutrient composition of meals from a regional Meals on Wheels (MOW) service. Methods Referral sources were obtained via retrospective chart audit and compared for 2008 and 2012. Nutrient content of the three most common meal combinations was compared against MOW recommendations of one-third daily energy and one-half daily protein requirements. Results There was a decline in overall uptake and referrals from hospitals. The "main meal" alone was the most popular meal choice, but did not meet energy requirements for men or women, nor protein requirements for men. The combination of a soup, main and dessert met the MOW recommendations for women only. Conclusions Investigation into how older people access MOW services is required. Innovative strategies are required to increase the nutrient content of meals, within the context of meal ordering preferences of consumers.

Perinatal care has been recognized as an integral part of ensuring quality health care in hospitals, and the focus on perinatal care quality is increasing. The previous hospital literature has focused much attention on measuring and improving quality of care generally, but recently there has been a call for a more comprehensive approach to measuring quality in the perinatal care setting. The perinatal literature is limited in addressing the association between organizational factors and perinatal quality. Using chart audit data for more than 10 000 maternity patients, we used multiple regression analysis to examine the association of organizational factors and perinatal quality of care. Findings show that ownership, setting (location), and hospital policy on infant feeding were statistically significant. Findings suggest that it is important that hospital boards and leaders develop and implement organizational policies to enhance perinatal quality of care.

Purpose The purpose of this EBP project was to align NG and OG tube placement and verification practices with evidence-based recommendations for children. Practice change An evidence-based NG/OG Tube Placement Algorithm was developed. The algorithm provided an individualized approach based on patient condition as well as a tiered approach that incorporated radiographs, tube measurement and marking, and pH testing. Methods A systematic appraisal of literature identified 40 studies supporting the development of the practice change. A 9-item questionnaire was administered to nurses across five pediatric units to assess current tube verification practices. Education was provided in participating units through a Competency Fair. Post-implementation evaluation included re-administering the practice survey and conducting a chart audit of NG/OG events occurring in the year following the practice change. Results Seventy-one nurses completed the pre-implementation survey; 64 nurses completed the post-implementation survey. Strategies for checking NG/OG placement varied across units prior to implementation; however, auscultation was the most likely to be used strategy and assessing pH was the least likely to be used strategy across units. Post-implementation, aspiration and checking pH were the most frequently endorsed assessment strategy, and auscultation was the least endorsed strategy. The post-implementation chart audit revealed that 73% of NG/OG tubes were checked for placement on insertion with radiograph or aspirate pH. Conclusions Implementation of an NG/OG Tube Placement Algorithm standardized NG/OG care across five pediatric units. Additional efforts are underway to further improve adherence to protocol in order to ensure safe, evidence-based practice for children with NG/OG tubes.

ObjectivesCardiovascular magnetic resonance (CMR) imaging is the gold-standard test for the assessment of heart function. Despite its importance, many jurisdictions lack specific billing codes that can be used to identify patient receipt of CMR in administrative databases, limiting the ability to perform ‘big data’ CMR studies. Our objective was to identify the optimal billing code combination to identify patients who underwent CMR using administrative data in Ontario.DesignRetrospective cohort study.SettingQuaternary care academic referral centre in Ontario, Canada.ParticipantsWe tested all billing code combinations in order to identify the optimal one to determine receipt of CMR. The reference gold standard was a list of all cardiothoracic magnetic resonance scans performed at Sunnybrook Health Sciences Centre between 1 January 2014 and 31 December 2016, verified by chart audit. We assessed the diagnostic performance (accuracy, sensitivity, specificity, positive predictive value and negative predictive value) for all code combinations.ResultsOur gold-standard cohort consisted of 2339 thoracic MRIs that were performed at Sunnybrook Health Sciences Centre from 1 January 2014 to 31 December 2016. Of these, 2139 (91.5%) were CMRs and 200 (8.5%) were chest MRIs. We identified the most accurate billing combination for the determination of patient receipt of CMR. This combination resulted in an accuracy of 95.3% (95% CI 94.4% to 96.2%), sensitivity of 97.4% (95% CI 96.6% to 98.1%), specificity of 86.4% (95% CI 83.1% to 89.6%), positive predictive value of 96.9% (95% CI 96.1% to 97.6%) and negative predictive value of 88.4% (95% CI 85.4% to 91.5%).ConclusionsOur study is the first to verify the ability to accurately identify patient receipt of CMR using administrative data, facilitating more robust population-based CMR studies in the future.

ContextA rapid method of methadone conversion known as the Perth Protocol is commonly used in Australian palliative care units. There has been no follow-up or validation of this method and no comparison between different methods of conversion.ObjectivesThe primary objective of this study was to test the hypothesis that the achieved doses of methadone are independent of the conversion method (rapid vs slower). The secondary objectives included examining the relationship between calculated target doses, actual achieved doses and duration of conversions.MethodsThis is a retrospective chart audit conducted at two hospital sites in the Brisbane metropolitan area of Australia which used different methadone conversion methods.ResultsMethadone conversion ratios depended on previous opioid exposure and on the method of conversion used. The method most commonly used in Australia for calculating target doses for methadone when converting from strong opioids is a poor predictor of actual dose achieved. More appropriate conversion ratios are suggested.ConclusionFurther research is needed to refine the ratios used in practice when converting patients from strong opioids to methadone. Caution and clinical expertise are required. A palliative methadone registry may provide useful insights.

The aim of this study was to identify if patients presenting to a paediatric emergency department were due National Immunisation Program recommended vaccines in order to determine missed opportunities for vaccination or vaccination referral.A hospital chart audit assessed the documentation of an immunisation history, in comparison to the immunisation histories available from national and state immunisation databases to determine accuracy; to identify if patients were due vaccines as determined by the National Immunisation Program; and to identify factors associated with those due vaccines.Potential opportunities to vaccinate children due vaccines were missed (10/114, 8.8%); with less than half (4/10, 40%) correctly documented as due vaccines. Despite identification of due vaccines, no vaccines were administered. Almost one third of patients (34/114, 30%) had no immunisation history documented in the chart. 'Medically at risk' children (Odds Ratio [OR] 29.7, 95% CI 4.5-196, p0.001) were statistically more likely to be due vaccines. Likelihood of being due vaccines was higher, but not statistically significant, for those with no identified general practitioner (OR 4.5, 95% CI 0.96-20.6, p=0.08), and for those presenting with injury rather than illness (OR 2.0, 95%CI 0.51-8.1, p=0.48).Opportunities to vaccinate children presenting to the emergency department are currently being missed. A particular focus is needed for 'medically at risk' children and those with no identified general practitioner. Larger studies may confirm other risk factors. Further research is required into the attainment of an immunisation history during the hospital admission process and the accuracy of these methods.

During the 2009 H1N1 pandemic, 99 severe respiratory illness (SRI) cases were reported in Manitoba. The cause of illness was often not established. Many of these cases may have been unidentified pH1N1. We conducted a chart audit of all severe SRI cases and compared their demographic and clinical characteristics to severe pH1N1 cases. 73 of the 170 cases reviewed were confirmed pH1N1, 53 were SRI with an identified cause, and 44 were SRI with no identified cause. Unexplained SRI cases were similar to pH1N1 cases in terms of risk factors, geographic and temporal distribution, clinical presentation and outcomes. We found that unexplained SRI cases often resembled severe pH1N1 cases, suggesting that these cases were at least in part caused by undiagnosed pH1N1. The overall impact of the pandemic may have been underestimated, especially among the most severely affected indigenous and northern communities.

ObjectivesOpioid-related deaths continue to increase in North America, an epidemic that was initiated by high rates of opioid prescribing. We designed a multifaceted, theory-informed Opioid Self-Assessment (OSA) package, to increase adherence to the Canadian Opioid Guideline among family physicians. This study aimed to assess changes in Canadian family physicians’ knowledge and practices after completing the OSA package.DesignWe conducted a mixed-method evaluation using a pre-test and post-test design that involved the collection of both qualitative and quantitative data.SettingThis research was conducted in the primary care setting in Ontario, Canada.ParticipantsWe recruited a purposive sample of nine family physicians in Ontario who use long-term opioid therapy to treat patients with chronic pain.InterventionsThe OSA package included four components: an online knowledge test, an online learning programme, a safe medication practice self-assessment questionnaire and chart audit with feedback.Outcome measuresOur measures included changes in knowledge, opioid safety practices and physicians’ perspectives on the OSA package.ResultsWe found statistically significant improvements between pre-test and post-test knowledge scores at both baseline and 6-month follow-up. Physicians’ scores improved significantly on five of the seven core characteristics of the practice self-assessment questionnaire. On the chart audits, we observed an improvement in patient education between baseline and 6 months. Qualitative interviews showed that participants appreciated embedded resources in the OSA package. The completion of the package stimulated identification of gaps or deficits in practice and served as a useful reminder to discuss risk and safety with patients. Participants described the chart review as helpful in prompting discussions with their patients, identifying deficits and strengths and a ‘primary motivator’ for project participation.ConclusionsThe OSA package has the potential to improve medication safety practices in primary care related to opioid monitoring and adherence to current opioid guidelines.

Increasing demand for palliative care unit (PCU) admissions has led to a stronger focus on discharge planning. This has resulted in shorter inpatient length of stays (LOS), and stable patients not requiring specialist palliative care services being referred for placement in residential aged care facilities (RACFs). The process of placement is time-consuming and can be distressing to patients and families, so RACF placement should only be proposed in patients whose prognosis is relatively good (i.e., weeks to months).Our aim was to identify the outcomes of palliative care inpatients referred for residential aged care placement.A retrospective chart audit was conducted. The patients' outcomes (discharge or death and survival time) were recorded and analyzed using SPSS statistical software. Subjects were 100 consecutive inpatients from a 30-bed PCU who had been referred for RACF placement.Of the 100 patients referred for RACF placement 73 of 100 (73%) patients had a malignant diagnosis, whereas 27 (27%) had a noncancer diagnosis. Thirty-eight (38%) patients died before discharge, including 33 of 73 (45%) patients with cancer and 5 of 27 (13%) patients with nonmalignant conditions. In particular, 12 of 17 (71%) patients with metastatic non-small cell lung (NCSLC) cancer died before or soon after discharge.Over one-third of all patients died before discharge to an RACF could take place. The rate of death before discharge was higher among patients who had cancer. Patients suffering from NCSLC need to be more carefully selected for placement as only one-third of these patients survived to discharge.

The revised standard of care for breastfeeding infants at risk of developing hypoglycemia during transitioning to extrauterine life was developed using the American Academy of Pediatrics (AAP) 2011 hypoglycemia guidelines, the Academy of Breastfeeding Medicine protocol, and staff input. A pre/postimplementation chart audit indicated support of infant safety by glucose stabilization, breastfeeding within the first hour of life, and breastfeeding frequency without an increase in blood sampling, formula use, or admissions to the special care nursery.

OBJECTIVE. The Western Neuro Sensory Stimulation Profile (WNSSP) presents a hierarchy of items suggestive of a sequence of recovery. The aim of this study was to understand the sequence of recovery of neurobehavioral function in patients with brain injury and determine whether this sequence was consistent with the WNSSP test item order. METHOD. We conducted a retrospective clinical chart audit of 37 adult inpatients (mean age = 29 yr; 31 men, 6 women) with a diagnosis of traumatic brain injury and a minimum of two medical record entries on the WNSSP. The sequence of recovery was statistically derived from the content and structure of the WNSSP. RESULTS. Our analysis did not support the current item ordering of the WNSSP as a function of the sequence of recovery from coma, with the exception of the Arousal/Attention subscale. CONCLUSION. WNSSP item performance suggested a sequence of recovery; clinicians may consider a revised item order that reflects this observed order.

Rehabilitation positively influences return to activities and social roles in people with aphasia. The cognitive-communication disorder (CCD) found following a right hemisphere stroke has been less extensively researched with rehabilitation access and outcomes yet to be determined.To document rehabilitation access and outcomes for people with CCD post-stroke; and compare outcomes based on presence (viz CCD; aphasia) or absence of communication impairment.A retrospective chart audit was completed for patients with first onset unilateral stroke, with a hospital length of stay (LOS) of at least two days and a communication assessment by a speech pathologist. Data extracted included presence and severity of communication impairment, access to and LOS in a rehabilitation unit, and functional outcome measures recorded at rehabilitation discharge.The majority of the 115 patients who met inclusion criteria were living independently (n = 112, 97.4%) at the time of stroke. CCD (66%) was diagnosed with similar frequency to aphasia (68%). The presence of communication impairment did not result in significant differences in rehabilitation LOS and discharge destination when compared to hemispheric strokes without communication impairment. Severity of CCD was an independent predictor of functional gain by rehabilitation discharge.People with CCD require comparable access to rehabilitation as people with aphasia, and severity of CCD should be considered in determining rehabilitation LOS. A large number of people are discharged with ongoing CCD which warrants exploration of potential participation restrictions created by the communication impairment.

Objective Nutrition is an important part of recovery for hospitalized patients. The aim of this study was to assess the nutritional adequacy of meals provided to and consumed by patients prescribed a therapeutic diet. Methods Patients (N = 110) prescribed a therapeutic diet (texture-modified, low-fiber, oral fluid, or food allergy or intolerance diets) for medical or nutritional reasons were recruited from six wards of a tertiary hospital. Complete (24-h) dietary provisions and intakes were directly observed and analyzed for energy (kJ) and protein (g) content. A chart audit gathered demographic, clinical, and nutrition-related information to calculate each patient's disease-specific estimated energy and protein requirements. Provisions and intake were considered adequate if they met ≥75% of the patient's estimated requirements. Results Mean energy and protein provided to patients (5844 ± 2319 kJ, 53 ± 30 g) were significantly lower than their mean estimated requirements (8786 ± 1641 kJ, 86 ± 18 g). Consequently, mean nutrition intake (4088 ± 2423 kJ, 37 ± 28 g) were significantly lower than estimated requirements. Only 37% (41) of patients were provided with and 18% (20) consumed adequate nutrition to meet their estimated requirements. No therapeutic diet provided adequate food to meet the energy and protein requirements of all recipients. Patients on oral fluid diets had the highest estimated requirements (9497 ± 1455 kJ, 93 ± 16 g) and the lowest nutrient provision (3497 ± 1388 kJ, 25 ± 19 g) and intake (2156 ± 1394 kJ, 14 ± 14 g). Conclusion Hospitalized patients prescribed therapeutic diets (particularly fluid-only diets) are at risk for malnutrition. Further research is required to determine the most effective strategies to improve nutritional provision and intake among patients prescribed therapeutic diets.

Summary Background Out of hospital cardiac arrest is associated with a high rate of mortality, and poor neurological outcomes. Favourable neuro-protective effects are associated with induced hypothermia and international recommendations exist for therapeutic hypothermia. Objective This study reviews practice for therapeutic hypothermia for out of hospital cardiac arrest patients within one ICU. It aims to describe the level of adherence to the guideline, identify barriers to implementation and to improve adherence. Setting This project was conducted in an adult ICU which admits 2000 patients yearly. Methods A retrospective chart audit was used to document practice for a 12 month period. Results 33 patients were admitted to the ICU with a diagnosis of out of hospital cardiac arrest and met study inclusion criteria. From this sample of 33 patients, four patients (12%) were at the goal temperature of 32.5–33.5 °C, in the target time of 2 h. Nearly half ( n = 17) were not cooled at all. The length of time the patient was in the ICU prior to active cooling commencing varied from n = 15, 45%) to >3 h ( n = 5, 15%). Twenty-four percent ( n = 9) were cooled for the recommended length of time. There were medical orders stating a target temperature in nearly half of the cases ( n = 18), however, only 27% ( n = 9) were consistent with the ICU guidelines. A number of strategies have been initiated. They aim to improve communication and ready access to the required materials. Conclusions The audit indicated that less than a third of the patients experienced therapeutic induced hypothermia and only 12% were at goal temperature within the required 2 h. Strategies initiated to improve guideline implementation included; regular education sessions with ICU staff; placing a cooling blanket on the bed prior to admitting a patient post OOHCA; improving ready access to cooling agents and the addition of a care path for the induction and maintenance of therapeutic hypothermia to support and prompt clinicians when using the computerised patient record system.

We implemented an antimicrobial stewardship program at an urban, 60-bed long-term acute care hospital using a strategy of weekly postprescriptive chart audit with intervention and feedback. The results for the first 15 months demonstrated 80% acceptance of recommendations, a 21% reduction in use, and a 28% reduction in cost per patient-day.

Objectives To determine whether and to what extent simple screening tools might identify nursing home (NH) residents who are at high risk of becoming septic. Design Retrospective chart audit of all residents who had been hospitalized and returned to participating NHs during the study period. Setting and Participants A total of 236 NH residents, 59 of whom returned from hospitals with a diagnosis of sepsis and 177 who had nonsepsis discharge diagnoses, from 31 community NHs that are typical of US nursing homes overall. Measures NH documentation of vital signs, mental status change, and medical provider visits 0–12 and 13–72 hours prior to the hospitalization. The specificity and sensitivity of 5 screening tools were evaluated for their ability to detect residents with incipient sepsis during 0–12 and 13–72 hours prior to hospitalization: The Systemic Inflammatory Response Syndrome criteria, the quick Sequential Organ Failure Assessment (SOFA), the 100-100-100 Early Detection Tool, and temperature thresholds of 99.0°F and 100.2°F. In addition, to validate the hospital diagnosis of sepsis, hospital discharge records in the NHs were audited to calculate SOFA scores. Results Documentation of 1 or more vital signs was absent in 26%–34% of cases. Among persons with complete vital sign documentation, during the 12 hours prior to hospitalization, the most sensitive screening tools were the 100-100-100 Criteria (79%) and an oral temperature >99.0°F (51%); and the most specific tools being a temperature >100.2°F (93%), the quick SOFA (88%), the Systemic Inflammatory Response Syndrome criteria (86%), and a temperature >99.0°F (85%). Many SOFA data points were missing from the record; in spite of this, 65% of cases met criteria for sepsis. Conclusions NHs need better systems to monitor NH residents whose status is changing, and to present that information to medical providers in real time, either through rapid medical response programs or telemetry.

An audit of second stage caesarean section (C/S) at a tertiary hospital was undertaken to compare the frequency of perinatal and maternal complications between first and second stage C/S and to evaluate the training level of physicians.A prospective chart audit of all women who underwent emergency C/S over a 7-month period at a tertiary hospital was conducted. The patients' hospital records were assessed on a daily basis and all relevant information recorded on a structured data sheet categorising demographics, indications for C/S, level of training of decision-maker and surgeon, a consultant's presence, operative complications and neonatal outcome at 5 min post-delivery. The frequency of maternal and neonatal complications was the main outcome measures.There were 975 first stage and 116 second stage C/S. The commonest causes of second stage C/S were cephalo-pelvic disproportion, prolonged second stage and fetal distress. First stage C/S took a mean time of 35.5 min, while second stage C/S took an average time of 41.6 min to perform (p=0.001). There were 37 and 84 records of complications occurring in first and second stage C/S, respectively.Maternal complications were significantly higher in second stage C/S while neonatal complications were not significantly different between first and second stage C/S. There was little guidance from consultants at decision-making for second stage C/S.

Objectives: The objective of the current study was to provide a contemporary review of electroconvulsive therapy (ECT) practice in Far North Queensland, Australia. Method: Demographic, diagnostic and treatment characteristics were extracted from the hospital files of people who received ECT between 2011 and 2013. Data were quantitatively analysed and described. Results: Depressive illnesses were the most common indicator for treatment. However, psychotic illnesses also made up a large proportion of treated cases. The technical aspects of treatment were commensurate with previous Australian findings except for the higher incidence of bifrontal ECT and maintenance treatment. Conclusions: Further research is needed across Australia to determine whether the findings of the current study represent changes in Australian ECT practice.

Purpose: To examine (1) the frequency and types of painful procedures, (2) the frequency and types of analgesic/sedative use, and (3) the frequency of documented pain assessments that infants experience during the five days following a diagnosis of necrotizing enterocolitis (NEC).Design: A retrospective descriptive cohort design.Sample: Thirty-nine infants from one tertiary care unit diagnosed with stage II NEC.Main Outcome Variable: Painful procedure data were classified into highly invasive procedures and moderately invasive procedures and were collected for five days following the diagnosis of NEC. Frequency and types of analgesic/sedative administration and frequency of documented pain assessments during each of the five days following the NEC diagnosis were collected.Results: The average number of painful procedures was 16.3 per day, with documented PIPP scores performed on 30–60 percent of the infants during each of the days following the diagnosis of NEC. At no time were more than two PIPP scores per infant documented in a 24-hour period. Analgesics were used in 52–76 percent of infants during the first three days following the diagnosis of NEC, but use decreased gradually on the fourth and fifth days. No correlation between painful procedures and analgesic/sedative administration on any day was found. Similarly, no correlation between documented PIPP scores and analgesic/sedative use on any day was found.

Background Recommendations for postoperative antibiotics for appendicitis were published by the American Pediatric Surgical Association (APSA) in 2010. However, implementation of practice recommendations often takes years. We measured compliance of pediatric surgeons (who receive reminders every 6months from the Division Chief) with the APSA recommendations. Methods With Research Ethics Board approval, we completed a retrospective review of children who underwent appendectomy since 2010. Compliance with APSA recommendations was analyzed descriptively. Agreement between pediatric surgeons and pathologists was analyzed by kappa. Results We reviewed 242 charts. Patients were excluded for missing data ( n =5) and diagnosis other than appendicitis ( n =27), resulting in 210 patients with appendicitis (119 acute, 91 perforated). Agreement of perforation status between surgeons and pathologists was good ( κ =0.75; 95% CI: 0.66–0.83). Many patients with nonperforated appendicitis received antibiotics in excess of the APSA recommendations (62/119 (52%)), as did those with uncomplicated perforated appendicitis (52/84 (62%)). Conclusions Despite the availability of published recommendations, surgeons continue to prescribe postoperative antibiotics for appendicitis in excess of the recommendations. Overtreatment leads to potential medication errors and increased length-of-stay/medication costs. An intensive implementation program with ongoing education/monitoring may improve compliance with established recommendations to decrease the use of excess postoperative antibiotics and their associated costs/risks.

The goal of this study was to establish patients' perspectives on the acceptability of wait times, the impact of wait times on their health and the possibility of using electronic consultations (eConsultations) to avoid visits to specialists. A 2-stage patient survey (self-administered and with a follow-up telephone call) and a chart audit was conducted on a sequential sample of patients attending their initial consultations in a tertiary diabetes and endocrinology centre. Patients' perspectives on actual and ideal wait times, the impact of waiting for access, the effectiveness of the referral-consultation process and attitudes toward eConsultations as an alternative to traditional referral-consultations were collected. The study involved 101 patients (22% for diabetes, 78% for endocrinologic conditions), whose comments were collated and categorized. Of the 101 patients who completed the survey, 61 also completed telephone interviews. The average wait time was 19 weeks; the median 10 weeks. More than 30% of patients waited longer than 6 months and 6% waited longer than 1 year. Overall, 90% of patients thought that the maximum wait time should be less than 3 months. While waiting, 58% of patients worried about a serious undiagnosed disease, 30% found their symptoms had affected their daily activities and 24% had to miss work or school due to symptoms. Of the patients, 46% considered eConsultation a viable alternative to face-to-face visits. Excessive wait times for specialist care remain barriers and have negative impacts on patients. Wait times significantly exceeded times patients considered acceptable. eConsultations provide acceptable alternatives for many patients, and they reduced the number of patients requiring traditional consultations.

Objectives To evaluate quality of care delivered to patients presenting to the emergency department (ED) with pain and managed by emergency nurse practitioners by: 1Evaluating time to analgesia from initial presentation 2Evaluating time from being seen to next analgesia 3Measuring pain score documentation Background The delivery of quality care in the emergency department (ED) is emerging as one of the most important service indicators being measured by health services. Emergency nurse practitioner services are designed to improve timely, quality care for patients. One of the goals of quality emergency care is the timely and effective delivery of analgesia for patients. Timely analgesia is an important indicator of ED service performance. Methods A retrospective explicit chart review of 128 consecutive patients with pain and managed by emergency nurse practitioners was conducted. Data collected included demographics, presenting complaint, pain scores, and time to first dose of analgesia. Patients were identified from the ED patient information system (Cerner log) and data were extracted from electronic medical records. Results Pain scores were documented in 67 (52.3%; 95% CI: 43.3–61.2) patients. The median time to analgesia from presentation was 60.5 (IQR 30–87) minutes, with 34 (26.6%; 95% CI: 19.1–35.1) patients receiving analgesia within 30 minutes of presentation to hospital. There were 22 (17.2%; 95% CI: 11.1–24.9) patients who received analgesia prior to assessment by a nurse practitioner. Among patients who received analgesia after assessment by a nurse practitioner, the median time to analgesia after assessment was 25 (IQR 12–50) minutes, with 65 (61.3%; 95% CI: 51.4–70.6) patients receiving analgesia within 30 minutes of assessment. Conclusions The majority of patients assessed by nurse practitioners received analgesia within 30 minutes after assessment. However, opportunities for substantial improvement in such times along with documentation of pain scores were identified and will be targeted in future research.

OBJECTIVE To determine the effectiveness of an online module for reducing insulin administration errors by nurses caring for hospitalized pediatric patients. RESEARCH DESIGN AND METHODS Pediatric nursing staff completed a mandatory online educational module teaching insulin pharmacokinetics and the insulin order form, using diluted insulin and finishing with 15 interactive cases. A chart audit to determine all possible insulin errors of patients receiving insulin was done before and 2–6 months after the educational module. RESULTS All of the medical center's 283 pediatric nurses successfully completed the educational module. A total of 24 charts were audited in the preintervention phase and 22 in the postintervention phase. The preintervention insulin error rate was 14.8%, reduced to 1.7% (P < 0.001) postintervention. Improvement occurred in correct insulin dosing and type, timing of administration, and timely blood glucose monitoring and documentation. CONCLUSIONS An interactive online educational module can be an effective strategy for reducing pediatric nurses' insulin administration errors.

With specialist palliative care services becoming widespread, and the place of the GP in palliative care being examined, audit of patient care delivered by GPs is required in order to ensure adequate standards of care.We aimed to evaluate symptomatic care delivered to palliative care patients by GPs in an Australian community hospice with a developed quality assurance programme.The study was set in a newly established community-based, GP-run hospice in a provincial city in Queensland, Australia. A chart audit was carried out of the first 20 patients admitted to a community-based hospice, in order to establish (i) whether attempts were made by the treating doctor to find the direct cause of symptoms before initiating management; and (ii) whether management accorded with developed consensus-based guidelines.Twenty patients were treated by 14 GPs; 135 new symptoms were identified in the records of these patients. Of the 125 symptoms for which guidelines could be identified in the literature, in 87 (70%) an attempt by the treating GP to find a direct cause could be demonstrated. Of the 114 symptoms with treatments defined in the guidelines, 107 (90%) treatments conformed to the guidelines. Constipation, nausea/vomiting, anorexia and back pain were the conditions for which there were the fewest attempts at establishing a direct cause before treatment. In most cases these conditions were treated in accordance with the guidelines.Quality assurance mechanisms present in an in-patient palliative care setting appear to be associated with high-quality care by GPs.

OBJECTIVES. This study measured the cancer screening rates of family physicians and compared the measures obtained through physician self-reports, chart audits, and patient surveys. METHODS. A cancer screening survey was sent to 50% of the members of the Washington Academy of Family Physicians, with 326 family physicians (74% response rate) completing the survey. Sixty physicians were recruited for the patient survey and chart audit phase, with a 90% participation rate. Patient surveys were conducted with about 350 patients per physician, and chart audits were conducted on a subset of about 50 patients per physician. Each physician's rate of providing each service was computed from the self-report, the patient survey, and the chart audit. RESULTS. Physicians provided many of these services at rates different from those commonly recommended. Large discrepancies were found between the rates measured by different methods. Correlations between rates derived from chart audits and patient surveys were high; however, correlations between rates from physician self-report and either patient survey or chart audit were much lower for all services. CONCLUSIONS. Studies of physicians' provision of cancer prevention services should not rely on physician self-report, but should obtain the rates through patient surveys or chart audits.

Despite the known risks and the widespread administration of PRN (pro re nata or “as needed”) psychotropic medications in inpatient settings, little is known about their use with hospitalized older adults. This exploratory descriptive study examined the use of PRN psychotropic medications and nonpharmacologic interventions to manage symptoms in older adults hospitalized in two acute care geropsychiatric settings. A retrospective chart audit was conducted. A major finding was the lack of documentation regarding PRN administration. In 81.3% of cases at Site A and 55.3% of cases at Site B, no reason for administration was documented. No medication response was documented in 92.4% of cases at Site A and 47.5% of cases at Site B. No nonpharmacologic interventions were documented for 69% of Site A patients or 64% of Site B patients. To ensure patient safety and to inform best clinical practice, the lack of documentation surrounding administration of PRN medications and nonpharmacologic interventions must be resolved.

Despite recent emphasis on educational outcomes, program directors still rely on standard evaluation techniques such as tests of knowledge and subjective ratings.To assess the correlation of standard internal medicine (IM) residency evaluation scores (attending global evaluations, In-Training examination, and Mini-Clinical Examination Exercise) with documented performance of preventive measures for continuity clinic patients.Cross-sectional study of 132 IM residents attending an IM teaching clinic, July 2000 to June 2003, comparing standard evaluations with chart audit.Mean resident performance ranged from 53% (SD = 24) through 89% (SD = 20) across the 6 preventive measures abstracted from 1,102 patient charts. We found weak and mostly not significant correlations between standard measures and performance of preventive services.Standard measures are not adequate surrogates for measuring clinical outcomes. This supports the Accreditation Council for Graduate Medical Education's recommendations to incorporate novel Toolbox measures, like chart audit, into residency evaluations.

Objective: To investigate the nature and acuity of medical presentations of patrons and staff attending the Melbourne 2006 Commonwealth Games (M2006) venues and festival live sites. Design and setting: Retrospective case series chart audit of patients who were managed by St John Ambulance during the M2006. Participants: Patients who presented requiring first-aid review or treatment at any of the 21 designated event venues or 16 live sites during their prescribed operating hours between 15 March 2006 and 26 March 2006. Main outcome measures: Provisional diagnosis and ambulance transport to hospital. Results: A total of 3514 presentations occurred during the study period, of which 2279 (64.9%, 95% CI, 63.3%–66.4%) occurred at event venues. Headaches, soft tissue injuries, blisters and other wounds accounted for 64.1% (95% CI, 62.5%–65.73%) of presentations. A total of 303 patients were referred for further medical care, including 69 patients (1.96%, 95% CI, 1.54%–2.49%) who required transport to hospital via ambulance. Traumatic injuries accounted for 42.0% (95% CI, 30.5%–54.5%) of patients transported by ambulance to hospital. The patient presentation rate across all venues was 0.857 per 1000 patrons. The transport to hospital rate was 0.0186 per 1000 patrons. Conclusions: The majority of first-aid presentations during the M2006 were of low acuity and treatment resulted in return of patrons to the event, with only a small number requiring ambulance transport to hospital.

Determine A1C, blood pressure (BP), and total cholesterol (TC) (Diabetes ABCs) control in a community-based endocrinology practice (CBEP) and compare levels to national averages. Additionally, determine patient factors associated with ABC control.A retrospective chart audit of 395 consecutive patients seen for diabetes management was conducted for years 2000-2004 to examine levels of control of the ABCs. Multivariate models were used to determine patient factors associated with control.Significantly more patients met the goal of A1C7% in the CBEP compared to national estimates (CBEP: 47.1% vs. NHANES 1999-2000: 37%, p=0.003). Similar patterns were observed for BP (CBEP: 53.2% vs. NHANES 1999-2000: 35.8%, p0.0001), TC (CBEP: 82% vs. NHANES 1999-2000: 48.2%, p0.0001), and all three ABCs (CBEP: 22%, vs. NHANES 1999-2000: 7.3%, p0.0001). The proportion of patients meeting all three ABC goals in the CBEP increased significantly over time (p0.0001). Multivariate models demonstrated that patients not needing insulin (p0.0001), and taking fewer BP (p0.0001), and cholesterol-lowering medications (p0.02) were significantly more likely to have ABCs in control.Attainment of ABC goals is feasible in a CBEP and can be achieved at rates higher than national averages. Attention to factors that affect these goals is warranted.

Palliative Performance Scale (PPS) scores have shown potential for prognosticating survival in Caucasian samples, but have not been studied for prognostic value in cancer patients from minority groups. Using data obtained from a retrospective chart audit of 492 cancer patients admitted over an 18-month period to a minority-serving home-based hospice and palliative care program, we examined the relationship between PPS scores and length of survival (survival days). Patients with PPS scores of 10% to 30% had fewer survival days than those with scores of 40% and those with scores of 50% to 100% (median = 6, 19, and 34 days, respectively; F = 25.02, P < 0.001). A PPS score of 40% serves as a reliable inclusion criterion for a study requiring two weeks for completion, while 50% to 100% is required for a three-week study. Findings from a predominantly minority sample are similar to those from predominantly Caucasian samples.

The widespread use of alcohol and other drugs poses particular problems during hospitalisation. Although nurses have been identified as an appropriate group to screen patients and provide acute and ongoing management to people with drug and alcohol-related problems, rates of screening are low. The aims of this study were to identify current practices for screening by nurses working in medical and surgical wards, determine their knowledge relating to problems associated with substance use and identify their self-reported skills in managing patients with drug- and alcohol-related problems.A chart audit of medical records was completed and a survey was distributed to nurses working in the study wards.Screening for alcohol and drug use was documented on only 22/79 medical records, and detailed information about quantity and duration of use was recorded in only nine. Overall, the nurses reported that they had little knowledge about substance use problems, and felt that they lacked skills to care adequately for these patients.The results of this study suggest a need for a comprehensive training and education to ensure that nurses are familiar with policies and protocols for management of patients and to assist nurses to provide evidence-based care and make appropriate referrals to specialist services.

Purpose To assess the degree of concordance between the information (drug quantity, days' supply, and daily dose) recorded on hospital discharge prescriptions and what appears in a public drug insurance electronic claims database. Methods A retrospective chart audit of hospital discharge prescriptions with linkage to a prescription claims database was conducted. Three hundred and forty-five post-myocardial infarction patients discharged from an Ontario university-affiliated teaching hospital were included. The percentage of linkable records with perfect agreement between the written prescription and the insurance claim was our measure of concordance. Results Seventy-seven per cent and 82% of discharge prescriptions were filled within 7 days, and 120 days post-discharge, respectively. Of those dispensed and that contained adequate information, concordance was perfect for days' supply, quantity, and daily dose for 70.7% (95%CI 67.9–73.4%), 65.9% (95%CI 63.2–68.7%), and 75.9% (95%CI 73.2–78.6%) of prescriptions, respectively. For cardiac drugs, which comprised the majority of filled prescriptions, concordance was greater for daily dose and days' supply than for quantity (75.7% [95%CI 72.7–78.6%] and 75.5% [95%CI 72.6–78.4%] vs. 65.3% [95%CI 62.3–68.4%]). Concordance varied by medication type. Conclusion Most hospital discharge prescriptions were filled within 1 week. Among the data elements studied, concordance between written prescriptions and insurance claims was greatest for daily dose. Concordance was greater for scheduled cardiac medications than for other medications. Copyright © 2006 John Wiley & Sons, Ltd.

BACKGROUND: Off-label use of recombinant factor VIIa (rFVIIa) occurs despite minimal data. The purpose of this study was to describe prescribing practices and clinical outcomes for off-label rFVIIa use. STUDY DESIGN AND METHODS: A retrospective, multicenter chart audit of 315 nonhemophiliac patients was performed. RESULTS: Off-label indications included prevention of bleeding primarily related to procedural manipulation in 37.8 percent of patients and treatment of bleeding in 62.2 percent of patients. Baseline coagulopathy was present in 79.7 percent of patients. Prescriber specialty varied. The median doses for prevention and treatment were 75.6 and 89.4 µg per kg, respectively (p = 0.0006). The international normalized ratio (INR) decreased (p

Objective: To evaluate the outcomes of implementation of a developmental care model in an Australian tertiary NICU.Study Design: A retrospective chart audit was used to determine the differences between predevelopmental and developmental care outcomes for infants, parents, the unit, and nursing.Sample: Two subsets of infants were selected for comparison: one of infants receiving predevelopmental care (n = 42) and another of infants receiving developmental care (n = 42).Results: Infants receiving developmental care required less time on total parenteral nutrition, required less exogenous surfactant, and had less documented feeding intolerance. Changes were observed in ambience and in the use of space for providing parent-infant care. Also observed was the individualized expertise of nursing staff and of parents.

Purpose: The changeover in residents that occurs each July in university-affiliated hospitals has been postulated to result in impaired delivery of patient care (the “July phenomenon”). To assess the impact of this process on patient safety, we examined the incidence and sources of medical error and adverse outcomes on a pediatric surgery service during the final month of an academic year and the first month of the subsequent academic year. Methods: All admissions to two pediatric surgeons during June and July 2002 were prospectively followed. In-patient care was reviewed daily by the attending surgeon, a pediatric surgery fellow and a medical student. Errors committed by doctors, nurses, and allied health workers were identified through daily patient encounters, nursing rounds, medical rounds, and chart audit. Adverse outcomes were evaluated based on type and contributing factors, including involvement of residents. To correct for variations in length of stay, incidence of errors and adverse outcomes were expressed as a percentage of total patient days. Results: The error rate was 46/643 patient days (7.1%) in June, and 58/776 patient days (7.5%) in July (p = 0.9). Total adverse outcome rate was also not significantly different between the two months (5% vs 6.7%, p = 0.21). Resident error accounted for 52.2% of errors in June and 39.7% of errors in July (p = 0.28), and the likelihood of a resident error resulting in an adverse outcome was also similar between months (10.8% vs 22.4%, p = 0.2). The incidence of resident error was not influenced by whether the resident was on-call, post-call or neither. Conclusion: Resident changeover at the completion of an academic year was not associated with an increased number of medical errors or adverse outcomes, indicating that effective systems are in place to prevent the “July phenomenon”. The on-call status of the resident did not appear to affect the likelihood of resident error.

Background The Agency for Health Care Policy and Research (AHCPR) smoking cessation guideline outlines a set of recommendations for physicians to follow in daily practice. However, the effectiveness of this guideline has not been reported. The goal of this project was to evaluate the effect of the AHCPR smoking cessation guideline on provider practices with smokers and on patient smoking rates. Methods Patient survey and chart review data from 138 Veterans Administration (VA) acute care medical centers with outpatient facilities were examined. Data were available from both sources in 1996, 1997, and 1998. At the midpoint of this period (1997), the VA recommended the AHCPR smoking cessation clinical practice guideline for implementation throughout the VA healthcare system. Results From 1996 to 1998, both the chart audit and the patient survey showed a significant increase in the percentage of patients in the VA who were counseled about smoking and a significant decrease in the percentage of patients who smoke. Conclusions Because the VA tied the guideline implementation to report cards and other performance-enhancing measures, guideline adherence may have been maximized in this setting. These findings suggest that healthcare systems should take an integrated approach to guideline implementation.

Multiple factors, including personal and cultural values, physical and medical factors, and various healthcare systems' forces, influence the place of death of patients with cancer. The purpose of this retrospective chart audit study was to examine the influence of sociodemographic factors, family support, patient functioning, and care needs on the place of death for patients with cancer served by a home care program in Taiwan. Among the 264 study patients, 182 (69%) died at home and 82 (31%) died in the hospital. Significant differences were found between patients dying at home or in a hospital predominantly in the categories of patient functioning and care needs. From the multivariate logistic regression model, home care patients with cancer who were never rehospitalized, who received more home care visits, and who were referred to home care services at the greatest functionally dependent status and with pain were more likely to die at home. Overall, this model could accurately classify 78% of the place of death, which is higher than other published studies. Understanding factors that influence place of death of terminally ill patients with cancer allow healthcare professionals to modify healthcare systems and tailor effective interventions to help patients die at the place they prefer.

The purpose of this paper was to determine if providing patient specific Quality of Life (QL) information to clinic staff before a clinic appointment improved patient care in a lung cancer outpatient clinic. Patients were sequentially assigned to either a usual care control group or the experimental group, which completed a computerized version of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire in order to provide the clinic staff with QL information prior to the clinic appointment. The control group completed the EORTC QLQ-C30 paper version after the clinic appointment. Outcome measures were patient satisfaction, the degree to which issues identified on the QL questionnaire were addressed in the appointment, and a chart audit, which measured charting of QL issues and actions taken by the clincian relating to QL. In the experimental group, more QL issues identified by the patient on the EORTC QLQ-C30 were addressed during the clinic appointment than in the control group. As well, marginally more categories were charted and a trend towards more actions being taken was seen in the experimental group. Patients reported being equally and highly satisfied with the treatment in both groups. The clinical implication is that the computerized administration of the EORTC QLQ-C30 questionnaire and providing staff with a report highlighting patient-specific QL deficits is a simple, time-effective and acceptable means of improving patient-provider communication in a busy outpatient clinic. Large trials studying its effectiveness in different patient populations and regions would further elucidate the nature of this effect and potentially improve the overall quality of care that patients receive.