Search

Background: Acute Heart Failure (AHF) is a leading cause of hospitalizations and remains a significant socioeconomic burden. Despite advances in medical care, mortality and rehospitalization rates remain high. Previous AHF audits have revealed regional differences and a poor adherence to guidelines. This study aimed to assess guideline adherence in a public teaching hospital to identify areas for improvement. Methods: This retrospective observational study examined clinical routine data of patients hospitalized for AHF at a Swiss public teaching hospital between 2018 and 2019. AHF management was evaluated against the relevant guidelines of the European Society of Cardiology. Results: The study included 760 AHF cases of 726 patients (median age 84 years, range 45–101, 50% female). NT-pro-BNP levels were measured in 92% of the cases. Electrocardiography was performed in 95% and chest X-rays in 90% of cases. Echocardiography was conducted in 54% of all cases and in 63% of newly diagnosed AHF cases. Intravenous furosemide was initiated in 76%. In the subgroup of cases with reduced ejection fraction (HFrEF), 86% were discharged with beta-blockers and 69% with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Among cases with left ventricular ejection fraction ≤ 35%, mineralocorticoid receptor antagonists were prescribed in 55%. Conclusions: We observed generally good adherence to guideline recommendations. However, several improvements are needed in initial assessment and documentation, diagnostic procedures such as echocardiography, discharge medication, and lifestyle recommendations. Compared to other studies, our diagnostic workup was more aligned with guidelines, the use of intravenous diuretics was similar, and the duration of hospital stay and mortality rates were comparable. [ABSTRACT FROM AUTHOR]

Background The current hepatitis B (HBV) and hepatitis C virus (HCV) screening practices may fail to detect many infected patients who could benefit from new therapeutic agents to limit progression to cirrhosis and hepatocellular carcinoma. Objectives This study assessed the test positivity rate and cascade of care of viral hepatitis patients in primary care in a low endemic region as well as the testing policy of abnormal alanine aminotransferase (ALT) level. Methods This is a retrospective clinical audit among primary health care practices in Flanders, Belgium, assessing patients with an active medical file between 2019 and 2021. Results A total of 84/89 (94.4%) primary health care practices participated representing 621,573 patients of which 1069 patients (0.17%) were registered as having viral hepatitis, not further specified. Detailed information was available from 38 practices representing 243,723/621,573 (39.2%) patients of which 169 (0.07%) were HBsAg positive and 99 (0.04%) anti-HCV positive. A total of 96/134(71.6%) chronic HBV-infected and 31/77(40.3%) chronic HCV-infected patients were referred to a hepatologist. A total of 30,573/621,573(4.9%) patients had an abnormal ALT level, and by at random selection, more detailed information was obtained on 211 patients. Information on high-risk groups was missing in up to 60%. In patients with abnormal ALT level, HBsAg and anti-HCV testing were conducted in 37/211(17.5%) and 25/211(11.8%), respectively. Conclusion In a low endemic region, the testing rate and cascade of care of HBV and HCV-infected patients can be improved in primary care, especially in high-risk groups and patients with abnormal ALT levels. [ABSTRACT FROM AUTHOR]

Community genetic services were introduced in South Africa almost seven decades ago, with medical geneticists and genetic counsellors being formally recognized for the past 30 years. Initial training platforms were established at academic centres countrywide, and posts for relevant healthcare professionals, including medical geneticists and genetic counsellors were created in the public sector. Despite these early advances, the number of these specialists required to address the rising burden of congenital disorders in the country remains far below required targets established by the National Department of Health. The aim of this study was to analyse the retrospective, current and projected number of medical geneticists and genetic counsellors in South Africa. The results indicate the number of practicing medical geneticists (n = 13) and genetic counsellors (n = 28) are currently at 10% and 5% of capacity targets, respectively. There is unequal distribution of these specialists between the public and private healthcare sectors, and geographical maldistribution. An alarming trend of emigration is particularly prevalent among newly qualified genetic counsellors. With the proportion of congenital disorders expected to continue to rise in coming years, together with the increasing proportion of ageing South Africans, it is imperative that health workforce planning addresses the ever-widening gap between the supply, demand and unmet need for these crucial specialists in South Africa. [ABSTRACT FROM AUTHOR]

Impaired self-awareness impacts outcomes for individuals with brain injury. Self-awareness is a complex construct, with little known about how its presentation differs across diagnostic groups, or how brain injury-related changes are expressed by individuals in the early phase post-brain injury. This study aims to identify differences and similarities in patterns of self-awareness between patients with different brain injury diagnoses, and provide a clinical account of how individuals with ABI describe changes to themselves arising from brain injury. This is a mixed methods retrospective cohort study involving an audit of medical files that included extraction of data from the Self-Awareness of Deficits Interview. Quantitative and qualitative techniques were used to analyse data from 173 participants. Individuals identified a range of brain injury-related impairments across domains, with greatest difficulty noted with linking impairments to functional implications and setting realistic goals. There were similarities and distinct differences in the expression of changes across diagnostic groups. Two main themes that aligned with self-awareness theory were identified from the data: 1/ Development of self-awareness; and 2/ Dimensions of self-awareness. These interrelated themes demonstrated the multifaceted nature of the clinical presentation of self-awareness, and highlight the need for an individualized approach to cognitive rehabilitation. [ABSTRACT FROM AUTHOR]

Copyright of Public Money & Management is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective Design Setting Participants Main Outcome Measure(s) Results Conclusion To measure compliance with Advance Care Directives (ACDs) for decedents in a rural setting.Observational, cross‐sectional medical records audit comparing requests in ACDs with actual outcomes.Rural Australian coastal district.People who had an ACD, died during the study period (30 May 2020 to 15 December 2021) and participated in a local research project.Compliance was measured by comparing stated requests in the ACD with outcomes recorded in medical records. This included the place of death and a list of ‘unacceptable interventions’.Sixty‐eight people met the inclusion criteria (age range of 46–92 [mean 67 years; median 74 years]; 42 [62%] male). The main cause of death was cancer (n = 48; 71%). Preferred place of death was not stated in 16 ACDs. Compliance with documented preferred place of death was 63% (33/52): 48% (16/33) when the preferred place of death was home; 78% (7/9) when sub‐acute was preferred; and 100% (10/10) when hospital was preferred. Compliance was 100% with ‘unacceptable interventions’.These results demonstrate strong compliance with rural patients' requests in ACDs, particularly ‘unacceptable interventions’. Home was the most common preferred place of death, but the compliance measure (48%) was the lowest in this study. This requires further exploration. [ABSTRACT FROM AUTHOR]

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]

This document discusses the need for changes in pharmacy education in Poland in order to improve the quality of patient care. The role of pharmacists in Poland is currently limited to dispensing medications, and there is a lack of emphasis on pharmaceutical care and patient health outcomes. The document proposes a comprehensive strategy for curriculum reform, which involves analyzing the current environment, making strategic choices, and implementing solutions. The goal is to transform the curriculum to better prepare pharmacists to communicate effectively with healthcare professionals and patients, provide appropriate medication advice, and manage pharmacy resources. [Extracted from the article]

Background Headache disorders are globally prevalent and insufficient treatment contribute to low quality of life, increased disability, and socioeconomic costs. However, headache can to a large extent be treated appropriately by general practitioners. Objective To explore general practitioners' (GPs') management of patients with headache lasting ≥6 months. Methods In this retrospective descriptive cross-sectional study based on medical audit, all GPs practicing in Vejle municipality (population 116,992), Denmark, were invited to review their latest 20 patients with headache. Outcome measures were headache diagnostics, treatment, and referrals. Factors associated with referral to neurological treatment were examined by logistic regression. Results Of 26 invited practices, 19 participated reporting on 367 patients with lasting headache (71.4% women; mean-age 48.5 years). One hundred and sixty-one patients had migraine (44%; IQR: 28–60%), 140 (38%; IQR: 25–44%) had tension-type headache; 243 (66%; IQR: 50–79%) used simple analgesics, 147 (40%; IQR: 29–59%) triptans, 37 (10%; IQR: 0–14%) opioids, 93 (25%; IQR: 20–35%) were prescribed preventive medication; 176 (48%; IQR: 48–59%) were referred to neurologist, and 92 (25%; IQR: 10–37%) were referred to CT or MRI scan. Associated factors for referral were >1 headache diagnosis (aOR 1.75 [95% CI: 1.05–2.95]; P = 0.03), post-traumatic headache (aOR 2.53 [95% CI: 1.25–5.38]; P = 0.01), unspecific headache (aOR 2.04 [95% CI: 1.08–3.93]; P = 0.03), and using preventive treatment (aOR 2.75 [95% CI: 1.68–4.57]; P < 0.001). Conclusion This study provides insights to how GPs manage patients with long-lasting headache. Focus should be on reducing opioids, increasing preventive treatment, and keeping more patients in primary care. [ABSTRACT FROM AUTHOR]

Background: Gonorrhoea notifications have increased substantially in Australia over the past decade. Neisseria gonorrhoeae is already highly resistant to several antibiotics and so, alternatives to first-line treatment are generally strongly discouraged. The penicillin allergy label (AL) on patient medical records has previously been shown to influence prescribing practices, to the detriment of best-practice management and antimicrobial stewardship. This study aimed to understand how the penicillin AL influences antibiotic selection for gonorrhoea treatment at Canberra Sexual Health Centre. Methods: A retrospective chart audit of gonorrhoea cases treated at Canberra Sexual Health Centre between January 2020 and October 2023 (n = 619 patients, n = 728 cases). Antibiotic selection was assessed according to penicillin AL status. Ceftriaxone selection was assessed according to penicillin allergy severity reported in the medical records and as determined using a validated antibiotic allergy assessment tool. Results: Cases with a penicillin AL were more likely to receive antibiotics other than ceftriaxone (n = 7/41, 17.1%) than cases without the label (n = 8/687, 1.2%, P < 0.000). Most penicillin ALs had non-specific severity ratings in the medical records, but had insufficient information (n = 28/41, 68.3%) to apply the assessment tool. Those reported as low-severity in the records were more likely to receive ceftriaxone (n = 21/22, 95.5%) than those reported as moderate–high (n = 7/11, 63.6%) or unreported (n = 6/8, 0.75%). Conclusions: Treatment of gonorrhoea in outpatient settings requires an understanding of penicillin allergy, and the ability to quickly and accurately identify penicillin-AL patients who can safely tolerate ceftriaxone. Institutionally endorsed penicillin allergy de-labelling protocols and access to easy-to-navigate prescribing advice within national sexually transmitted infection management guidelines would support this. Although designed to protect patients, the penicillin allergy label on medical records is associated with increased use of less effective, more toxic and more expensive antibiotics. This study found that patients with the label were significantly less likely to receive first-line treatment (ceftriaxone) for gonorrhoea infection, even if they were likely able to tolerate the antibiotic. This impact on antibiotic prescribing is detrimental to patient care, healthcare costs and antimicrobial stewardship, and may occur in other jurisdictions, populations and care settings. [ABSTRACT FROM AUTHOR]

To analyze the research status of clinical governance (CG); the most productive authors, countries and organizations; connections among research themes. We used a 'funnel model', consisting of 3 layers describing various CG domains and settings. We retrieved bibliometric data from 1998 to 2021 from the Scopus database. Text mining, visual analysis, descriptive statistics and data visualization were performed. Citation bursts were detected. The total number of studies was 2429. On a global scale, there is a swinging trend in publications, with four peaks detected (2000, 2009, 2013, 2021). Citation burst keywords include: "national health service", "medical audit", "psychological aspect", "quality improvement" and "surveys and questionnaires". UK is the most productive and cited country. The most active organizations were in the UK, Australia, USA, Italy and Iran. The most productive journals and authors were identified. The most frequent keywords identified were 'health care quality', 'clinical governance', 'organization and management' and 'medical audit'. Research trends for each CG domain and setting type were reported. By using scientometric methodology, we created a thorough scientific picture on CG, including the mapping of pivotal concepts as a function of time. [ABSTRACT FROM AUTHOR]

In 2016, a new addiction treatment service, Allorfik, was introduced in Greenland. Allorfik has, throughout the implementation and after, used auditing of patient records with feedback to develop the quality of care in treatment. Audits and feedback are routinely done in each treatment center. This study wishes to investigate the development of the quality of treatment through the case notes from the journal audits. This study is based on case notes audits from 2019, 2020 and 2021. In the audits, the focus has been on the quality of documentation and content for ten specific areas in each patient record. Each area was scored on a Likert scale of 0–4 for both outcomes. Statistical analyses were done using Stata 17, and P-values < 0.05 were considered statistically significant. We present baseline characteristics for patients and illustrate the development of quality for both outcomes as time trends with scatter plots. The analysis was based on data from 454 patients and audits of their case notes. The mean number of weeks in treatment is 12.72, and the mean age for the people in the audited case notes is 39. Time had a positive effect on both outcomes, and so each month, documentation increased by 0.21 points (p-value = <0.001), and content increased by 0.27 points (p-value = <0.001). For documentation and content, the quality level has increased significantly with time, and the quality of case notes is at an excellent level at the final audits of all treatment centers. [ABSTRACT FROM AUTHOR]

Background: In recent decades, venous thromboembolism (VTE) has been acknowledged as a health issue that can be prevented. Among hospitalized patients, thromboembolism is a serious complication. Patients in the intensive care unit (ICU) are more susceptible to thrombotic events because of supplementary risk factors like central catheters, mechanical ventilation, and immobilization. Aim: This study aims to assess the appropriateness of VTE prophylaxis practices in a medical ICU of a tertiary care hospital. The IMPROVE VTE RAM was compared with clinical judgment for any significant difference in the risk assessment. Methods: It was a retrospective cross sectional observational study carried out on the patients admitted to the medical ICU of the Vascular Surgery department from March 2023 to August 2023. Medical records and risk assessment were done using the IMPROVE VTE RAM. The prophylaxis was given to patients based on American Society of Haematology (ASH) guidelines. Results: This was a 6 months retrospective study and a total number of 50 patients were included in the study. However, appropriate risk assessment was not done in any patient. Based on IMPROVE VTE RAM 1 patient (2%) was in low risk, 37 (74%) in moderate risk, and 12 (24%) in high risk for VTE. Thus Prophylaxis was given to a total of 44 patients out of which 27 received unfractionated heparin and the rest of all patients received Low Molecular Weight Heparin. Mechanical prophylaxis was given to 2 patients. The regular emphasis on DVT prophylaxis and the critical care nurses' ongoing daily audit were able to commence DVT prophylaxis in the majority of patients. According to IMPROVE VTE RAM, the accuracy of clinicians' judgment in comparison to validated risk assessment tools was only 89%. Conclusion: Critically ill admitted patients are more likely to experience VTE and bleeding episodes. Therefore adequate prophylaxis is essential but unfortunately is not routinely used in critical care settings. There is an urgent need to identify the gaps and address areas such as thromboprophylaxis and consistent care that require attention. Healthcare professionals must be made aware of the significance of risk assessment for bleeding and VTE in all critically ill patients, using any validated risk assessment tool. [ABSTRACT FROM AUTHOR]

Introduction: In the backdrop of escalating healthcare costs and an increasing focus on resource optimization, this audit study delves into the realm of anesthesia management, specifically exploring the application of low-flow anesthesia (LFA). The primary objective was to assess adherence to hospital standards and evaluate the economic implications of LFA (<1 L/min). Materials and Methods: This retrospective audit focused on 700 adult patients undergoing elective surgeries with general anesthesia. Data sources included anesthesia records, electronic recording systems, and audits by a dedicated team. Fresh gas flow rates (FGFRs), minimum alveolar concentration (MAC), and volatile anesthetic consumption were analyzed. Cost comparisons between low-flow and high-flow anesthesia were conducted, employing specific cost per milliliter metrics. Results: The average FGFR during the maintenance phase was found to be 0.45 ± 0.88 L/min. Adherence to hospital standards was notably high, with 94.29% of patients being maintained on low-flow gas rates. The differences in anesthetic consumption between low-flow and high-flow FGFR were statistically significant for both desflurane (12.17 ± 10.84 ml/MAC hour versus 43.12 ± 27.25 ml/MAC hour) and sevoflurane (3.48 ± 7.22 ml/MAC hour versus 5.20 ± 5.20 ml/MAC hour, P < 0.001). The calculated savings per patient with low-flow desflurane and sevoflurane anesthesia compared to high flow were found to be 109.25 AED and 6.74 AED, respectively. Conclusion: This audit advocates for the widespread adoption of LFA as a standard practice. Beyond aligning with hospital standards, the study highlights the multi-faceted benefits of LFA, encompassing economic savings, environmental safety, and enhanced patient care. [ABSTRACT FROM AUTHOR]

Introduction: The International Atomic Energy Agency (IAEA) introduced a Quality Management Audits in Nuclear Medicine (QUANUM) programme, to improve nuclear medicine practice standards aligned with international standards through self‐assessments. The absence of quality management audits in nuclear medicine departments could potentially result in a compromise in the safety and quality of patient care. To date, there is no evidence that quality audits have been conducted in nuclear medicine departments of this middle‐income country. This quality audit, therefore, assessed conformance to the IAEA QUANUM programme in four nuclear medicine departments. Methods: The study adopted a quantitative methodological exploratory approach. The IAEA QUANUM programme was used to audit nuclear medicine services' overall activity such as clinical practice, management, radiopharmacy, general and radiation safety, quality assurance, operations and services. The data was collected via document analysis in four nuclear medicine department identified as Sites A–D. Results: Overall results showed that Site A conformed with 247 out of 370 (67%) counts and non‐conformed with 123 out of 370 (33%) counts whilst Site B conformed with 205 out of 342 (60%) counts and non‐conformed with 137 out of 342 counts (40%). Site C conformed with 259 out of 345 (75%) counts and non‐conformed with 86 out of 345 (25%) counts. Site D conformed with 166 out of 349 (48%) counts and non‐conformed with 183 out of 349 (52%) counts. The study yielded 125 overall recommendations. Conclusions: All the sites demonstrated good compliance to international standards in radionuclide therapy. Site A complied poorly in strategies and policies, whilst Site B complied poorly in quality control of equipment. Site C showed poor compliance to human resource development and Site D showed aspects pertaining to administration and management as well as evaluation of quality systems. [ABSTRACT FROM AUTHOR]

Background and objectives: Some hospital dental departments offer treatment such as full dental clearance to low income, high health needs patients, as capacity allows. Many patients accessing this pathway have chronic health conditions. This study describes an interdepartmental quality assurance initiative, which included a clinical audit focussed on measuring equity of access to a hospital dental clearance pathway. This study's secondary focus on diabetes was because it is an example of a chronic health condition associated with high health needs and suboptimal oral health. Methods: This retrospective clinical audit reviewed e-health records of consecutive patients accessing Te Whatu Ora Waitaha's dental clearance pathway over eighteen months. Demographic data included prioritised ethnicity and NZDep2018. Clinical data included clinical diagnoses, medications, and for patients with diabetes, HbAlc (glycated haemoglobin). Results: Dental and medical records of 220 patients were reviewed. 23% were Maori and 17% had diabetes. Patients undergoing dental clearance had a higher NZDep2018 score, when compared to the local adult population (p<0.001). Summarising clinical data from those with diabetes (N=37), and without diabetes (N=183), showed that diabetes was associated with a greater number of diagnoses (p<0.001), and more prescribed medications (p<0.001). Most people with diabetes had an HbAlc above target. Conclusions: This study showed that it is possible to develop a pathway for publicly funded dental clearance so that barriers to access are minimised for patients with high social deprivation, Maori, and those with long-term conditions such as diabetes. This approach allowed the hospital dental service to focus on patients with the highest health needs. [ABSTRACT FROM AUTHOR]

Abstract Background Audit and feedback (A&F) is a widely used implementation strategy to evaluate and improve medical practice. The optimal design of an A&F system is uncertain and structured process evaluations are currently lacking. This study aimed to develop and validate a questionnaire to evaluate the use of automated A&F systems. Methods Based on the Clinical Performance Feedback Intervention Theory (CP-FIT) and the REFLECT-52 (REassessing audit & Feedback interventions: a tooL for Evaluating Compliance with suggested besT practices) evaluation tool a questionnaire was designed for the purpose of evaluating automated A&F systems. A Rand-modified Delphi method was used to develop the process evaluation and obtain validation. Fourteen experts from different domains in primary care consented to participate and individually scored the questions on a 9-point Likert scale. Afterwards, the questions were discussed in a consensus meeting. After approval, the final questionnaire was compiled. Results A 34-question questionnaire composed of 57 items was developed and presented to the expert panel. The consensus meeting resulted in a selection of 31 questions, subdivided into 43 items. A final list of 30 questions consisting of 42 items was obtained. Conclusion A questionnaire consisting of 30 questions was drawn up for the assessment and improvement of automated A&F systems, based on CP-FIT and REFLECT-52 theory and approved by experts. Next steps will be piloting and implementation of the questionnaire.

Despite clear benefit from palliative care in end-stage chronic diseases, access is often limited, and rural access largely undescribed. This study sought to determine if a palliative approach is provided to people with chronic disease in their terminal hospital admission. Multisite, retrospective medical record audit, of decedents with a primary diagnosis of chronic lung, heart, or renal failure, or multimorbidity of these conditions over 2019. Of 241 decedents, across five clinical sites, 143 (59.3%) were men, with mean age 80.47 years (SD 11.509), and diagnoses of chronic lung (n = 56, 23.2%), heart (n = 56, 23.2%), renal (n = 24, 10.0%) or multimorbidity disease (n = 105, 43.6%), and had 2.88 (3.04SD) admissions within 12 months. Outpatient chronic disease care was evident (n = 171, 73.7%), however, contact with a private physician (n = 91, 37.8%), chronic disease program (n = 61, 25.3%), or specialist nurse (n = 17, 7.1%) were less apparent. " Not-for-resuscitation " orders were common (n = 139, 57.7%), however, advance care planning (n = 71, 29.5%), preferred place of death (n = 18, 7.9%), and spiritual support (n = 18, 7.5%) were rarely documented. Referral to and input from palliative services were low (n = 74, 30.7% and n = 49, 20.3%), as was review of nonessential medications or blood tests (n = 86, 35.7%, and n = 78, 32.4%). Opioids were prescribed in 45.2% (n = 109). Hospital site and diagnosis were significantly associated with outpatient care and palliative approach (P <0.001). End-of-life planning and specialist palliative care involvement occurred infrequently for people with chronic disease who died in rural hospitals. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations. [ABSTRACT FROM AUTHOR]

Clinical trial participation continues to be low, slowing new cancer therapy development. Few strategies have been prospectively tested to address barriers to enrollment. We investigated the effectiveness of a physician audit and feedback report to improve clinical trial enrollment. We conducted a randomized quality improvement study among radiation oncologists at a multisite tertiary cancer network. Physicians in the intervention group received quarterly audit and feedback reports comparing the physician's trial enrollments with those of their peers. The primary outcome was trial enrollments. Among physicians randomized to receive the feedback report (n = 30), the median proportion of patients enrolled during the study period increased to 6.1% (IQR, 2.6%-9.3%) from 3.2% (IQR, 1.1%-10%) at baseline. Among those not receiving the feedback report (n = 29), the median proportion of patients enrolled increased to 4.1% (IQR, 1.3%-7.6%) from 1.6% (IQR, 0%-4.1%) at baseline. There was a nonsignificant change in the proportion of enrollments associated with receiving the feedback report (−0.6%; 95% CI, −3.0% to 1.8%; P =.6). Notably, there was an interaction between baseline trial accrual and receipt of feedback reports (P =.005), with enrollment declining among high accruers. There was an increase in enrollment throughout the study, regardless of study group (P =.001). In this study, a positive effect of physician audit and feedback on clinical trial enrollment was not observed. Future efforts should avoid disincentivizing high accruers and might consider pairing feedback with other patient- or physician-level strategies. The increase in trial enrollment in both groups over time highlights the importance of including a comparison group in quality improvement studies to reduce confounding from secular trends. [ABSTRACT FROM AUTHOR]

A shift in practice by anaesthetists away from anaesthetic gases with high global warming potential towards lower emission techniques (e.g. total intravenous anaesthesia) could result in significant carbon savings for the health system. The purpose of this qualitative interview study was to understand anaesthetists' perspectives on the carbon footprint of anaesthesia, and views on shifting practice towards more environmentally sustainable options. Anaesthetists were recruited from four hospitals in Western Sydney, Australia. Data were organised according to the capability–opportunity–motivation model of behaviour change. Twenty-eight anaesthetists were interviewed (July−September 2021). Participants' age ranged from 29 to 62 years (mean 43 years), 39% were female, and half had completed their anaesthesia training between 2010 and 2019. Challenges to the wider use of greener anaesthetic agents were identified across all components of the capability–opportunity–motivation model: capability (gaps in clinician skills and experience, uncertainty regarding research evidence); opportunity (norms, time, and resource pressures); and motivation (beliefs, habits, responsibility and guilt). Suggestions for encouraging a shift to more environmentally friendly anaesthesia included access to education and training, implementing guidelines and audit/feedback models, environmental restructuring, improving resource availability, reducing low value care, and building the research evidence base on the safety of alternative agents and their impacts on patient outcomes. We identified opportunities and challenges to reducing the carbon footprint of anaesthesia in Australian hospitals by way of system-level and individual behavioural change. Our findings will be used to inform the development of communication and behavioural interventions aiming to mitigate carbon emissions of healthcare. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to determine the extent to which people admitted to a private psychiatric inpatient unit access and utilise the gymnasium and individualised coaching with an exercise physiologist (EP). Methods: An audit of the medical record of 100 consecutive discharges and 60 individuals referred to an EP during the audit period was undertaken. Selected demographic information, physical health status, psychiatric diagnosis and routinely collected outcome data were extracted from files. Results: Twenty-four percent of people discharged from the hospital had documentary evidence of having attended the gym. These people were noted to have used the gym regularly and had an exercise prescription documented on discharge. Those with substance use disorder were more likely to use the gym than those diagnosed with an affective disorder. There were no significant differences in outcomes between those who were noted to exercise and those who did not. Conclusion: Those who may most benefit from coaching around exercise in the context of hospital admission are not presently the individuals most likely to be referred to an EP. Standardised procedures for assessment, referral, exercise prescription and ongoing monitoring of activity and outcomes are recommended across the care continuum. [ABSTRACT FROM AUTHOR]

Objective: This study examined the rates and persistence of clozapine-induced tachycardia and heart-rate differences in patients treated with β-blockers in the largest sample of patients with a psychotic disorder to date. Method: An audit of medical files for 101 patients who attended a clozapine community clinic and analysis of monthly measurements of resting heart rates. Results: 51% met the clinical criteria for tachycardia. Heart rates were stable over time. β-blockers were associated with small but significant reductions in heart rates. Conclusion: The cardiovascular risks of clozapine are often overlooked. β-blockers are useful in lowering heart rates but they may be insufficient to reduce cardiac risk. [ABSTRACT FROM AUTHOR]

Purpose: Survivorship care plans (SCP) are recommended as integral to survivorship care but are not routinely provided in many centers. We explore whether SCP from the Sydney Cancer Survivorship Centre (SCSC) clinic was received by general practitioners (GP) and cancer specialists, and their views on SCP. Methods: A mixed‐method study comprising a quality assurance audit, a questionnaire of GP practices and GP, and semi‐structured interviews of cancer specialists who referred patients to the SCSC clinic between 2019–2020. Descriptive statistics were used for quantitative data and content analysis for qualitative data. Results: The audit found 153/190 (80.5%) SCSC attendees had SCP uploaded to hospital medical records. The response rate from GP practices was 41%; among the 55 responding practices, 38 (69%) did not receive the SCP. The response rate from GP was 19%; among the 29 responding GP, 25 (86%) indicated the SCP was worthwhile, especially follow‐up plans and multidisciplinary team recommendations. Analysis of 14 cancer specialist interviews identified themes of 1) awareness of SCP; 2) access: SCP difficult to locate; 3) process: access and distribution require improvement; 4) systemic issues; 5) content and layout: more concise and better readability required; 6) value: mainly for GP and survivors; 7) use of SCP: limited; 8) recommendations: improve delivery process, enhance layout/content, more stakeholder input, more tailored information. Conclusion: Although response rates from GP were low, those responding perceived SCP to be useful. Cancer specialists believed SCP were more valuable for GP and survivors. Process issues, especially SCP delivery, need to be improved. [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: Despite advances in therapy, community-acquired pneumonia (CAP) is still associated with significant morbidity and mortality. Several studies conducted in different countries have reported suboptimal adherence to the guidelines. However, there are currently no available data on adherence to CAP guidelines specifically in Switzerland. Objectives: The aim of this study was to audit the quality of diagnosis and therapy of CAP at a Swiss general hospital. Methods: A retrospective, observational, single-center cohort study was conducted, including patients older than 18 years diagnosed with CAP and admitted to a medical ward throughout 2019 without prior antibiotic therapy prescribed by their general practitioner (GP). The baseline characteristics of the patients were analyzed, and the diagnostic workup and treatment were compared to the Swiss guidelines for CAP. Results: A total of 254 patients diagnosed with CAP were included in this study (median age 78 years, 51.6% males). Atypical pneumonia was diagnosed in 4% of patients, while an organism was identified in 33% of cases, with Streptococcus pneumoniae being the most frequently detected pathogen (57%). A chest image was taken in almost all patients. Documentation of respiratory rate was missing in 23% of cases. Procalcitonin was measured in 23.2% of cases. Pneumococcal and legionella urinary antigen testing was performed on approximately 90% of all patients and blood cultures were drawn in approximately 80% of patients. In 39% of cases, arterial blood gas analysis was performed. Guideline adherence for the administration of empiric antibiotics was documented/recorded in 75% of cases. Twelve different antibiotic regimens were administered, and they were mostly amoxicillin/clavulanate with or without macrolides, as suggested by the guidelines. In particular, the use of ceftriaxone was higher (19.7%) compared to the Swiss guidelines. The average length of antibiotic therapy was longer (8.2 days) compared to the guidelines (5–7 days). Oral steroid therapy was administered to 29.1% of patients, including to 75% of those diagnosed with COPD. Conclusion: Overall, guideline adherence was moderately low, especially with regards to the assessment of respiratory rate, performance of arterial blood gas analysis, and sputum collection. Regarding antibiotic therapy, the use of ceftriaxone and the length of antibiotic therapy should be reduced. Further research is needed to identify the reasons for guideline non-adherence, and to find effective measures for the improvement of guideline adherence. [ABSTRACT FROM AUTHOR]

Background: The need for better end-of-life care for people with dementia has been acknowledged. Existing literature suggests that people dying with dementia have less access to palliative care, yet little is known about the care provided to people with dementia at the end of life. This study aimed to establish evidence related to end-of-life care for people dying with dementia in hospital compared to other settings. Methods: A retrospective clinical audit of people who had a diagnosis of dementia and had accessed services within a local health district, who died between 2015 and 2019, was conducted. A total of 705 people were identified, and a subset of 299 people randomly selected for manual audit. Chi-square p-values were used to compare the place of death, and a t-test or non-parametric test was used to assess the significance of the difference, as appropriate. Measures of functional decline within one month of death were assessed using mixed effects logistic regression models. Results: The characteristics of people differed by place of death, with people who died in hospital more likely to be living at home and to not have a spouse. Less than 1 in 5 people had advance care directives or plans. Many were still being actively treated at the time of death: almost half of people who died in hospital had an investigation in their final 72 hours, less than half of people were coded as receiving palliative care at death, and more than 2 in 3 people did not get access to specialist palliative care. Declining function was associated with the terminal phase. Conclusion: This study provides novel insights for those providing end-of-life care for people with dementia. Healthcare professionals and policy makers should consider how demographic characteristics relate to the places people with dementia receive end-of-life care. The care provided to people with dementia in the last year of their life highlights the need for more support to prepare advance care documentation and timely consideration for palliative care. Changes in markers of nutritional status and function in people with advanced dementia may help with identification of terminal phases. [ABSTRACT FROM AUTHOR]

Data interoperability in health-care is a problem that has yet to be solved. The key question is how to accomplish data confidentiality, data integrity, user anonymity, drug traceability, and data misuse in the health-care industry, including detecting fake drugs. Blockchain technology combined with smart contracts (Chain code) provides a novel technique to securely store patient medical records. Patients will have more control over their information thanks to Blockchain, and health providers, such as hospitals, will have access to patient medical records held by others. Furthermore, Blockchain in healthcare allows users to check the accuracy of patient health information, drug traceability, conduct immutable medical audits, and maintain data security. In this article, we design a secure decentralized authentication framework for Telecare medical information system using Blockchain (TMIS-Chain). Smart contracts written in the Solidity programming language are used to create the proposed decentralized system. Consequently, the healthcare contracts are compiled using Remix and deployed to the personal Blockchain network. In addition, the security strength of the protocol is verified using a push button tool called Automated Validation of Internet Security Protocols and Applications. Finally, a rigorous performance evaluation is carried out to measure the computational and communication overhead of the proposed system. The results shows that the proposed decentralized authentication framework is secure, efficient, and practically implementable in the healthcare system. [ABSTRACT FROM AUTHOR]

Background: There is significant unmet need for effective and efficiently delivered care for people with Parkinson's disease (PwP). We undertook a service improvement initiative to co-develop and implement a new care pathway, Home Based Care (HBC), based on supported self-management, remote monitoring and the ability to trigger a healthcare contact when needed. Objective: To evaluate feasibility, acceptability and safety of Home Based Care. Methods: We evaluated data from the first 100 patients on HBC for 6 months. Patient monitoring, performed at baseline and 6-monthly, comprised motor (MDS-UPDRS II and accelerometer), non-motor (NMSQ, PDSS-2, HADS) and quality of life (PDQ) measures. Care quality was audited against Parkinson's UK national audit standards. Process measures captured feasibility. Acceptability was assessed using a mixed-methods approach comprising questionnaires and semi-structured interviews. Results: Between October 2019 and January 2021, 108 PwP were enrolled onto HBC, with data from 100 being available at 6 months. Over 90% of all questionnaires were returned, 97% were complete or had < 3 missing items. Reporting and communications occurred within agreed timeframes. Compared with baseline, after 6m on HBC, PD symptoms were stable; more PwP felt listened to (90% vs. 79%) and able to seek help (79% vs. 68%). HBC met 93% of national audit criteria. Key themes from the interviews included autonomy and empowerment. Conclusions: We have demonstrated acceptability, feasibility and safety of our novel remotely delivered Parkinson's care pathway. Ensuring scalability will widen its reach and realize its benefits for underserved communities, enabling formal comparisons with standard care and cost-effectiveness evaluation. [ABSTRACT FROM AUTHOR]

Objective: The Glasgow Coma Scale (GCS) is widely used to objectively describe the extent of patients' impaired consciousness. However, there are known variations in scoring GCS both in adults and children which may impact patient management. The aim of this audit was to assess the application of GCS by medical and nursing staff in pediatric medical patients. Subject and Methods: An online questionnaire was distributed amongst doctors and nurses working in the Department of Child and Adolescent Health at Mater Dei Hospital in Malta. The participants assigned GCS for 8 case scenarios involving children of different ages with varying levels of consciousness. Results were analyzed by calculating percentage agreement and by Cronbach's alpha. Results: Sixty-six participants were studied, with a response rate of 52%. Performance was poor overall, with Cronbach alpha 0.53. Correlation was better at the upper and lower ends of the scale and the worst performance was for verbal response. Only respondents with 5–10 years of experience achieved acceptable consistency in the application of the GCS (Cronbach alpha 0.78). Conclusion: There is considerable variation in application of GCS in pediatric patients, highlighting the need for education and training to improve consistency for this commonly used neurological assessment tool. [ABSTRACT FROM AUTHOR]

The Medical Record (MR) contains the information which is needed to plan, provide, and evaluate the care given to the individual. It also serves as a pivotal tool for communicating information to all the health personnel who manage the patient, and it contributes to the continuity of patient care. There is an unmet need of identifying and correcting the issues faced with MR and Medical Records Departments (MRDs) so that higher efficiency can be achieved. This study was conducted to study the deficiencies and discrepancies found in MRD files during COVID management and to correlate the deficiencies with the facilities available and the workflow. Later Lean Management (LM) was applied to ensure compliance and efficiency in the system. An observational study was done on the audit of COVID 19 patient files and facilities in the care centres. Process mapping was done. The data for LM were collected by brainstorming, observation, interview, and workflow review of several processes, values, number of wastes, and suggestions were documented the MRD staff. Area available was 400 m2 which is adequate against the norm of 350 m2. The existing staff of 30 was adequate as per norms. Deficiencies were observed in physical examination, history, radiology, and laboratory reports. The findings showed that the MRD units had 13 current processes, 26 wastes, and 10 values were identified. In addition, they were offered a total of 25 comments on eliminating the waste. Staff and equipment were adequate. Recommendations include regular staff training and usage of electronic medical records, focus on deficiency check by specific MRD staff on regular basis monitored by the administration and supported by the medical audit committee. The study also recommends that suggestions applied after LM should be implemented in letter and spirit and a repeat study of LM is advisable after regular intervals to maintain the quality standards and to maintain or further improve the efficiency. [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]

Aim: Problematic externalising behaviours in adolescents are associated with high individual and societal burden. A school‐based multidisciplinary health clinic, Ngaramadhi Space (NS), was developed at Yudi Gunyi School, a specialised behavioural school in Sydney, Australia, to improve access to holistic health‐care and behavioural support. This evaluation aimed to describe the demographics, clinic attendance, health screening, recommendations made, and changes in Strengths and Difficulties Questionnaire (SDQ) scores of students attending the clinic. Methods: Retrospective evaluation of students including changes in SDQ scores using descriptive statistics (26 July 2016 to 14 May 2019; n = 79). Results: Prior to the assessment, few students engaged with a paediatrician or mental health professional (22.8%; 27.8%, respectively). Child protection services were involved with 76%. NS attendance was high (failure‐to‐attend = 7.6%; cancellations = 8.9%). New issues found at the assessment included: parental separation (31.6%); trauma history (27.8%); substance use (19%); emotional wellbeing concerns (16.5%), learning difficulties (12.7%), domestic violence (12.7%) and medical conditions (10.1%). SDQ teacher reports showed a significant decrease in total difficulties scores (M = 6.2, SD = 6.165, P < 0.05, eta squared = 1.013 (large effect)) and all subsets. No significant differences in parent and self‐reported SDQ. Conclusions: Students with problematic externalising behaviour have unmet health and social needs. The NS school‐based integrated health‐care model offers a novel, convenient and innovative way to engage these students. This approach has high initial attendance rates with teacher‐reported SDQ results showing some behavioural improvement. Further qualitative studies are required. [ABSTRACT FROM AUTHOR]

Translation for medical devices often presents a unique set of challenges arising from the products' complex natures and associated regulatory requirements. Beyond medical expertise, linguists -- from translators and editors to bilingual quality assessors -- may require strong software localisation skills and knowledge of intricate engineering topics. Supply chain audits related to medical devices can, in many cases, demand more extensive compliance measures for language service providers than those required by most other clients. [ABSTRACT FROM AUTHOR]

ABSTRACT Objectives: To estimate the risk of post-vasectomy infections in various settings and across various surgical techniques and sanitization practices. Patients and Methods: Retrospective review of the records of 133,044 vasectomized patients from four large practices/network of practices using the no-scalpel vasectomy (NSV) technique in Canada (2011-2021), Colombia (2015-2020), New Zealand (2018-2021), and the United Kingdom (2006-2019). We defined infection as any mention in medical records of any antibiotics prescribed for a genital or urinary condition following vasectomy. Results: Post-vasectomy infection risks were 0.8% (219 infections/26,809 procedures), 2.1% (390/18,490), 1.0% (100/10,506), and 1.3% (1,007/77,239) in Canada, Colombia, New Zealand, and the UK, respectively. Audit period comparison suggests a limited effect on the risk of infection of excising a short vas segment, applying topical antibiotic on scrotal opening, wearing a surgical mask in Canada, type of skin disinfectant, and use of non-sterile gloves in New Zealand. Risk of infection was lower in Colombia when mucosal cautery and fascial interposition [FI] were used for vas occlusion compared to ligation, excision, and FI (0.9% vs. 2.1%, p

Background: Monitoring of maternal near miss cases are now being considered as a measure of the quality of maternal health care. The study of maternal near miss helps to identify causes of severe maternal complications and in turn implement changes in the treatment strategies and improve the obstetric care. Aims and objectives: To find the incidence of maternal near miss (MNM), Maternal deaths (MD), mortality index (MI=MD/MNM+MD). To assess the direct and underlying cause for near miss morbidity and mortality; To study the complications encountered and critical interventions needed. Materials and methods-This was a prospective observational study conducted in Rural Tertiary Medical College from Jan 2021 to Jan 2022. Results: There were a total of 2750 deliveries and 2725 live births during the study period, 46 cases were maternal near miss cases. There were 4 maternal deaths. Majority of patients were between 25-29 yrs. Both morbidity and mortality were higher in the multigravida patients. In our study most of the patients with life threatening conditions were in the first trimester, between the gestational age of 1-12 weeks, majority of the cases underwent laparotomy for ectopic pregnancy. Most of the near miss cases were unbooked (no antenatal visit in our hospital n-37). Haemorrhage was the leading cause of MNM cases followed by Hypertensive disorders.Majority of the cases with haemorrhage were due to ruptured ectopic followed by abruptio placentae and placenta previa .There were 46 maternal near miss cases and 4 maternal deaths. Conclusion: Study of near miss cases is an important indicator of obstetric care and thus helps improve the health system by implementing changes in the treatment strategies. [ABSTRACT FROM AUTHOR]

An 'audit' is defined as 'the review and the evaluation of the health care procedures and documentation for the purpose of comparing the quality of care which is provided, with the accepted standards'. Studying the prescription audit is that part of the audit which seeks to monitor, evaluate and if necessary, suggest modifications in the prescribing practices of medical practitioners. In this study, we aimed to study the prescription pattern and assess the quality of prescription, with the standard prescription norms in Out Patient department of various specialities of the District Hospital, Bandipora. This observational study was conducted on the patients receiving medication during treatment in the outpatient departments of various specialities of the District Hospital, Bandipora, over a period of one month and the calculated sample size was 95 (according to the guidelines of prescription audit by MoHFW). An additional sample of 5 was included in the study, making the total sample size 100. A total of 20 parameters were assessed using a checklist. It was found that out of 100 study participants, brief history was mentioned in 51% prescriptions; dosage, duration and frequency was mentioned in 72% prescriptions, sign and stamp of the treating doctor was present on 37% prescriptions; medications were written in capital letters in 70% prescriptions, but were written in generic form in only 17% prescriptions. 78% of the medication orders were clear and readable; route of administration was not mentioned in 65% prescriptions. Vitamins, tonics or enzymes were prescribed in only 10% prescriptions, while antibiotics were prescribed in 44% prescriptions. [ABSTRACT FROM AUTHOR]

Background: Neonatal near-miss (NNM) can be considered as an end of a spectrum that includes stillbirths and neonatal deaths. Clinical audits of NNM might reduce perinatal adverse outcomes. The aim of this review is to evaluate the effectiveness of NNM audits for reducing perinatal mortality and morbidity and explore related contextual factors. Methods: PubMed, Embase, Scopus, CINAHL, LILACS and SciELO were searched in February/2023. Randomized and observational studies of NNM clinical audits were included without restrictions on setting, publication date or language. Primary outcomes: perinatal mortality, morbidity and NNM. Secondary outcomes: factors contributing to NNM and measures of quality of care. Study characteristics, methodological quality and outcome were extracted and assessed by two independent reviewers. Narrative synthesis was performed. Results: Of 3081 titles and abstracts screened, 36 articles had full-text review. Two studies identified, rated, and classified contributing care factors and generated recommendations to improve the quality of care. No study reported the primary outcomes for the review (change in perinatal mortality, morbidity and NNM rates resulting from an audit process), thus precluding meta-analysis. Three studies were multidisciplinary NNM audits and were assessed for additional contextual factors. Conclusion: There was little data available to determine the effectiveness of clinical audits of NNM. While trials randomised at patient level to test our research question would be difficult or unethical for both NNM and perinatal death audits, other strategies such as large, well-designed before-and-after studies within services or comparisons between services could contribute evidence. This review supports a Call to Action for NNM audits. Adoption of formal audit methodology, standardised NNM definitions, evaluation of parent's engagement and measurement of the effectiveness of quality improvement cycles for improving outcomes are needed. [ABSTRACT FROM AUTHOR]

Background/Aim: There has been increasing focus and research over the past decades on defining, identifying, visualizing and reducing unwarranted clinical variation in clinical practice. Both clinician-driven initiatives such as the US based "Choosing Wisely" campaign and the top-down driven "Evidence-based intervention programme (EBI)" launched by NHS UK to improve quality of care by reducing unnecessary interventions have shown marginal results. We present the findings from a mixed-methods audit performed to evaluate the compliance by senior hospital leaders of a new regional strategy to reduce unwarranted variation in outcomes and utilization rates. Methods: Seventy-five mid- to senior-division and department leaders from eight hospital trusts in South-Eastern Norway Regional Trust (HSO) were invited to participate in evaluating the response and compliance of the regional leadership strategy for reducing unwarranted variation in patient outcomes and service utilization rates. Results: The audit revealed that the aim of reducing unwanted variation was not clearly communicated by senior HSO management. There was varying use of data from the national quality registers and health atlases for quality improvement. One third of the clinical leaders reported a lack of scrutiny of their work and were insufficiently aware of the HSO's top-management and the hospital's Boards strategic expectations about the importance of reducing unwarranted variation in their hospital utilization. Conclusions: We found that the strategic aim of reducing unwanted clinical variation was not clearly communicated by senior HSO management to hospital boards and senior management. The hospitals could benefit from a better understanding of causes of variation by strengthening their efforts to reduce unwarranted variation in utilization rates as a key element in improving health care quality and patient safety. The findings of the audit are relevant for other healthcare organizations trying to improve their quality and reduce unnecessary variation. [ABSTRACT FROM AUTHOR]

Background: The Long-Term Care QUERI program supported implementation of the Life-Sustaining Treatment Decisions Initiative in US Veterans Health Administration long-term care settings. The program worked with eleven Community Living Centers (CLCs) and twelve Home-Based Primary Care (HBPC) programs to increase rates of completed templates, using audit with feedback. We distributed monthly feedback reports to site champions showing the number of Veterans with appropriate documentation. Although feedback reports are a common implementation tool, little is known about the most effective ways to design, distribute, and support them. We sought to test tailoring reports with tips using site-specific data, as well as national comparator data. Methods: We conducted a cluster randomized controlled trial of monthly feedback reports utilizing site-tailored tips and national comparator data compared to our original feedback reports that included only graphical and numerical data. CLC and HBPC team members were invited to participate in brief surveys each quarter to determine if they had received and used the feedback reports. The outcome for CLC residents was the percent with a completed LST template any time prior to the 14th day of their stay. The outcome for HBPC residents was the percent of Veterans with a completed LST template by their second HBPC visit. Results: The response rate to the survey ranged between 6.8 and 19.3% of staff members across the CLC and HBPC sites with 12.8–25.5% of survey respondents reporting that they had seen the feedback reports. The linear regression models showed no significant association between receiving the enhanced feedback reports and having a higher documentation completion rate. Conclusions: Receiving feedback reports tailored to sites by including tips based on baseline context assessments and qualitative findings, and reports showing national comparator data, did not have an impact on the number of Veterans with a completed LST template. Having a higher proportion of CLC or HBPC team members view the reports was not associated with an increase in LST template completion. These findings suggest that tailored audit with feedback may not have been effective at the program level, although the proportion of respondents who reported seeing the reports was small. [ABSTRACT FROM AUTHOR]

Critical care practice is constantly evolving. Pressures for bed availability in publicly funded healthcare systems have led to an increase in patients delayed in their discharge from critical care to the wards. This has resulted in more patients discharged directly home (DDH) from the intensive care unit (ICU). However, few formal pathways for DDH exist. We have performed a retrospective audit of the patients discharged home from our unit in the largest tertiary referral hospital in the Republic of Ireland from 2017 to 2022 to investigate their characteristics and the safety of this practice, given the understandable patient safety concerns raised. Results In total, 84 patients have been DDH from our unit between 2017 and 2022 from a total of 4747 patients. The overall rate of DDH increased year on year, and the vast majority of these patients were initially admitted from the emergency department or following elective major surgery. Most patients had an APACHE score of less than 11 points, and the majority were admitted for less than 3 days, with single organ failure. There was a gender divide, as greater than 60% of the patients admitted were male, with a mean age of 44. Conclusion DDH has been an important tool in improving patient flow through the hospital, avoiding unnecessary de-escalation to the ward for a select group of critical care patients. The re-admission rate in the year post-ICU discharge was very low, showing that DDH has not adversely impacted patient safety. [ABSTRACT FROM AUTHOR]

Background: Failure to detect cognitive impairment (CI) in hospitalised older inpatients has serious medical and legal implications, including for the implementation of care planning. This mixed methods study aimed to determine amongst hospital in-patients aged ≥ 65 years: (1) Rates of documentation of screening for CI, including the factors associated with completion of screening; (2) Rates of undocumented CI amongst patients who had not received screening during their admission; (3) Healthcare provider practices and barriers related to CI screening. Methods: A mixed methods study incorporating a clinical audit and interviews with healthcare providers was conducted at one Australian public hospital. Patients were eligible for inclusion if they were aged 65 years and older and were admitted to a participating ward for a minimum of 48 h. Patient characteristics, whether CI screening had been documented, were extracted using a template. Patients who had not been screened for CI completed the Montreal Cognitive Assessment (MoCA) to determine cognitive status. Interviews were conducted with healthcare providers to understand practices and barriers to screening for CI. Results: Of the 165 patients included, 34.5% (n = 57) had screening for CI documented for their current admission. Patients aged > 85 years and those with two or more admissions had greater odds of having CI screening documented. Among patients without CI screening documented, 72% (n = 78) were identified as cognitively impaired. While healthcare providers agreed CI screening was beneficial, they identified lack of time and poor knowledge as barriers to undertaking screening. Conclusions: CI is frequently unrecognised in the hospital setting which is a missed opportunity for the provision of appropriate care. Future research should identify feasible and effective strategies to increase implementation of CI screening in hospitals. [ABSTRACT FROM AUTHOR]

Computed Tomography (CT) technology has evolved into avital diagnostic tool in modern medical practice, leading to the development and extension of the CT radiographer's role. While some countries have made progress in developing and extending radiographers' roles in CT, resourceconstrained settings like Zimbabwe have been slower to implement these changes. The purpose of this review is to inform role changes for radiographers in Zimbabwe and similar settings by reviewing the literature on role development and extension for radiographers in CT. The review explores the concepts of role development and extension, emphasizing the necessity for changes in radiographers' roles in CT due to factors such as radiologistsshortages, cost containment, quality improvement needs, and technological advancements. It also addresses the opposition to role development and extension, emphasizing the fundamentalimpetus for these changes should be to provide high-quality and effective patient-centered care. The paper delves into specific areas of role development and extension for radiographers in CT, including intravenous (IV) cannulation and contrast media administration, performing CT colonoscopy examinations, reporting on CT brains, and the significance of research and clinical audit in CT. It underscores the potential benefits of these expanded roles, such as improved patient care, workflow efficiency, and the workload of radiologists, as well as advancements in education, service delivery, and technological innovations. The review underscores the need for further research to ensure evidencebased implementation of role development and extension for radiographers in CT. Embracing these changes and providing the necessary support and training can lead to improved patient care, address skill shortages, and advance the radiography profession in resource-constrained settings like Zimbabwe. [ABSTRACT FROM AUTHOR]

Background: Virtual models of care were implemented to ease hospital bed pressure during COVID-19. We evaluated the medication management of COVID-19 patients transferred to virtual models of care. Method: A retrospective audit of COVID-19 patients transferred from inpatient units to virtual care during January 2022 and surveys from patients transferred during December 2021–February 2022 was carried out. Results: One hundred patients were randomly selected: mean age 59 years (SD: 19.8), mean number of medicines at admission 4.3 (SD: 4.03), mean length of virtual ward stay 4.4 days (SD: 2.1). Pharmacists reviewed 43% (43/100) of patients' medications during their hospital stay and provided 29% (29/100) with discharge medicine lists at transfer. Ninety-two (92%) patients were prescribed at least one new high-risk medicine whilst in hospital, but this was not a factor considered to receive a pharmacist medication review. Forty patients (40%) were discharged on newly commenced high-risk medicines, and this was also not a factor in receiving a pharmacist discharge medication list. In total, 25% of patient surveys (96/378) were returned: 70% (66/96) reported adequate medicine information at transfer and 55% (52/96) during the virtual model period. Conclusion: Patient survey data show overall positive experiences of medication management and support. Audit data highlight gaps in medication management during the transfer to a virtual model, highlighting the need for patient prioritisation. [ABSTRACT FROM AUTHOR]

Introduction: Prescribing guidance for disease-modifying treatment (DMT) in multiple sclerosis (MS) is centred on a clinical diagnosis of relapsing–remitting MS (RRMS). DMT prescription guidelines and monitoring vary across countries. Standardising the approach to diagnosis of disease course, for example, assigning RRMS or secondary progressive MS (SPMS) diagnoses, allows examination of the impact of health system characteristics on the stated clinical diagnosis and treatment access. Methods: We analysed registry data from six cohorts in five countries (Czech Republic, Denmark, Germany, Sweden and United Kingdom) on patients with an initial diagnosis of RRMS. We standardised our approach utilising a pre-existing algorithm (DecisionTree, DT) to determine patient diagnoses of RRMS or secondary progressive MS (SPMS). We identified five global drivers of DMT prescribing: Provision, Availability, Funding, Monitoring and Audit, data were analysed against these concepts using meta-analysis and univariate meta-regression. Results: In 64,235 patients, we found variations in DMT use between countries, with higher usage in RRMS and lower usage in SPMS, with correspondingly lower usage in the UK compared to other registers. Factors such as female gender (p = 0.041), increasing disability via Expanded Disability Status Scale (EDSS) score (p = 0.004), and the presence of monitoring (p = 0.029) in SPMS influenced the likelihood of receiving DMTs. Standardising the diagnosis revealed differences in reclassification rates from clinical RRMS to DT-SPMS, with Sweden having the lowest rate Sweden (Sweden 0.009, range: Denmark 0.103 – UK portal 0.311). Those with higher EDSS at index (p < 0.03) and female gender (p < 0.049) were more likely to be reclassified from RRMS to DT-SPMS. The study also explored the impact of diagnosis on DMT usage in clinical SPMS, finding that the prescribing environment and auditing practices affected access to treatment. Discussion: This highlights the importance of a healthcare system's approach to verifying the clinical label of MS course in facilitating appropriate prescribing, with some flexibility allowed in uncertain cases to ensure continued access to treatment. [ABSTRACT FROM AUTHOR]