Search

Background: Patients in rural Australia have limited access to intravitreal treatments due to a maldistribution of the ophthalmology workforce. To improve access, a novel outreach service model was implemented whereby junior medical staff administered intravitreal injections under a supervising ophthalmology consultant. This model involves outreach visits in hospitals, mobile clinics and a remote hub with intravitreal injections administered by junior doctors overseen by an ophthalmologist. The article explores the safety of this approach with respect to the rate of post‐injection endophthalmitis. Methods: A retrospective audit was conducted by the Lions Outback Vision outreach ophthalmology service from 2017 to mid‐2023. The number of injections, locations, diagnoses, intravitreal agents used, designation of administering doctor and cases of endophthalmitis were reviewed. Results: A 12 632 intravitreal injections were administered across 32 locations throughout rural Western Australia in the 6.5‐year period. Three cases of endophthalmitis occurred representing a rate of 0.0237%. Conclusion: The rate of endophthalmitis in the outreach service is comparable to other centres. The outreach model with supervising ophthalmology consultant support in person or via telehealth and administration of injections by junior medical staff has improved access for underserved or marginalised populations. [ABSTRACT FROM AUTHOR]

Surgical antibiotic prophylaxis (SAP) is an important preventive measure, aiming to minimize surgical site infections. However, despite evidence-based guidelines, adherence to SAP protocols remains suboptimal in clinical practice. The aim of this study was to assess the adequacy of SAP in a high-complexity hospital and investigate associated factors. A cross-sectional design was conducted, involving surgeries performed by expert teams in cardiology, urology, neurology, and gastrointestinal. SAP prescriptions were evaluated based on indication, antibiotic choice, dosage, and duration, according to the hospital protocol. Data analysis included descriptive statistics and association tests between protocol adherence and patient demographics, clinical variables, surgical teams, and types of surgeries. Out of 1,864 surgeries, only 20.7% adhered to SAP protocols. Lower adherence rates were observed for antibiotic choice and duration of prophylaxis. Neurological surgeries exhibited significantly lower adherence, particularly concerning antibiotic choice and duration. Factors associated with nonadherence included elevated preoperative blood glucose levels, prolonged hospitalization, and extended surgical duration. Logistic regression analysis identified surgical teams as significant factors influencing protocol adherence. Despite the relatively high adherence to antibiotic dosage, challenges persist in antibiotic choice and duration adjustment. Poor glycemic control, prolonged surgery, and surgical teams were variables associated with inappropriate practice. • Prescribers' adherence to surgical antibiotic prophylaxis (SAP) protocols is low. • The most frequent conduct is the prolongation of antimicrobial prophylaxis. • The use of antibiotics with a broader spectrum than necessary is also observed. • These practices are more common in neurological and urological surgeries. • Some poor clinical features were associated with inappropriate SAP utilization. [ABSTRACT FROM AUTHOR]

Background/Objectives: Evidence-based guidelines and care standards recommend offering oral nutrition supplements to all older adults with hip fracture, not just those already malnourished. This study aimed to identify the proportion of inpatients in a sample of hospitals in two countries that were provided with oral nutritional supplementation (ONS) following a hip fracture and to identify factors associated with ONS provision. Methods: An analysis of prospectively collected data from a bi-national Hip Fracture Registry nutrition sprint and registry audit data limited to older adults (≥65 years) undergoing surgical intervention for a fractured hip from 1 to 31 August 2021. Multivariable logistic regression was used to identify factors associated with providing ONS. Results: Patient-level data was available for 385 older adults (median 85 years; 60.5% female) admitted to twenty-nine hospitals. Less than half (n = 47.3%) of the audited inpatients were provided ONS. After adjusting for covariates, ONS was more likely to be provided to older adults who were identified as malnourished on formal testing (OR 11.92; 95%CI 6.57, 21.69). Other factors associated with prescription of ONS included those who did not have a preoperative medical assessment (OR 2.26; 95%CI 1.19, 4.27) or were cognitively impaired (OR 1.83; 95%CI 1.01, 3.32), severely frail, or terminally ill (OR 3.17; 95%CI 1.10, 9.17). Conclusions: ONS was provided in line with evidence-based recommendations for less than half of the older adults with a hip fracture in 29 hospitals in two countries. A structured approach to implementation may be required to reduce complications and improve outcomes for all older adults after a hip fracture, not just those assessed as cognitively impaired, frail, and/or malnourished. [ABSTRACT FROM AUTHOR]

Objective Survival of neonates with esophageal atresia (EA) is relatively high and stable, resulting in increased attention to optimizing care and longer-term morbidity. This study aimed to reach consensus on a quality indicator set for benchmarking EA care between hospitals, regions, or countries in a European clinical audit. Methods Using an online Delphi method, a panel of EA health care professionals and patient representatives rated potential outcome, structure, and process indicators for EA care identified through systematic literature and guideline review on a nine-point Likert scale in three questionnaires. Items were included based on predefined criteria. In rounds 2 and 3, participants were asked to select the five to ten most essential of the included indicators. Results An international panel of 14 patient representatives and 71 multidisciplinary health care professionals representing 41 European hospitals completed all questionnaires (response rate: 81%), eventually including 22 baseline characteristics and 32 indicators. After ranking, 10 indicators were prioritized by both stakeholder groups. In addition, each stakeholder group highly prioritized one additional indicator. Following an additional online vote by the other group, these were both added to the final set. Conclusion This study established a core indicator set of twenty-two baseline characteristics, eight outcome indicators, one structure indicator, and three process indicators for evaluating (quality of) EA care in Europe. These indicators, covering various aspects of EA care, will be implemented in the European Pediatric Surgical Audit to enable recognition of practice variation and focus EA care improvement initiatives. [ABSTRACT FROM AUTHOR]

Background/Objectives: There seems to be a global reduction in the number of clinical post-mortems requested and performed worldwide, suggesting a decreasing need for post-mortem examinations. Despite advances in medical technology, autopsies remain a relevant tool to determine cause of death. Methods: A total of 276 post-mortem results were extracted from the NHLS lab track database, of which only 152 were included in this study. Discrepancies between ante and post-mortem diagnoses were evaluated using the Goldman classification. Data were analysed using STATA-18. Results: The sample consisted largely of females (n = 101, 66.45%) aged 30 and above (n = 58, 33.80%), with a mean age of 28.3. Of the 152 samples analysed, 60% (n = 92) of all postmortems showed a correlation between ante- and post-mortem diagnoses. However, 29.1% (n = 45) of cases showed major discrepancies which could have been prevented if correct diagnoses were made. Metabolic diseases were most frequently misdiagnosed (p = 0.020), with more cases of Class I discrepancies than Class V discrepancies (15.5% (n = 7) vs. 2.1% (n = 2), respectively. Additionally, infections (n = 59; 39%) were the most common cause of death. Conclusions: Even with marked improvements in diagnostic technology, a post-mortem examination is a necessary quality control tool that can be used to verify cause of death, and thus improve clinical practice. [ABSTRACT FROM AUTHOR]

Assessment of pressure ulcer (PU) risk remains a challenge in clinical practice. The first part of this article (Martin and Holloway, 2024) discussed the evidence base underpinning the development of clinical guidelines for PUs alongside the creation of the bundle approach regarding PU prevention. This article, part two, presents the results of a clinical audit that explores compliance against a PU prevention bundle (the aSSKINg framework) in an adult community nursing setting in the south-east of England. The clinical audit was conducted between July-December 2021 and included records of 150 patients. Overall, compliance against the aSSKINg framework was poor, with only two criterion being met: equipment provision for chair and referral to the tissue viability team. Short-term recommendations are that mandatory PU training for staff in the management of PUs should be implemented, and the tissue viability nurse network should be increased. The long-term recommendation was the introduction of the aSSKINg framework as a template into the electronic patient record. [ABSTRACT FROM AUTHOR]

To analyse the compliance of surgical care provided to patients diagnosed with carcinoma endometrium, to the European Society of Gynaeacological Oncology (ESGO) quality indicators. This is a retrospective audit done in the Department of Gynaecologic Oncology. Electronic medical records of patients who underwent surgical management of carcinoma endometrium from January 2020 to December 2021 were assessed. A total of 163 patients had undergone primary surgery, and 2 patients had surgery for recurrence. The audit showed that the target for categories of general indicators and pre-operative work-up was met. There was lack in compliance to the intraoperative management, with only 34% among presumed early-stage disease undergoing successful MIS, 31% undergoing sentinel lymph node procedure and 53% among them being done using indocyanine green with 18% bilateral mapping rate. None of the patients had complete molecular classification. Compliance to adjuvant treatment provided was adequate. Minimal required elements in surgical reports were in 81% and pathological reports in 91% of patients falling short of the set target. The audit helped us identify the need to increase MIS and use and adapt sentinel lymph node procedure with ICG dye more aggressively. There also is a need for improvement in documentation of pertinent information on surgical and pathology reporting. Molecular classification should be routinely incorporated into the diagnostic algorithm to aid in adjuvant therapy. [ABSTRACT FROM AUTHOR]

Introduction: Preterm birth continues to be one of the most significant contributors to perinatal death. This study aims to evaluate the quality of antenatal care provided to women delivering preterm. Methods: This was a retrospective, descriptive, longitudinal review of all women who had antenatal care within a single Australian tertiary hospital and delivered spontaneously between 24 and 37 weeks of gestation, using an auditable scoring system assessing potential interventions for prevention of preterm birth. The review was limited to singleton pregnancies without fetal abnormalities delivering between January 2013 and April 2015. The audit tool was developed by reference to established 'best practice' guidance for prediction and prevention of preterm birth based on Royal Australian and New Zealand College of Obstetricians and Gynaecologists guidelines and published literature. Different pathways were assessed for women deemed either low- or high-risk at the outset of antenatal care. Results: A series of 161 pregnancies that delivered preterm (between 24 and 37 weeks' gestation) were reviewed. The quality of antenatal care was scored 'good' in 42.9% and 50% of high-risk and low-risk women, respectively. Care was scored 'adequate', with room for improvement in 51.4% and 45.2% of the two corresponding groups. The main deficiencies in care were recorded evidence of assessment of cervical length (absent in 35% of cases) and failure to screen for bacterial vaginosis in high-risk women. Conclusions: Auditing antenatal care for prevention of preterm birth allows identification of suboptimal practice allowing service improvement and potential intervention for preterm birth prevention. [ABSTRACT FROM AUTHOR]

(1) Background: Medication adherence is influenced by a variety of intricate factors, presenting hurdles for nurses working to improve it among adults with chronic conditions. Pinpointing the reasons for non-adherence is crucial for customizing interventions. The objective of this quality improvement project was to improve medication adherence among adults with chronic diseases in primary healthcare by promoting evidence-based practices, identifying barriers and facilitators to compliance, and developing strategies to ensure optimal adherence through engaging the nursing team, enhancing knowledge, and evaluating the effectiveness of the implemented strategies. (2) Methods: This study was a quality improvement project that utilized the JBI Evidence Implementation framework, the Practical Application of Clinical Evidence System, and the Getting Research into Practice audit tool across three phases: (i) forming a project team and conducting a baseline audit, (ii) offering feedback via the GRiP tool, and (iii) conducting a follow-up audit to assess best practice outcomes. The study was conducted between September 2021 and March 2022 in the community care unit of Algarve Regional Health Administration, targeting adults with chronic illnesses. (3) Results: A total of 148 individuals were audited, including 8 nurses, 70 baseline patients, and 70 post-implementation patients. Initial compliance with key best practices was low, with several criteria at 0% compliance at baseline. Post-intervention, we observed significant improvements; compliance with key best practices improved dramatically, with many reaching 100%. Notable improvements included enhanced patient education on medication management, regular medication adherence assessments, and increased engagement of healthcare professionals in adherence activities. (4) Conclusions: This quality improvement project demonstrated that structured, evidence-based interventions could significantly enhance medication adherence among adults with chronic diseases. The success of the project highlights the potential of similar strategies to be applied broadly in primary healthcare settings to improve health outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background The optimisation of patients in primary care is a prime opportunity to manage patient care within the community and reduce the burden of referrals on secondary care. This paper presents a quality improvement clinical programme taking place within an NHS Primary Care Network as part of the wider Leicester Leicestershire Rutland integrated chronic kidney disease programme. Method Patients are optimised to guidelines from the National Institute for Health and Care Excellence, by a primary care clinical team who are supported by nephrology consultants and nephrology pharmacists. Multidisciplinary team meetings take place with secondary care specialists and primary care staff. Learning is passed to the community clinicians for better patient treatment locally. Results A total of 526 patients were reviewed under this project.The total number of referrals to secondary care which were discharged following first outpatient appointment, reduced from 42.9% to 10%. This reduction of 32.9% represents the optimisation of patient cases through this quality improvement project. Patients can be optimised and managed within the community, reducing the number of unnecessary referrals to secondary care. Conclusion This programme has the potential to offer significant improvement in patient outcomes when expanded to a larger patient base. Medicine management and the use of clinical staff are optimised in both primary and secondary care.

Intravenous patient-controlled analgesia (PCA) is valuable for delivering opioids in a flexible and timely manner. Although it is designed to offer personalized analgesia driven by the patients themselves, users often report insufficient pain relief, which can be addressed by optimizing its settings and multimodal analgesia. We adopted a systematic approach to modify PCA protocols by utilizing a serial audit process based on institutional PCA data. This review retrospectively examined the process, encompassing data from 13,230 patients who had used PCA devices. The two modifications to the fentanyl-based PCA protocols resulted in three distinct phases. In the first phase, high opioid consumption and unintended PCA withdrawal were the common issues. These were addressed in the second phase by omitting the routine use of basal infusion. However, this led to increased delivery-to-demand ratios, mitigated in the third phase by increasing the bolus dose from 15 μg to 20 μg. These serial protocol changes have produced varied outcomes across different surgical departments, underscoring the need for careful and gradual adjustments and thorough impact assessments. Drawing insights from this audit process, we incorporated findings from the literature on PCA settings and multimodal analgesic approaches. This review underscores the significance of iterative feedback and refinement of analgesic protocols to achieve optimal postoperative pain management. Additionally, it discusses critical considerations regarding the postoperative audit processes.

(1) Background: Medication adherence is influenced by a variety of intricate factors, presenting hurdles for nurses working to improve it among adults with chronic conditions. Pinpointing the reasons for non-adherence is crucial for customizing interventions. The objective of this quality improvement project was to improve medication adherence among adults with chronic diseases in primary healthcare by promoting evidence-based practices, identifying barriers and facilitators to compliance, and developing strategies to ensure optimal adherence through engaging the nursing team, enhancing knowledge, and evaluating the effectiveness of the implemented strategies. (2) Methods: This study was a quality improvement project that utilized the JBI Evidence Implementation framework, the Practical Application of Clinical Evidence System, and the Getting Research into Practice audit tool across three phases: (i) forming a project team and conducting a baseline audit, (ii) offering feedback via the GRiP tool, and (iii) conducting a follow-up audit to assess best practice outcomes. The study was conducted between September 2021 and March 2022 in the community care unit of Algarve Regional Health Administration, targeting adults with chronic illnesses. (3) Results: A total of 148 individuals were audited, including 8 nurses, 70 baseline patients, and 70 post-implementation patients. Initial compliance with key best practices was low, with several criteria at 0% compliance at baseline. Post-intervention, we observed significant improvements; compliance with key best practices improved dramatically, with many reaching 100%. Notable improvements included enhanced patient education on medication management, regular medication adherence assessments, and increased engagement of healthcare professionals in adherence activities. (4) Conclusions: This quality improvement project demonstrated that structured, evidence-based interventions could significantly enhance medication adherence among adults with chronic diseases. The success of the project highlights the potential of similar strategies to be applied broadly in primary healthcare settings to improve health outcomes.

Introduction: Diarrhoea is the second leading cause of under-five mortality globally and ranks second among the top 10 priority child health problems in Nigeria. The World Health Organization (WHO) has recommended some cost-effective, evidence- based interventions for diarrhoea case management. It is needful to evaluate the current practice in the treatment of diarrhoea in under-fives in health facilities in the country. Objective: To determine the extent to which current treatment practice for diarrhoea in underfives conforms to the WHO recommendation. Method: A clinical audit was conducted between May and June 2013 in 32 health facilities in the Southern Senatorial district of Cross River State, Nigeria. Trained field workers extracted information from patients’ case records using a validated audit tool. Treatment was checked as appropriate, inappropriate, wrong or none, based on prescription on patients’ case records. Result: Of the 370 case records audited, prescription for diarrhoea was appropriate in 40 (10.8%), inappropriate in 231 (62.4%), wrong in 82 (22.2%) and no prescription was made in 17 (4.6%). Conclusion: Treatment of diarrhoea in under-fives in health facilities in the State is suboptimum. Retraining of health workers on the current WHO and UNICEF treatment guidelines is highly recommended.

Background: The optimisation of patients in primary care is a prime opportunity to manage patient care within the community and reduce the burden of referrals on secondary care. This paper presents a quality improvement clinical programme taking place within an NHS Primary Care Network as part of the wider Leicester Leicestershire Rutland integrated chronic kidney disease programme. Method: Patients are optimised to guidelines from the National Institute for Health and Care Excellence, by a primary care clinical team who are supported by nephrology consultants and nephrology pharmacists. Multidisciplinary team meetings take place with secondary care specialists and primary care staff. Learning is passed to the community clinicians for better patient treatment locally. Results: A total of 526 patients were reviewed under this project.The total number of referrals to secondary care which were discharged following first outpatient appointment, reduced from 42.9% to 10%. This reduction of 32.9% represents the optimisation of patient cases through this quality improvement project. Patients can be optimised and managed within the community, reducing the number of unnecessary referrals to secondary care. Conclusion: This programme has the potential to offer significant improvement in patient outcomes when expanded to a larger patient base. Medicine management and the use of clinical staff are optimised in both primary and secondary care. [ABSTRACT FROM AUTHOR]

Introduction: Clinical auditing represents a valuable and cost-effective method for the collection of patient outcomes and is increasingly being used to inform clinical guidelines. The aim of this clinical audit was to assess patient outcomes across a small subset of acupuncture practitioners and private practices in the United Kingdom. Methods: The Measure Yourself Medical Outcomes Profile (MYMOP) questionnaire and the Patient Global Impression of Change (PGIC) scale were used as outcome measures. Additional questions assessed adverse events and patient experience with care. Clinical data were collected utilising an electronic patient-reported outcome measures (ePROMs) system. Results: Baseline data were collected for a total of 233 health complaints (from 232 patients), of which 45.9% were musculoskeletal and 26.2% were psychological. Follow-up outcomes data were available for 144 health complaints (61.8% completion rate). For PGIC responses, >90% of health complaints were reported as at least 'minimally improved'. This was reduced to >51% when controlling for missing data. There was a gradual improvement in both mean MYMOP scores (24.5%–43.0%) and PGIC responses of 'very much improved' (12.3%–56.3%) over a 6-month period. A clinically significant improvement (>1 point change, p ⩽ 0.001) was seen in mean MYMOP scores compared to baseline from 4 to 8 weeks and symptom 1 MYMOP scores from 1 to 4 weeks. A moderately strong, negative correlation was seen between outcome measures (r = −0.507, p < 0.001). Conclusions: The majority of patients reported clinically meaningful improvements for their main health complaints/symptoms, which appeared to be sustained in the medium to long-term. [ABSTRACT FROM AUTHOR]

Background: Critical illness survival rates have improved, but patients frequently face prolonged new or worsened physical, cognitive and psychosocial impairments. These difficulties associated with critical care admission are known as post-intensive care syndrome (PICS). Aims: The multidisciplinary Intensive care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) programme was developed to support patients in the recovery period from critical illness. During the COVID-19 pandemic, the psychology support offered by this service was adapted from an in-person group to individual remote review. This audit evaluated both the extent to which this input aligned with the recommended guidelines and the acceptability of this adapted delivery to this patient group, which could help guide post-pandemic psychology input to the service. Study Design: The records of 207 patients were analysed retrospectively. The nature of support offered to a sub-sample of 50 patients detailed in clinical summary letters was compared with the Faculty of Intensive Care Medicine (2019) guidelines. Telephone calls were made to gather feedback on the virtual psychology support from 10 patients. Results: Psychological difficulties were identified by 111 of the 207 patients who attended the virtual clinic. A total of 88 of these patients accepted referral for virtual psychology support and 67 (76%) of those patients attended. The virtual psychology support offered was found to be largely in accordance with ICU aftercare guidance and acceptable to patients. Patients found the summary letters of consultations accurate and helpful. Most patients expressed a preference for in-person support and the opportunity to meet other patients. Conclusions: The adaptations to the psychology support offered by InS:PIRE during the COVID-19 pandemic were found to be largely in line with ICU aftercare psychology guidelines and were acceptable to patients. Further research is needed on future methods of delivering psychology support for this patient group. Relevance to Clinical Practice: This audit highlights issues important to patients in the post-ICU period based on individual consultations not previously possible. Patient opinion was sought on the impact of changing the delivery of post-ICU psychological support, which will help guide future improvements in the service. [ABSTRACT FROM AUTHOR]

Promoting safe sleep to decrease sudden unexpected infant death is challenging in the hospital setting. Concern for adherence to safe sleep practice across inpatient units at a large pediatric hospital. Used quality improvement methodologies to promote safe sleep across all units. Development of a multidisciplinary expert group, hospital-wide guidelines, targeted interventions, and bedside audits to track progress. Adherence to safe sleep practices improved from 9% to 53%. Objects in the crib were a major barrier to maintaining a safe sleep environment. Safe sleep practices were less likely to be observed in infants with increased medical complexity (p =.027). Quality improvement methodology improved adherence to infant safe sleep guidelines across multiple units. Medically complex infants continue to be a challenge to safe sleep. Therefore, ongoing education for staff and further research into best practices for the most complex infant populations are necessary. [ABSTRACT FROM AUTHOR]

Objective: A clinical audit was carried out on the opinions of doctors working in the Emergency Department (ED) of a large urban hospital regarding the diagnosis and management of cervical spine radiculopathy (CSR). Using international guidelines and current research, it aimed to determine if patients attending this ED were diagnosed and managed in line with best practice, and to identify any discrepancies or areas for improvement in relation to this. Method: Doctors working in this ED were sent an online questionnaire and descriptive analysis was performed on the results to ascertain how they diagnose and manage patients who present with symptoms of CSR. It covered; presentation and definitions of CSR, identification of red flags, clinical tests used, diagnostic test criteria, appropriate management, education and advice given, and the criteria for further management. Additionally, it looked at their opinion on the services' needs. Results: Most agreed that CSR will improve within 4 weeks with non‐operative management; however, there was a lack of consensus regarding the most affected nerve root, differential diagnosis and appropriate diagnostic tests. Opinions aligned regarding the identification of red flags and early management, especially with widespread neurological deficits. However, the management of ongoing pain or new neurological signs, differed between clinicians. Most participants strongly agreed that access to MRIs affected referrals within an ED episode. Conclusion: Overall, the opinions matched recommended guidelines; however, some gaps in knowledge and differing management approaches were identified, indicating the need for ongoing education and standardisation of management. [ABSTRACT FROM AUTHOR]

Pressure ulcers (PUs) represent a burden to the health economy and patients alike. Despite national and international guidelines regarding the management of risk, the incidence and prevalence across England remains high. Detecting early the risk of PUs is paramount, and requires using a valid risk assessment tool alongside clinical judgement and management of associated risk factors. There is a need to implement prevention strategies. Introducing care bundles for pressure ulcers, for example SKIN, SSKIN and most recently aSSKINg, is designed to guide clinicians and reduce variations in care. This article presents a review of the evidence on compliance with guidelines, frameworks, pathways or care bundles within primary and secondary care settings. This article focuses on the literature review that was conducted to inform a subsequent clinical audit of compliance with the aSSKINg framework in a Community NHS Foundation Trust in the South East of England. [ABSTRACT FROM AUTHOR]

Background and Aim: Test‐sets are standardized assessments used to evaluate reader performance in breast screening. Understanding how test‐set results affect real‐world performance can help refine their use as a quality improvement tool. The aim of this study is to explore if mammographic test‐set results could identify breast‐screening readers who improved their cancer detection in association with test‐set training. Methods: Test‐set results of 41 participants were linked to their annual cancer detection rate change in two periods oriented around their first test‐set participation year. Correlation tests and a multiple linear regression model investigated the relationship between each metric in the test‐set results and the change in detection rates. Additionally, participants were divided based on their improvement status between the two periods, and Mann–Whitney U test was used to determine if the subgroups differed in their test‐set metrics. Results: Test‐set records indicated multiple significant correlations with the change in breast cancer detection rate: a moderate positive correlation with sensitivity (0.688, p < 0.001), a moderate negative correlation with specificity (−0.528, p < 0.001), and a low to moderate positive correlation with lesion sensitivity (0.469, p = 0.002), and the number of years screen‐reading mammograms (0.365, p = 0.02). In addition, the overall regression was statistically significant (F (2,38) = 18.456 p < 0.001), with an R² of 0.493 (adjusted R² = 0.466) based on sensitivity (F = 27.132, p < 0.001) and specificity (F = 9.78, p = 0.003). Subgrouping the cohort based on the change in cancer detection indicated that the improved group is significantly higher in sensitivity (p < 0.001) and lesion sensitivity (p = 0.02) but lower in specificity (p = 0.003). Conclusion: Sensitivity and specificity are the strongest test‐set performance measures to predict the change in breast cancer detection in real‐world breast screening settings following test‐set participation. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this clinical audit was to assess patient demographics, outcomes and experience with care in patients who received acupuncture in a private practice setting in the United Kingdom. Methods: Demographic and clinical data were extracted from patients' records over a 7-year period. The Measure Yourself Medical Outcomes Profile (MYMOP) questionnaire and an adapted Patient Global Impression of Change (PGIC) scale were used routinely to monitor patient outcomes over an 18-month period. Finally, a retrospective questionnaire was used to assess patient beliefs regarding treatment effectiveness, adverse events and overall experience with care. Patients not providing consent or known to be deceased were excluded. Results: Data were collected for 306 patients presenting with 376 separate health complaints, 58% of which were musculoskeletal. Follow-up outcomes (MYMOP scores (n = 51) and PGIC scale responses (n = 50)) showed a clinically significant improvement compared to baseline for the majority of health complaints (93% of PGIC scores were 'improved' and 79% MYMOP demonstrated > 1 point change). Total mean MYMOP severity scores were reduced by almost 50% (p < 0.001) after 1–4 weeks, and this was sustained in the medium-to-long term. There was a strong negative correlation (r = −0.767, p < 0.001) between the MYMOP and PGIC scores. A total of 118 health complaints were reported by 85/255 patients who responded to a retrospective questionnaire. Over 84% of patients believed that the treatments they received were 'effective' at addressing their health complaints. Seven minor adverse events were reported and four patients experienced negative treatment outcomes. Conclusions: Although musculoskeletal conditions were the most common, this audit found that patients sought treatment for a wide range of predominantly chronic health complaints, for many of which there is a currently a lack of quality evidence to support the use of acupuncture. Overall, the small sample of patients who responded to outcome questionnaires reported clinically meaningful and sustained improvements. [ABSTRACT FROM AUTHOR]

Background: Our study focuses on vasectomies, an underutilised contraception method worldwide. Little is known about post-vasectomy semen analysis (PVSA) adherence in our setting, which is an essential step in confirming the procedure’s success. We aimed to describe patient adherence to post-vasectomy follow-up and the success of procedures performed by different surgeon categories at three Cape Town district health facilities. Methods: We conducted a retrospective descriptive audit. We extracted sociodemographic and procedural information from theatre records and patient folders. The PVSA results were retrieved from Groote Schuur Hospital’s Reproductive Medicine Unit. Results: The records of 270 patients who underwent vasectomies in local district-level facilities from September 2016 to July 2021 were included. Only 122 (45.2%) semen analysis results were retrievable, of which 115 (94.2%) showed that the procedure was successful. Incomplete patient records significantly impacted the study. A data-collection instrument and implementing standardised stationery were developed, which some sites already use. These measures are designed to ensure more comprehensive datasets for future audits. Conclusion: The study’s findings have identified flaws in record-keeping practices at the three study sites, a crucial step towards improving post-vasectomy care. Tracking procedural success and patient adherence to post-vasectomy semen analyses using the implemented stationery may assist future research and help drive quality improvement projects. Contribution: This audit strengthens our understanding of improving this underutilised family planning option in the district health services. In partnership with the local teams, a revised clinical care pathway was developed to inform the delivery of an evidence-informed vasectomy service.

Abstract Background The findings of pre-operative investigations help to identify risk factors that may affect the course of surgery or post-operative recovery by contributing to informed consent conversations between the surgical team and the patient, as well as guiding surgical and anesthetic planning. Certainly, preoperative tests are valuable when they offer additional information beyond what can be gathered from a patient’s history and physical examination alone. Preoperative testing practices differ significantly among hospitals, and even within the same hospital, clinicians may have varying approaches to requesting tests. This study aimed to investigate preoperative testing practices and compare them with the latest guidelines from the National Institute for Health and Care Excellence (NICE). Methods This three-month institutionally based study was carried out at the Debre Tabor Comprehensive Specialized Hospital from May 1 to July 30, 2023, including individuals aged 16 years and older who were not pregnant and had undergone elective surgery in the gynecological, orthopedic, and general units. Data on the sociodemographic characteristics, the existence of comorbidities, the invasiveness of surgery, and the tests taken into consideration by the guideline were gathered using a self-administered questionnaire. After rigorously analyzing and revising the results of preoperative investigation approaches, we compared them to the standard of recommendations. Moreover, the data was analyzed and graphically presented using Microsoft Excel 2013. Results During the data collection period, 247 elective patients underwent general, orthopedic, and gynecological operations. The majority of patients, 107 (43.32%), were between the ages of 16 and 40 and had an American Society of Anesthesiologists (ASA) class one (92.71%). 350 investigations were requested in total. Of these, 71 (20.28%) tests were ordered without a justified reason or in contravention of NICE recommendations. Conclusions In our hospital’s surgical clinical practice, unnecessary preoperative testing is still common, especially when it comes to organ function tests, electrocardiograms (ECGs), and complete blood counts (FBCs). When deciding whether preoperative studies are required, it is critical to consider aspects including a complete patient history, a physical examination, and the invasiveness of the surgery.

Abstract Background Chemotherapy, whilst treating tumours, can also lead to numerous adverse reactions such as nausea and vomiting, fatigue and kidney toxicity, threatening the physical and mental health of patients. Simultaneously, misuse of chemotherapeutic drugs can seriously endanger patients' lives. Therefore, to maintain the safety of chemotherapy for cancer patients and to reduce the incidence of adverse reactions to chemotherapy, many guidelines state that a comprehensive assessment of the cancer patient should be conducted and documented before chemotherapy. This recommended procedure, however, has yet to be extensively embraced in Chinese hospitals. As such, this study aimed to standardise the content of pre-chemotherapy assessment for cancer patients in hospitals and to improve nurses' adherence to pre-chemotherapy assessment of cancer patients by conducting a national multi-site evidence implementation in China, hence protecting the safety of cancer patients undergoing chemotherapy and reducing the incidence of adverse reactions to chemotherapy in patients. Methods The national multi-site evidence implementation project was launched by a JBI Centre of Excellence in China and conducted using the JBI approach to evidence implementation. A pre- and post-audit approach was used to evaluate the effectiveness of the project. This project had seven phases: training, planning, baseline audit, evidence implementation, two rounds of follow-up audits (3 and 9 months after evidence implementation, respectively) and sustainability assessment. A live online broadcast allowed all participating hospitals to come together to provide a summary and feedback on the implementation of the project. Results Seventy-four hospitals from 32 cities in China participated in the project, four withdrew during the project's implementation, and 70 hospitals completed the project. The pre-and post-audit showed a significant improvement in the compliance rate of nurses performing pre-chemotherapy assessments for cancer patients. Patient satisfaction and chemotherapy safety were also improved through the project's implementation, and the participating nurses' enthusiasm and belief in implementing evidence into practice was increased. Conclusion The study demonstrated the feasibility of academic centres working with hospitals to promote the dissemination of evidence in clinical practice to accelerate knowledge translation. Further research is needed on the effectiveness of cross-regional and cross-organisational collaborations to facilitate evidence dissemination.

Background: The findings of pre-operative investigations help to identify risk factors that may affect the course of surgery or post-operative recovery by contributing to informed consent conversations between the surgical team and the patient, as well as guiding surgical and anesthetic planning. Certainly, preoperative tests are valuable when they offer additional information beyond what can be gathered from a patient's history and physical examination alone. Preoperative testing practices differ significantly among hospitals, and even within the same hospital, clinicians may have varying approaches to requesting tests. This study aimed to investigate preoperative testing practices and compare them with the latest guidelines from the National Institute for Health and Care Excellence (NICE). Methods: This three-month institutionally based study was carried out at the Debre Tabor Comprehensive Specialized Hospital from May 1 to July 30, 2023, including individuals aged 16 years and older who were not pregnant and had undergone elective surgery in the gynecological, orthopedic, and general units. Data on the sociodemographic characteristics, the existence of comorbidities, the invasiveness of surgery, and the tests taken into consideration by the guideline were gathered using a self-administered questionnaire. After rigorously analyzing and revising the results of preoperative investigation approaches, we compared them to the standard of recommendations. Moreover, the data was analyzed and graphically presented using Microsoft Excel 2013. Results: During the data collection period, 247 elective patients underwent general, orthopedic, and gynecological operations. The majority of patients, 107 (43.32%), were between the ages of 16 and 40 and had an American Society of Anesthesiologists (ASA) class one (92.71%). 350 investigations were requested in total. Of these, 71 (20.28%) tests were ordered without a justified reason or in contravention of NICE recommendations. Conclusions: In our hospital's surgical clinical practice, unnecessary preoperative testing is still common, especially when it comes to organ function tests, electrocardiograms (ECGs), and complete blood counts (FBCs). When deciding whether preoperative studies are required, it is critical to consider aspects including a complete patient history, a physical examination, and the invasiveness of the surgery. [ABSTRACT FROM AUTHOR]

Background: Chemotherapy, whilst treating tumours, can also lead to numerous adverse reactions such as nausea and vomiting, fatigue and kidney toxicity, threatening the physical and mental health of patients. Simultaneously, misuse of chemotherapeutic drugs can seriously endanger patients' lives. Therefore, to maintain the safety of chemotherapy for cancer patients and to reduce the incidence of adverse reactions to chemotherapy, many guidelines state that a comprehensive assessment of the cancer patient should be conducted and documented before chemotherapy. This recommended procedure, however, has yet to be extensively embraced in Chinese hospitals. As such, this study aimed to standardise the content of pre-chemotherapy assessment for cancer patients in hospitals and to improve nurses' adherence to pre-chemotherapy assessment of cancer patients by conducting a national multi-site evidence implementation in China, hence protecting the safety of cancer patients undergoing chemotherapy and reducing the incidence of adverse reactions to chemotherapy in patients. Methods: The national multi-site evidence implementation project was launched by a JBI Centre of Excellence in China and conducted using the JBI approach to evidence implementation. A pre- and post-audit approach was used to evaluate the effectiveness of the project. This project had seven phases: training, planning, baseline audit, evidence implementation, two rounds of follow-up audits (3 and 9 months after evidence implementation, respectively) and sustainability assessment. A live online broadcast allowed all participating hospitals to come together to provide a summary and feedback on the implementation of the project. Results: Seventy-four hospitals from 32 cities in China participated in the project, four withdrew during the project's implementation, and 70 hospitals completed the project. The pre-and post-audit showed a significant improvement in the compliance rate of nurses performing pre-chemotherapy assessments for cancer patients. Patient satisfaction and chemotherapy safety were also improved through the project's implementation, and the participating nurses' enthusiasm and belief in implementing evidence into practice was increased. Conclusion: The study demonstrated the feasibility of academic centres working with hospitals to promote the dissemination of evidence in clinical practice to accelerate knowledge translation. Further research is needed on the effectiveness of cross-regional and cross-organisational collaborations to facilitate evidence dissemination. [ABSTRACT FROM AUTHOR]

Background: Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospital admission. However, the majority resolve spontaneously and only a minority require inpatient intervention. We aimed to describe the epidemiology and aetiology of acute LGIB admissions in our institution. We also aimed to validate the Oakland Score, which can identify patients at low risk of adverse outcome from LGIB, in our population and determine the proportion who could have safely avoided admission. Methods: Using the prospective, validated Otago Clinical Audit database (DIVA), we searched for adult patients admitted to Dunedin Hospital with a primary diagnosis of LGIB between January 2013 and December 2020. We retrieved data to calculate the Oakland Score and details of inpatient treatment from the electronic patient record. We excluded patients admitted electively, admissions related to inflammatory bowel disease, and those with upper gastrointestinal bleeding. Results: We identified 761 patients of which 501 met inclusion criteria (56% male, median age 76 years, 82% NZ European). Overall, 72% were managed with observation or diagnostic endoscopy, 32% received blood products, and 7% required haemostatic intervention to control bleeding. The area under the receiver operating characteristic curve for the Oakland Score was 0.85 (95% CI, 0.81–0.89). A cut‐off score of ≤10 predicted a 95% probability of safely avoiding admission. This equates to saving 30 bed‐days annually. Conclusion: The majority of patients admitted with LGIB are managed conservatively. The Oakland Score could be used as a stratification tool to safely reduce the admission rate. [ABSTRACT FROM AUTHOR]

Background: Surgical operation notes are crucial in maintaining patient safety and have medico-legal importance. We aimed to quantitatively assess and improve the content of operative notes in General Surgery at a district general hospital in London. Material and methods: 100 operation notes written between 26th July and 24th October 2022 were analysed retrospectively. Operation notes were awarded a point for each of the key details recommended by the Royal College of Surgeons (RCS) that they included. A new operative template, pre-populated with headings based on the RCS guidelines, was made available to the surgical team. A further 100 operation notes between 1st December 2022 and 28th January 2023 were assessed using the same scoring system as in Cycle 1. Results: Mean operation note score significantly increased from 75.7% in Cycle 1 to 81.0% in Cycle 2 (P = 0.021). In Cycle 2, the 33% of operation notes used the new template scored significantly higher than those that did not (98.5% vs 68.2%, P < 0.0001). Conclusion: Operation note quality can be significantly improved using a template based on RCS guidelines. Templates are a cost-effective way to promote safer postoperative care and reduce the risk of medico-legal action against the operating team. Brief Abstract: We assessed the quality of surgical operation notes at a district general hospital in London using criteria recommended by the Royal College of Surgeons, before and after introducing an electronic operation note template. We observed a significant improvement in operation note quality after implementing the template, suggesting that this is a cost-effective way to promote safer postoperative care and reduce the risk of medico-legal action against the operating team. [ABSTRACT FROM AUTHOR]

Background: Extrapyramidal symptoms (EPS) can cause significant morbidity and impact negatively on patients' quality of life. Clinical guidelines provide recommendations regarding screening frequency and the use of structured tools to ensure adequate monitoring of EPS. Despite this, the literature indicates that the documentation and monitoring of EPS remain suboptimal. Aims: To devise an intervention that would lead to the improvement in the documentation and hence monitoring of EPS. Methods: An initial paper chart survey was conducted to assess the current extent of documentation and monitoring of EPS carried out in patient files of three distinct settings in our Mental Health Service (MHS): inpatient, rehabilitation, and assertive outreach. An intervention aimed at improving practice was subsequently designed and implemented. This involved adoption by the MHS of a new EPS monitoring tool and delivery of an educational session regarding its use. The extent of documentation and monitoring of EPS was re-surveyed post-intervention. Results: Initially, only 14.8% of inpatient records contained evidence of EPS documentation while no evidence at all was found across the other two MHS settings. Following the intervention, there was evidence of guideline concordant EPS monitoring using a structured tool in the clinical records of 75% of inpatients, 79.6% in the rehabilitation setting, and 18% in the assertive outreach programme. Conclusion: Documentation of EPS monitoring improved significantly across several settings affiliated with a Dublin North City MHS following the systematic adoption of the Extrapyramidal Symptom Scale (EPSS) and clinician education regarding its use. [ABSTRACT FROM AUTHOR]

Background: Cancer is common, and most cancer patients present initially to a general practitioner. The COVID-19 pandemic led to changes in the delivery of primary care, which could have affected cancer referrals. This observational study looked at two-week cancer referrals made before, during and after the first UK COVID-19 lockdown in 2020, at a GP practice in the Wirral, England. Methods: A search was conducted to find the cancer referrals made between 23rd March 2020 - 1st July 2020, during the first lockdown. Using the same methodology, cancer referral data was collected for the corresponding time periods in 2019 and 2021. The number of referrals and positive diagnostic yields were then compared. Results: The number of cancer referrals decreased by 40.4% in 2020, compared to 2019. In 2021, the number of referrals then increased by 225%, compared to 2020. Overall, the number of cancer referrals increased between 2019-2021. The positive diagnostic yield for the 2020 2WRs increased by 251.4%, compared to that of 2019. The calculated yield for the 2021 data then decreased by 10.8% compared to 2020. Overall, the positive diagnostic yield increased between 2019-2021. Conclusion: The numbers and outcomes of cancer referrals at this Wirral GP practice have changed considerably following the first UK COVID-19 lockdown in 2020, and the influence of the pandemic was still affecting cancer referrals in 2021. A greater focus on early cancer detection in primary care could help overcome the ways in which the pandemic has affected primary care delivery.

Abstract Background Non-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) intervention was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop. However, the trial results indicated that the expected practice change did not occur. The process evaluation aimed to assess implementation using the Consolidated Framework for Implementation Research, identify barriers and enablers to implementation and provide insights into the lack of effect of the InterACT intervention. Methods Qualitative data collection involved 38 semi-structured interviews with participating clinicians, members of the executive advisory groups overseeing the intervention at a site level, clinical auditors, and project leads. Online interviews were conducted at two times: implementation onset and completion. Data were coded to the Consolidated Framework for Implementation Research and deductively analysed. Results Overall, clinicians felt the premise and clinical reasoning behind InterACT were strong and could improve patient management. However, several prominent barriers affected implementation. These related to the potency of the nudge intervention and its integration into routine clinical practice, clinician beliefs and perceived self-efficacy, and wider contextual factors at the health system level. Conclusions An intervention designed to change clinical practice for patients at or near to end-of-life did not have the intended effect. Future interventions targeting this area of care should consider using multi-component strategies that address the identified barriers to implementation and clinician change of practice. Trial registration Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 06/05/2019).

Abstract Background This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations. Methods Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators. Results Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators. Conclusions This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

Background: There have been many studies linking falls and benign paroxysmal positional vertigo. This article collates those studies, and demonstrates how a community falls service fast-tracked patients with benign paroxysmal positional vertigo by implementing validated screening tools and recognised guidance. Objective: This study aimed to explore whether routine screening of referrals to a community falls service can identify those with benign paroxysmal positional vertigo, for fast-tracked management. Methods: Patients referred to a community falls service were screened for possible benign paroxysmal positional vertigo using the Dizziness Handicap Inventory, and triaged to a physiotherapy-led falls and benign paroxysmal positional vertigo assessment service. Results: Twenty-five per cent of patients were fast-tracked to a falls and benign paroxysmal positional vertigo assessment service for management. The community falls service waiting list reduced by 25 per cent. Conclusion: The data support incorporating assessment and treatment of benign paroxysmal positional vertigo into routine practice within all falls services. [ABSTRACT FROM AUTHOR]

Abstract Background Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation. Methods Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff. Results The program’s audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy. Conclusions Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

Background/Objectives: There seems to be a global reduction in the number of clinical post-mortems requested and performed worldwide, suggesting a decreasing need for post-mortem examinations. Despite advances in medical technology, autopsies remain a relevant tool to determine cause of death. Methods: A total of 276 post-mortem results were extracted from the NHLS lab track database, of which only 152 were included in this study. Discrepancies between ante and post-mortem diagnoses were evaluated using the Goldman classification. Data were analysed using STATA-18. Results: The sample consisted largely of females (n = 101, 66.45%) aged 30 and above (n = 58, 33.80%), with a mean age of 28.3. Of the 152 samples analysed, 60% (n = 92) of all postmortems showed a correlation between ante- and post-mortem diagnoses. However, 29.1% (n = 45) of cases showed major discrepancies which could have been prevented if correct diagnoses were made. Metabolic diseases were most frequently misdiagnosed (p = 0.020), with more cases of Class I discrepancies than Class V discrepancies (15.5% (n = 7) vs. 2.1% (n = 2), respectively. Additionally, infections (n = 59; 39%) were the most common cause of death. Conclusions: Even with marked improvements in diagnostic technology, a post-mortem examination is a necessary quality control tool that can be used to verify cause of death, and thus improve clinical practice.

Background: Non-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) intervention was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop. However, the trial results indicated that the expected practice change did not occur. The process evaluation aimed to assess implementation using the Consolidated Framework for Implementation Research, identify barriers and enablers to implementation and provide insights into the lack of effect of the InterACT intervention. Methods: Qualitative data collection involved 38 semi-structured interviews with participating clinicians, members of the executive advisory groups overseeing the intervention at a site level, clinical auditors, and project leads. Online interviews were conducted at two times: implementation onset and completion. Data were coded to the Consolidated Framework for Implementation Research and deductively analysed. Results: Overall, clinicians felt the premise and clinical reasoning behind InterACT were strong and could improve patient management. However, several prominent barriers affected implementation. These related to the potency of the nudge intervention and its integration into routine clinical practice, clinician beliefs and perceived self-efficacy, and wider contextual factors at the health system level. Conclusions: An intervention designed to change clinical practice for patients at or near to end-of-life did not have the intended effect. Future interventions targeting this area of care should consider using multi-component strategies that address the identified barriers to implementation and clinician change of practice. Trial registration: Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 06/05/2019). [ABSTRACT FROM AUTHOR]

Background: Alpha-1 antitrypsin deficiency (AATD) is an underdiagnosed condition despite being one of the most common inherited disorders in adults that is associated with an increased risk of developing chronic obstructive pulmonary disease (COPD). The aim was to evaluate the frequency of performing AAT levels and associated factors in COPD patients in an audit conducted in 2021–2022, as well as to compare with a previous audit conducted in 2014–2015. Methods: EPOCONSUL 2021 is a cross-sectional audit that evaluated the outpatient care provided to COPD patients in respiratory clinics in Spain based on available data from medical registries. Results: 4225 patients with a diagnosis of COPD from 45 centers were audited in 2021. A total of 1670 (39.5%) patients underwent AAT determination. Being treated at a specialized COPD outpatient clinic (OR 1.88, p = 0.007), age ≤ 55 years old (OR 1.84, p = 0.007) and a FEV1 < 50% (OR 1.86, p < 0.001) were associated with a higher likelihood of being tested for AAT, while Charlson index ≥ 3 (OR 0.63, p < 0.001) and genotyping of AATD availability (OR 0.42, p < 0.001) showed a statistically significant negative association. The analysis of cases included in respiratory units that participated in both audits showed an increase in the proportion of cases with AAT serum level testing available (adjusted OR 2.81, p < 0.001). The percentage of individuals with serum AAT levels < 60 mg/dL (a severe AATD) was 4%. Conclusions: Our analysis identifies significant improvements in adherence to the recommendation to test AAT levels in COPD patients, performed in 4 out of 10 patients, being more likely at younger ages and with higher COPD severity, and with a detection of severe AATD of 4% among those tested, suggesting that clinicians still perform AAT testing in COPD patients selectively. Therefore, efforts are still needed to optimize AATD screening and establish new early detection strategies to reduce morbidity and mortality in these patients. [ABSTRACT FROM AUTHOR]

Introduction: The emergency department is a fast-paced and complex health care setting, where critical care is provided to patients of all ages. However, various environmental factors, such as high patient volumes, overburdened staff, and frequent nurse turnover, can hinder the use of evidence-based practices during procedural sedation. Proper patient monitoring is essential to prevent adverse events during procedural sedation. Objectives: The goal of this implementation project was to enhance compliance with best practices for patient monitoring during procedural sedation in the emergency department. Methods: The project used the JBI Model of Evidence-Based Healthcare and JBI's Getting Research into Practice (GRiP) tool for implementing evidence-based monitoring practices for adult patients during procedural sedation in the emergency department. A baseline audit was conducted to assess current practice against evidence-based recommendations, followed by the implementation of strategies to improve compliance with best practices. The project concluded with a follow-up audit to determine any improvement in practice. Results: The baseline audit revealed 81% overall compliance with evidence-based practice. Three barriers were identified, namely, lack of staff education, increased turnover rate of nurses, and the need for nurses to be mobile during procedural sedation. Strategies were implemented to improve compliance with evidence-based practice. The follow-up audit showed an overall improvement of 95% after project implementation. Conclusions: The project improved best practices for patient monitoring during procedural sedation in the emergency department. However, more work remains to be done to ensure the sustainability of the best practices, including monitoring of end-tidal capnography and vital sign assessment. [ABSTRACT FROM AUTHOR]

Rationale: Audit and feedback is an evidence‐based implementation strategy, but studies reporting the use of theory to guide design elements are limited. Aims and Objectives: Within the context of a programme of research aiming to improve the implementation of supported asthma self‐management in UK primary care (IMPlementing IMProved Asthma self‐management as RouTine [IMP2ART]), we aimed to design and develop theoretically‐informed audit and feedback that highlighted supported asthma self‐management provision and areas for improvement in primary care general practices. Method: Aligned with the Medical Research Council (MRC) complex intervention framework, the audit and feedback was developed in three phases: (1) Development: literature and theory exploration, and prototype audit and feedback design; (2) Feasibility: eliciting feedback on the audit and feedback from general practice staff (n = 9); (3) Prepiloting: delivering the audit and feedback within the IMP2ART implementation strategy (incorporating patient and professional resources and an asthma review template) and eliciting clinician feedback (n = 9). Results: Audit and feedback design was guided by and mapped to existing literature suggestions and theory (e.g., Theoretical Domains Framework, Behaviour Change Technique Taxonomy). Feedback on the prototype audit and feedback confirmed feasibility but identified some refinements (a need to highlight supporting self‐management and importance of asthma action plans). Prepiloting informed integration with other IMP2ART programme strategies (e.g., patient resources and professional education). Conclusion: We conclude that a multistage development process including theory exploration and mapping, contributed to the design and delivery of the audit and feedback. Aligned with the MRC framework, the IMP2ART strategy (incorporating the audit and feedback) is now being tested in a UK‐wide cluster randomised controlled trial. [ABSTRACT FROM AUTHOR]

The purpose of this project was to determine the extent to which physiotherapists affiliated to occupational health services undertake the full clinical audit cycle. A sample of convenience was used to select physiotherapists that were in attendance over two conference days. Those who verbally consented to take part were asked to complete a survey and place it in an envelope which was immediately sealed to maintain confidentiality of responses. The majority of physiotherapists undertook clinical audit practice (94%). The common frequency of clinical audits was annually (77%). Most physiotherapists did not contribute their clinical audit outcomes into any quality improvement initiatives (42%). Occupational health services should encourage physiotherapists affiliated to them to identify and link their outcomes into broader quality improvement initiatives so that the full audit cycle can be completed. [ABSTRACT FROM AUTHOR]

Background: This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations. Methods: Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators. Results: Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators. Conclusions: This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts. [ABSTRACT FROM AUTHOR]

The aims of the service evaluation were to examine the effectiveness of multi-family therapy for anorexia nervosa (MFT-AN) on family relationships, as well as to understand families' experiences of MFT in a specialist child and adolescent eating disorders service between 2013–2021. Mixed-methods were used (t -tests and reflexive thematic analysis). Delivery was in-person in 2013–2019, and moved online from 2020 due to COVID-19. Responses from a total of 57 families and 190 people were analysed. MFT improved family functioning from pre-to post MFT as measured by the Systemic Clinical Observation in Routine Evaluation (SCORE-15). Sub-group analysis by family roles showed that at four-month follow-up, the effects were no longer significant among parents. On the contrary, preliminary analysis showed that although young people did not report any improvement at post-intervention, family functioning was reported to increase at follow-up. Four themes were constructed: being together as a family and as a group ; individuality: everyone's recovery is different ; MFT as an emotion 'hotpot', and in-person versus virtual groups: not a one-size-fits-all. More robust follow-up data are needed to ascertain the effects of online MFT-AN. [ABSTRACT FROM AUTHOR]

Health care as a service organization is associated with hospital-acquired infection which is drawing attention. There are concerns raised by patients, attenders, stake holders, insurers, government agencies, and regulatory bodies. The study aims to evaluate the awareness and the rate of compliance with hand hygiene. The audit methodology implemented is a concurrent medical record audit. The period of the audit was conducted for 6 months. A random sampling method was incorporated. The sample size was determined as 20% of the staff had been involved. The Total average level of awareness of hand hygiene and adherence to policy is 93.6%. The average of all the 3 categories of compliance at 5 levels of hand hygiene in percentage is 82.3%. Hand hygiene practices if stringently implemented will minimize the cross-transmission of infection in health care facilities. By knowing the awareness level and compliance level are measured with standardized training modules. Create awareness on hand hygiene and provide training with respect to the effectiveness of implementation. Incorporate hand hygiene steps as well as in the audit process. There is a requirement for training with respect to the effectiveness of the implementation of the techniques. The level of care and quality of services can be made better by incorporating quality improvement programs (QIPs). By regular audits, we can raise the service quality and benchmark it. [ABSTRACT FROM AUTHOR]

Introduction: Because of poor knowledge and awareness, gynecological cancers are late in diagnosis and outcome is worse. Objective: The aim of this audit was to assess the trend of the gynecological cancers for the year of 2022. Methods: This is an observational study on retrospectively collected data of gynecological cancer patients at National Institute of Cancer Research and Hospital (NICRH), Dhaka. All cases of cancer seen at the gynecology outpatient department and cases admitted in the gynecological oncology ward at NICRH, between the months of January to December 2022 were audited. Results: The results shown that about 5.8% of all the new cases were young women aged below 25 years. The majority of gynecological cancers were among women aged between 35 and 64 years (73.17%) and only 2.6% patients were aged above 75 years. Cervical cancer (59%) was the leading gynecological cancer among all female cancers attended at NICRH. In ovarian malignancy, most of the patients(61%) had stage lll disease and no patient in stage IV diseases. Due to improper evaluation of abnormal uterine bleeding, majority of the endometrial carcinoma patients (64%) presented with histopathology reports after hysterectomy. Conclusion: Cervical cancer in the commonest gynecological malignancy in this series. Most of the ovarian malignancies were in stage III. This study might help to get a in depth understanding of the trend of major gynecological cancers. [ABSTRACT FROM AUTHOR]

Background: The 2014 British Thyroid Association guidelines acknowledged the value of risk-stratifying thyroid nodules by utilising an ultrasound reporting system ('U' classification). This study assessed whether using pre-existing parameters in combination can better stratify patients' malignancy and completion thyroidectomy risks. Method: A multicentre, retrospective, observational review identified 936 NHS Greater Glasgow and Clyde patients from pathology records who underwent hemithyroidectomy between 1 January 2014 and 31 December 2019. Results: A total of 308 patients had thyroid malignancy, 180 (58.4 per cent) progressed to completion thyroidectomy. A nodule classified as 'U3' (indeterminate) was associated with a 35.4 per cent chance of malignancy and a 21.6 per cent risk of requiring completion surgery. Amalgamation of 'U' score with Thy score enhanced risk prediction. The malignancy rate in U3, Thy-3f nodules was 38 per cent, and 21 per cent required completion surgery. The malignancy and completion thyroidectomy rates were comparatively lower for U3, Thy-3a nodules (22 per cent and 14.3 per cent, respectively). Conclusion: Combining ultrasound 'U' score and Thy score improves pre-operative thyroid nodule risk stratification, leading to better informed patients regarding the risks of malignancy and completion surgery. A move towards an integrated assessment approach should be considered. [ABSTRACT FROM AUTHOR]

Objective The aims of this study were to evaluate whether oral retinoids (isotretinoin) prescription in female patients of acne is following standard guidelines/set protocol or not. Methods This clinical audit involved 50 female patients of child bearing age, with acne taking oral isotretinoin, who presented in the outpatient department of Mayo hospital Lahore. Patients were diagnosed clinically by the presence of open and closed comedones, papules, pustules, nodules involving the seborrhoeic sites. An informed consent was taken after which they were asked the relevant questions from the questionnaire. The standard was that 100% of patients should be counseled about the key three components (1) Liver function tests and fasting lipid profile monitoring at baseline, (2) Counseling for contraception and (3) Counseling for depressive symptoms. Results Out of 50 patients enrolled in our study, all (100%) were females, mean age being 23.32.49 (98%) of our patients were being counseled for contraception, while in 37 (70%) of the patients, routine monitoring for liver function tests and fasting lipid profile was being carried out. 15 (37%) of our patients were being counseled for depressive symptoms. Conclusion Prescribing oral isotretinoin requires certain prerequisites that are being fulfilled. However, more focused perspective should be followed in this regard. [ABSTRACT FROM AUTHOR]

Background: Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation. Methods: Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff. Results: The program's audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy. Conclusions: Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection. [ABSTRACT FROM AUTHOR]

Introduction: Poststroke depression (PSD) is common but insufficiently addressed by health professionals, and management is not always evidence-based. Objectives: This evidence implementation project aimed to improve adherence to evidence-based practice for screening, prevention, and management of patients with PSD in the neurology ward of the Fifth Affiliated Hospital of Zunyi Medical University, China. Methods: This project was based on the JBI methodological approach and was conducted in three phases, from January to June 2021: a baseline audit, implementation of strategies, and a follow-up audit. We utilized the JBI Practical Application of Clinical Evidence System software and the Getting Research into Practice tools. Fourteen nurses, 162 stroke patients, and their caregivers participated in this study. Results: The results of the baseline audit showed that compliance with evidence-based practice was poor, with 3/6 criteria showing 0% adherence and the other three audit criteria showing 5.7, 10.3, and 49.4% adherence, respectively. Through feedback to nurses regarding the baseline audit results, the project team identified five barriers and adopted a battery of strategies to overcome these barriers. The follow-up audit revealed significantly enhanced outcomes across all the best practice criteria, and the compliance of each criterion reached at least 80%. Conclusion: The implementation program designed to screen, prevent, and manage PSD in a tertiary hospital in China improved nurses' knowledge and compliance with evidence-based management of PSD. Further testing of this program in more hospitals is needed. [ABSTRACT FROM AUTHOR]

Health care systems use auditing processes to monitor compliance with evidence-based practices. The auditing process for a bundle targeting central line-associated bloodstream infection prevention at a large children's hospital was suboptimal. The purpose of this project was to implement a revised audit and feedback data collection process. The specific aims of the project were to evaluate (1) the number of completed audits and, (2) central line maintenance bundle compliance rates before and after implementing a new process. An innovative, electronic audit process was developed to allow data entry in real-time as central line-associated bloodstream infection prevention champions conducted audits. Data were fed into a robust electronic dashboard, allowing units to readily visualize their performance. Data was analyzed over a 52-month period (26 months pre- and post-implementation). The number of central line maintenance bundle audits significantly increased post-implementation from an average of 36 to 64 per month, P =.001. Central line maintenance bundle compliance scores also increased from an average compliance score of 76.3% to 89.3%, P =.001. Special cause variation was also noted in the statistical process control charts. This project demonstrated the effectiveness of using an electronic process to capture audit data to assist with quality improvement efforts. Other institutions may consider implementing a similar electronic audit process to capture infection prevention compliance data. • Central line-associated bloodstream infections are a leading cause of patient harm. • Evidence-based central line maintenance bundles prevent infection. • Audit and feedback are essential to improve clinical practice and bundle compliance. • The use of an electronic audit process increased engagement and bundle compliance. • Observation of practice to promote real-time education improves bundle compliance. [ABSTRACT FROM AUTHOR]

Introduction. Audit of medical services is essential means for provision of the qualified medical care to civilian population. The laws and regulations of a particular country should be considered when this means is implemented. The aim. We have researched the theoretical and methodical approaches to audit system organization of medical service quality in healthcare institutions of Ukraine. Materials and methods. We have analyzed the ideas of experts according to their clinical effect; goals; results and purposes before and after the implementation and receiving the primary feedback. We have described the precise selection of indices according to their effectiveness, taking into account the theories and empiric investigation of the latest researches and articles. The process assessment would be employed in order to define the most effective components of the audit. Results. We have distinguished the criteria of medical care in relation to the quality constituents, such as: patient’s orientation, effectiveness, safety, accessibility, economical effectiveness, timeliness. The results of the indicators are entered into the reporting form. In addition, problems which were identified at the stage of processing the results, and prevent the correct interpretation of the obtained indicator values, should be recorded in the reporting form. Definitely, conducting a clinical audit requires significant administrative resources and high motivation of the healthcare institution staff. The personal traits of the head of institution, including abilities to motivate a team, to use the newest data of analytical systems and registries, to know the background of audit, play a key role in this process. Conclusions. The expediency of regular audits once every 6-12 months was proved. It is suggested that clinical audit be implemented in healthcare institutions in order to ameliorate the procedure and effectiveness of medical care to patients via in-depth analysis of the aid’s constituents in comparison to the defined criteria and implementation of necessary changes.