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Pneumococcal disease is a healthcare concern with increasing financial and societal burden for adults over the age of 65 years and their caretakers. The Center for Disease Control and Prevention (CDC) recommends the use of pneumococcal vaccines in this population as a preventive measure helping minimize the mortality and morbidity. This project aimed at increasing the rate of pneumococcal vaccines in a Federally Qualified Health Center (FQHC). The interventions implemented included the use of audit, feedback and provider educational intervention aimed at increasing the knowledge and the intent to change and improve their practice. The key results indicated an increase in aggregate pneumococcal vaccines in the organization as well as an increase in individual and historical vaccination rates for the organization and individual providers. The implications for practice include the improvement in vaccination rates significantly impacting the health of the community, as well as an increase in education provided regarding vaccination. The questionnaire provided positive feedback on the intervention. Further research to determine vaccination availability and re-vaccination should be considered.

Background Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. Methods A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. Results In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. Conclusion After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) coordinates nation-wide audits of the National Inpatient Medication Chart (NIMC). Electronic Medication Management Systems (eMMS) are beginning to replace NIMCs in Australian hospitals. This article describes the NIMC audit experience in two Australian tertiary hospitals that have established eMMS. Medication charts at both hospitals were audited using the ACSQHC-provided audit tools (2012 Version). At both hospitals, eMMS charts exhibited higher levels of compliance with audit criteria than NIMCs, except for documentation of indication for medication. With eMMS, both hospitals exceeded national averages on many audited parameters, with the exceptions of documentation of weight and indication for medication. eMMS produces clearer, more complete medication orders and patient information, which may improve quality and safety of prescribing and reduce medication errors. Feedback was provided to the ACSQHC regarding aspects of the NIMC audit that did not align with eMMS for consideration in future audits.

BACKGROUND Evaluating the appropriateness of red blood cell (RBC) transfusion requires labor-intensive medical chart audits and expert adjudication. We sought to determine the appropriateness of RBC transfusions at 10 hospitals using retrospective chart review and to determine whether simple metrics (proportion of single-unit transfusions, RBCs/100 acute inpatient days, proportion of transfusions with pretransfusion hemoglobin

Background Unintended retained surgical sponges (URSSs) are preventable catastrophic events that occur in the surgical environment. Purpose A community hospital in the southern United States sought to reduce the occurrence of URSSs by implementing a quality improvement initiative. Methods We conducted a practice improvement project that incorporated safety-sponge technology preceded by education and training. Staff knowledge and practice expectations were assessed using a pre-post-intervention survey followed by internal audit. Results Staff knowledge significantly improved after the tailored education and training. A chart audit conducted 15 weeks after the intervention showed compliance with the technology was 99.4%, incorrect surgical counts went from 4% to 0.8%, and number of URSSs went from 2 to 0. Conclusion The project demonstrated a reduced risk of incorrect surgical counts and URSSs in the facility.

OBJECTIVE: To investigate the association between a set of comprehensive factors across international literature and rehabilitation length of stay. METHOD: A chart audit of 197 Australian hospital rehabilitation unit orthopaedic inpatients (2016-2018) was conducted. Items significantly associated with length of stay throughout univariate regressions were entered into a subsequent hierarchical multiple regression analysis, where variables were regressed against length of stay in two steps. Items which were relevant prior to admission to the rehabilitation unit, or immediately upon admission, were regressed against length of stay during the first step, while variables which emerged during admission were entered during the second step. RESULTS: Having pressure injuries during rehabilitation (p

CONTEXT: Toxicity-monitoring plays an important role in all cancer treatment, however, early recognition is vital for detecting and treating immune-related symptoms. Preparing a Patient Reported Outcomes tool and including melanoma patients receiving immunotherapy in the reporting of symptoms, may optimize toxicity-monitoring.OBJECTIVES: The objective of this study was to identify the symptoms and their equivalent questions to include from the Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (PRO-CTCAE) library for melanoma patients, receiving immunotherapy and, further, to evaluate if all relevant symptoms are covered by this tool.METHODS: To establish the relevant symptoms, three measures were taken. First, a literature search was carried out in three databases. Second, a chart audit was performed including medical records from melanoma patients receiving immunotherapy. Finally, the product information for the relevant immunotherapies was studied.RESULTS: Ten articles were included as a result of the literature search. As for the chart audit, a total of 37 patients (48 treatments with immunotherapy) were included. Overall, the reported symptoms from the literature review aligned with those identified in the chart audit. The examination of the product information supported the findings from review and chart audit, revealing only one additional symptom. In total, 28 PRO-CTCAE symptoms were selected comprising of 56 PRO-questions plus an additional question on blood in stool.CONCLUSION: When preparing a Patient Reported Outcomes tool it is important that the preparatory work of selecting questions is done properly. By going through the literature, performing a chart audit, and examining the product information, the most important and relevant symptoms have been uncovered, facilitating the design of a PROquestionnaire, based on PRO-CTCAE, that fits the patient population under investigation.

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.

© 2019, © 2019 Informa UK Limited, trading as Taylor & Francis Group. Background: Diabetes at the end of life (EoL) is characterized by blood glucose fluctuations that result from decreased oral intake, side effects of medications, altered physiology, and end-stage organ failure. With limited life expectancy and the presence of comorbidities, diabetes management can be challenging. While there is little clinical evidence to guide decision-makers, current practice depends on empiric and expert recommendations. Objective: To evaluate the current prescribing patterns and monitoring parameters in diabetes management at the EoL in patients at two palliative care inpatient units. Design: Retrospective clinical chart review. Setting/subjects: Adult patients attending the Palliative and Supportive Care Services at St Vincent's Private Hospital and Mater Adults Hospital, South Brisbane, Australia over a 24-month period, from October 2014 to October 2016. Results: A total of 145 charts were analysed. 139 patients were identified as having received glucose-lowering therapy (51% female, median age 71 years). Insulin therapy was used in 74 (51%) patients and oral and/or non-insulin therapies in 62 (43%). Blood glucose level monitoring was carried out a median of 4 times, range 1–6 times daily. Either continuously or at some stage of their treatment, 74 patients were receiving corticosteroids. Conclusion: Insulin therapy appears to be the safest and most effective approach, taking into consideration the patient needs and pharmacodynamic profile of each preparation. Without evidence-based guidelines on the optimal intervention to control diabetes at the EoL, therapy plans must be individualized to prevent symptomatic hyper- and hypoglycaemia with minimal patient discomfort and adverse drug reactions.

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.

Background: Homelessness is a growing Canada-wide concern. Those with no fixed address have increased rates of emergency department (ED) utilization and increased healthcare spending compared to the general population, with higher rates of acute and chronic illnesses, as well as all-cause mortality. EDs are uniquely situated to act as an access point to the network of available community services, however referral rates from the ED is uncertain. To date, there has been no data collected on London, Ontario's homeless population, their health burden, and their utilization patterns of the ED. Aim Statement: The primary objective of this study is to describe ED visits for adult patients with no fixed address in London, Ontario to assess for potential areas to improve care. Measures & Design: This is a retrospective chart review, of patients with no fixed address visiting London, Ontario Emergency Departments in 2018. ED visits were identified and pulled using either a diagnosis of “homeless”, a lack of postal code, or a postal code for a known shelter. Cases included based on postal code were manually reviewed to determine whether the patient had a resident address with the same postal code. Evaluation/Results: From this search, 4,294 visits were identified for 1237 unique patients. The median visits per person was 1 (IQR 1-2), with 388 patients having 3 or more visits, and the max being 138 visits. The median age was 38 (IQR 28-52), with 73% male. Ground ambulance was used for 46% of visits. 28% of visits were CTAS 1&2 and 5% were CTAS 5. Police facilitated visits in 401 cases. Top 3 discharge diagnosis categories were mental health (19%), infection (18%), drug misuse (17%). Discussion/Impact: Several errors were identified with our search strategy suggesting the current system of capturing homelessness in the EPR is not accurate, leading to an underestimation of the problem and limiting our ability to describe this population. The Ministry of Health mandates homelessness be applied as a tertiary discharge diagnosis during coding of the patient visit if possible. However, use of this code is inconsistent leading to large-scale omission of visits and an underrepresentation of pediatric cases. Systemic steps should be taken to improve identification of these patients moving forward.

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.

Study design: Retrospective chart audit. \ud \ud Objectives: The National Early Warning Score (NEWS) is based on seven physiological parameters which can be altered in some individuals with spinal cord injuries (SCI). The aim was to start the development of adapted NEWS suitable for SCI population. The objective was to determine the SBP NEWS specificity based on neurological level of injury (NLI) and completeness of injury. \ud \ud Setting: Tertiary centre in the UK. \ud \ud Methods: Adult patients admitted for the first time to the National Spinal Injuries Centre between 1st January 2015 and 31st December 2016 were included if they were > 6 months post-injury. Data were extracted retrospectively including the last ten consecutive BP and heart rate readings before discharge. Data were analysed based on different AIS grades, completeness of injury and NLI. \ud \ud Results: 191 patients were admitted in 2015 and 2016 and 142 patients were included in the primary analysis. The mean SBP ranged between 92 and 151 mmHg. Patients with the NLI of T6 and above (≥ T6) motor complete lesions had a significantly lower SBP than motor incomplete lesions. The specificity of the SBP NEWS was 35.3% in ≥ T6 motor complete individuals versus 80.3 % in ≥ T6 motor incomplete individuals.\ud \ud Conclusion: The baseline BP is significantly lower in the ≥ T6 motor complete SCI individuals (> 6 months post-injury) resulting in a very low specificity of 35.3 % to SBP NEWS which could lead to mismatch between clinical deterioration and NEWS resulting in lack of timely clinical response.

ObjectiveTo determine if an educational intervention can decrease the inappropriate antibiotic treatment of long-term care (LTC) residents with asymptomatic bacteriuria (ASB).DesignProspective chart audit between May and July 2017.SettingSeven LTC facilities in Regina, Saskatchewan, Canada.ParticipantsChart audits were performed on all LTC residents over 18 years of age with a positive urine culture. Educational sessions and tools were available to all clinical staff at participating LTC facilities.InterventionFifteen-minute educational sessions were provided to LTC facility staff outlining the harms of unnecessary antibiotic use, antibiotic resistance and the diagnostic criteria of a urinary tract infection (UTI). Educational sessions were complimented with posters and pocket cards that summarised UTI diagnostic criteria.Main outcome measureThe primary outcome measure was the number of residents who received inappropriate antibiotic treatment for ASB. Secondary outcome measures included the appropriateness of urine culture tests, number of tests and cost associated with inappropriate treatments.ResultsIn the preintervention period, 172 urine culture and sensitivity (UC&S) tests were performed, 62 (36.0%) were positive and 50/62 (80.6%) residents had ASB based on chart review. In the postintervention period, 151 UC&S tests were performed, 50 (33.1%) were positive and 35/50 (70.0%) residents had ASB. There was a statistically significant decrease in the number of residents treated with antibiotics for ASB, from 45/50 (90%) preintervention to 22/35 (62.9%) postintervention (χ2=9.087, p=0.003).ConclusionsAn educational intervention was associated with a statistically significant decrease in inappropriate antibiotic treatment of LTC residents with ASB.

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.

Aim: The present study aimed to assess the impact of a hospital-wide electronic medical record (EMR) on the way dietitians collect routine data for their assessments and its impact on their clinical documentation and service provision. Methods: Data were collected retrospectively from the following sources: interdepartmental chart audit, the EMR itself (nutrition diagnosis), National Health Roundtable database (admissions requiring nutrition events) and the hospital-wide Pressure Injury Prevention Audits (height, weight and malnutrition screening). Results: There were improvements in medical record accessibility (76.4% pre vs 100% post, P < 0.001), awareness of medical alerts (82.5% unaware pre vs 34.5% unaware post) and legibility of documentation (53.8% pre vs 99.2% post, P < 0.001). Improvements in accessing medical charts under 1 minute also occurred (65.8% pre vs 99.2% post, P < 0.001). The percentage of nutrition diagnoses resolved during admission increased from 20.0% in February 2016 to 34.0% in August 2017. A 72.0% increase in admissions requiring nutrition interventions was found with 4075 admissions pre- and 7035 post-EMR implementation. Time spent per nutrition event reduced by 22.0% (118 minutes pre and 92 minutes post). Hospital audit data revealed mean height and weight collected increased from 79.3 ± 3.8% (n = 8 audits totalling 3041/3834 patients) to 86.0 ± 2.6% (n = 5 audits totalling, 2544/2958 patients) post-EMR with malnutrition screening completion increasing from 57.5% to 74.0%. Conclusions: Findings indicate that EMR implementation has the potential to benefit the dietetic profession due to the potential to enhance the capacity and efficiency of dietetic departments.

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.

Continuing professional development (CPD) continues to gain acceptance as a model for health care professionals to engage in lifelong learning. Little is known about how CPD participants put the experience and the new knowledge into practice and whether it has impact on patient care outcomes. The primary objective of this study was to evaluate the effectiveness of CPD of Midwives on Essential Maternal and Newborn care skills on maternal and neonatal mortality in Embu County, Kenya. The study was an interventional non-randomized pretest post test study design of midwives from the participants of the 2010 ministry of health training on essential maternal and newborn care skills. Sixty (60) midwives working in maternity unit of Embu level five hospitals were targeted. The study was carried out in two phases. Phase one involved environmental scanning of the factors that support good performance in the workplace using a questionnaire. Phase two involved evaluation of the impact by testing a hypotheses using data collected by use of questionnaires, evaluation checklist and chart audit. Data were analyzed using qualitative content analysis and presented using percentages and frequency tables. Chi-square test and correlation analysis were used to show the association between variables, which are midwives essential maternal and newborn care skills and maternal and neonatal mortality. A chi-square χ2 = 14.143, df = 9 and a coefficient = 0.357. This coefficient is less than p-value at Alpha 0.05 and therefore is not significant, proving that the essential maternal and neonatal care skills do not contribute to reduction in mortalities as such two variables are almost independent of each other, whether one exists does not necessitate the existence of another nor does it reduce maternal and neonatal mortalities in Kenya.

Nurses on a neurological step-down unit were challenged to switch from documenting assessments by hand to documenting by using a highly technological, electronic format. Upon the switch to electronic documentation, it was discovered through a chart audit that neurological assessments were not being documented properly. The purpose of this project was to implement Care Organizer, an electronic nurse reminder tool, on a neurological step-down unit and to evaluate the tool's ability to assist RNs in documentation of neurological assessments. Fifty patients' charts were audited for documentation of neurological assessments. Thirty-two RNs completed an anonymous demographic survey and were provided with eight training sessions related to utilization of Care Organizer. The RNs were asked to complete an evaluation of the tool 2 weeks after training and again at 1 month after training. A second chart audit was conducted at 1 month to assess for improvement of documentation 1 month after training. Preimplementation/postimplementation chart audits revealed improvements in documentation of neurological assessments in seven of eight criteria examined. Nurses admitted discomfort with Care Organizer and verbalized concerns that it was not convenient and/or user-friendly. Most admitted that with collaboration between information technology department and nursing, the tool could be further developed to become more applicable to nurses.

Introduction In recent years researchers have reported deficits in the quality of care provided to patients with rheumatoid arthritis (RA), including low rates of performance on quality measures. We sought to determine the influence of a quality improvement (QI) continuing education program on rheumatologists’ performance on national quality measures for RA, along with other measures aligned with National Quality Strategy priorities. Performance was assessed through baseline and post-education chart audits. Methods Twenty community-based rheumatologists across the United States were recruited to participate in the QI education program and chart audits. Charts were retrospectively audited before (n = 160 charts) and after (n = 160 charts) the rheumatologists participated in a series of accredited QI-focused educational activities that included private audit feedback, small-group webinars, and online- and mobile-accessible print and video activities. The charts were audited for patient demographics and the rheumatologists’ documented performance on the 6 quality measures for RA included in the Physician Quality Reporting System (PQRS). In addition, charts were abstracted for documentation of patient counseling about medication benefits/risks and adherence, lifestyle modifications, and quality of life; assessment of RA medication side effects; and assessment of RA medication adherence. Results Mean rates of documented performance on 4 of the 6 PQRS measures for RA were significantly higher in the post-education versus baseline charts (absolute increases ranged from 9 to 24% of patient charts). In addition, after the intervention, significantly higher mean rates were observed for patient counseling about medications and quality of life, and for assessments of medication side effects and adherence (absolute increases ranged from 9 to 40% of patient charts). Conclusion This pragmatic study provides preliminary evidence for the positive influence of QI-focused education in helping rheumatologists improve performance on national quality measures for RA. Electronic supplementary material The online version of this article (doi:10.1007/s40744-015-0018-7) contains supplementary material, which is available to authorized users.

Background: Patients with end-stage kidney disease often have difficulty in adhering to aspects of their haemodialysis regimens. Objectives: This study aimed to quantify the number of patients who attended 100% of their scheduled haemodialysis sessions, and the number of patients who gained no more than one kilogram per day between dialysis sessions, over a three-month period. Design: Retrospective chart audit Participants Patients undergoing haemodialysis at an in-hospital centre in tropical Australia. Methods: A renal nurse audited the 72 charts pertaining to a 12-week period in 2013. Results: Patients attended 90.1% of all scheduled dialysis sessions. Forty-one patients attended all sessions, with the remaining 31 missing at least one scheduled session. One patient missed 16 scheduled sessions. The following were statistically less likely to attend all their scheduled sessions: Aboriginal and Torres Strait Islander patients; patients on a three times per week dialysis schedule; patients who had relocated from rural or regional towns and younger patients. The average daily weight gain ranged from 0.414 kg to 1.017 kg (mean = 0.885 kg). Younger patients were statistically less likely to adhere to fluid restrictions; patients without diabetes were more likely to adhere to the fluid allowances. Conclusions and applications to practice: Renal services need to assist patients to adhere to their regimens. Initially, this service will examine strategies to maximise the likelihood of patients attending all of their dialysis sessions. Such an outcome will help to delay deterioration in the patients' health status, while minimising additional strain on the health service.

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.

Fluid balance charts are an important monitoring document for patient safety and clinical care. The National Confidential Enquiry into Patient Outcome and Death report shows that inaccurate fluid balance monitoring impacts patient deaths in the perioperative period.1 Our audit aimed to assess accuracy, completeness and attitudes towards fluid balance charts including evidence of appropriate escalation when required. This work is part of an ongoing audit conducted over an acute surgical and medical ward in a …

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.

Entrustable professional activities (EPAs) are complex tasks representing vital physician functions in multiple competencies, used to demonstrate trainee development along milestones. Managing a nephrology outpatient clinic has been proposed as an EPA for nephrology fellowship training.Retrospective cohort study of nephrology fellow outpatient clinic performance using a previously validated chart audit tool.Outpatient encounter chart audits for training years 2008-2009 through 2012-2013, corresponding to participation in the Nephrology In-Training Examination (ITE). A median of 7 auditors (attending nephrologists) audited a mean of 1,686±408 (SD) charts per year. 18 fellows were audited; 12, in both of their training years.Proportion of chart audit and quality indicator deficiencies.Longitudinal deficiency and ITE performance.Among fellows audited in both their training years, chart audit deficiencies were fewer in the second versus the first year (5.4%±2.0% vs 17.3%±7.0%; P0.001) and declined between the first and second halves of the first year (22.2%±6.4% vs 12.3%±9.5%; P=0.002). Most deficiencies were omission errors, regardless of training year. Quality indicator deficiencies for hypertension and chronic kidney disease-associated anemia recognition and management were fewer during the second year (P0.001). Yearly audit deficiencies ≥5% were associated with an ITE score less than the 25th percentile for second-year fellows (P=0.03), with no significant association for first-year fellows. Auditor-reported deficiencies declined between the first and second halves of the year (17.0% vs 11.1%; P0.001), with a stable positive/neutral comment rate (17.3% vs 17.8%; P=0.6), suggesting that the decline was not due to auditor fatigue.Retrospective design and small trainee numbers.Managing a nephrology outpatient clinic is an EPA. The chart audit tool was used to assess longitudinal fellow performance in managing a nephrology outpatient clinic. Failure to progress may be quantitatively identified and remediated. The tool identifies deficiencies in all 6 competencies, not just medical knowledge, the primary focus of the ITE and the nephrology subspecialty board examination.

Background: As cross-border migration increases internationally, speech pathologists will see growing numbers of people with aphasia from culturally and linguistically diverse (CALD) backgrounds. A...

Background: In Australia, 36% of women who experienced violence by a partner reported that this occurred when they were pregnant.1 Around seventeen percent of women experience domestic violence (DV) for the first time during pregnancy. Routine enquiry about domestic violence during pregnancy is now accepted best practice. Training is essential to improve knowledge and practice. Yet very few studies have undertaken a comprehensive evaluation of training impact over time. Aim: This presentation will provide an overview of an evaluation of the longitudinal impact of a domestic violence training and support program to promote midwives’ routine antenatal enquiry for domestic violence using a mixed methods design. Method: Data sources included (1) surveys of midwives at 6 months post-training, (2) interviews with key stakeholders at 12 months, (3) chart audit data of screening, risk, and disclosure rates (for 16 months). Measures included midwives’ knowledge and preparation for routine antenatal enquiry, and perceptions of organisational barriers to routine enquiry. Findings: Forty (out of 83) participant surveys could be matched and responses compared to baseline and post-training scores. Wilcoxon signed-rank test identified that all 6-month follow-up scores were significantly higher than those at baseline. Level of preparedness increased from 42.3 to 51.05 (Z = 4.88, p 90%) reported improved confidence to undertake routine inquiry. A chart audit of screening rates for 16 months post-training revealed of the 6671 women presenting for antenatal care, nearly 90% were screened. Disclosure of domestic violence was low (

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.

Background: Heart failure (HF) is the primary cause of hospitalizations and readmissions to a hospital within 30 days of initial discharge. In 2010 HF cost an estimated $39.2 billion in health care services, lost productivity and medications. Optimizing outpatient care is vital to effectively manage this patient population. Objective: The purpose of this paper is to describe and evaluate the effectiveness of an optimized outpatient HF clinic. Patient outcomes from a Midwestern community hospital were based on quality of life (QOL) and readmission rates. Methods: A retrospective chart audit was conducted on a random sample of patients enrolled in the Heart Failure Recovery Center (HFRC). The QOL outcomes were measured using the Minnesota Living with Heart Failure® Questionnaire. Results: Enrolled patients demonstrated improvement in their QOL in the emotional, physical, and overall scores across the first 6 months of care. In addition, there were significantly fewer 30-day all-cause readmissions when compared to non-Clinic patients. Conclusion: Utilization of an APN-managed multidisciplinary HF clinic improved patient's QOL and contributed to one hospital's decreased all-cause readmission rates for the HF population.

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.

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and is a well-known cause of oropharyngeal, cervical, vaginal, vulvar, penile, and anal cancers. Despite the proven efficacy of the HPV vaccine, vaccination rates remain persistently low. Much literature has focused on attitudes toward the HPV vaccine; however, researchers have also investigated strategies clinicians can use to improve vaccination attitudes and acceptance. Such strategies include provider education, vaccine reminder/recall, and chart audit and feedback. The purpose of this integrative review is to uncover the best evidence-based practice interventions, with the aim of improving HPV knowledge, patient-provider conversations, and immunization uptake. This integrative review concludes that multicomponent interventions have a synergistic effect, resulting in increased provider vaccine support, improved patient/parental attitudes toward HPV vaccination, and increased immunization uptake. Such strategies hold much promise for today's pediatric providers as they work to combat current vaccination disparities.

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.

Although complete healing may appear to be the logical goal for most patients and clinicians, some wounds do not have the potential to heal due to a number of factors such as inadequate vasculature, coexisting medical conditions and medications that prohibit the healing process. Local management of wounds that are considered to have poor potential for healing remains elusive. The purpose of this article is to review the evidence that supports the use of topical antiseptic agents in non-healable wounds. Retrospective chart audit was conducted to evaluate the use of povidone iodine in the management of wounds that were deemed to have poor healing potential.