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PubMed1999

The impact of an acute pain service on postoperative pain management.

An audit of postoperative pain management was conducted before and after the introduction of an Acute Pain Service (APS) run entirely by medical staff. The ability of patients to complete two pain-scoring systems, a verbal rating score (VRS) and a numerical rating score (NRS, where 0 = no pain, 10 = worst pain) was compared. We surveyed 605 adults 24 hours postoperatively. For major operations, the incidence of "severe" or "unbearable" pain at rest (VRS) over the first 24 hours decreased from 18.1% before to 3.5% after the APS (P = 0.0002) and severe/unbearable pain with movement decreased from 50% to 31% (P = 0.0037). The average NRS pain scores fell from 4.65 to 3.37 at rest (P < 0.0001) and from 6.77 to 6.19 with movement (P = 0.046). The incidence of severe/unbearable pain at rest with patient-controlled analgesia (PCA) decreased from 19.7% to 3.2% after the APS (P = 0.0012) and with movement from 51.3% to 35.1% (P = 0.049). For epidural analgesia, severe/unbearable pain at rest was 18.8% prior to the APS and 4.4% after (P = 0.14), and with movement was 43.8% before and 19.1% after (P = 0.079). The NRS pain-scoring system was unsuitable for Aboriginal or Torres Strait Islander patients. Patient satisfaction was high both before and after the introduction of the APS, and was an unreliable indicator of effective pain relief. We conclude that an APS can improve postoperative pain control with PCA and epidural analgesia.

Acute Disease↗
PubMed2003

Environmental, health, and safety management systems and auditing programs: part I--The evolution.

Early auditing began as an effort to avoid fines or other action from governmental agencies, without being based on accepted standards. However, for EHS auditing to be accepted as credible in the business world, established standards were necessary. As companies expanded globally, the need for international EHS standards grew, international standards for quality management and environmental program management have now been universally accepted (ISO, 2002). Occupational health nurses increasingly are becoming involved in efforts to help their employers or clients develop management systems to handle EHS issues--whether ISO 9000 (or the automotive equivalent, QS-9000), ISO 14000, or other models are used as the basis for the management system. Many nurses are actively involved in ISO certification efforts. As an extension of those efforts, occupational health nurses are increasingly involved in EHS audits, whether audits are conducted by third parties, by company employees, or as part of a self audit. The next column in this series will focus on strategies to improve the management of occupational health programs so the programs will stand up to rigorous EHS audits.

Environmental Health↗
PubMed1995

An approach to the audit of tinnitus management.

This study examines the advantages and internal consistency of an open-ended questionnaire (Benefit-problem questionnaire), over the Tinnitus questionnaire used by Jakes et al. (1985) in the auditing of a stress management programme. The Tinnitus questionnaire showed very little difference pre- and post-treatment, while the Benefit/problem questionnaire showed good improvement over a number of variables. This included some of the more traditional orthogonal values of tinnitus complaint. The clinical assessment made blindly and over a different time scale to the Benefit/problem questionnaire matched these positive results quite closely.

Female↗
PubMedDate not supplied

Adult tetanus in Accra, why the high mortality? An audit of clinical management of tetanus.

BACKGROUND: Tetanus is a life threatening infection relatively uncommon in the developed countries but occurs frequently in developing countries with case fatality rates of 40-60 %. Recent review of adult tetanus at the Korle-bu Teaching Hospital showed a high case fatality of 50%. In order to determine the factors underlying this high case fatality we conducted a retrospective clinical audit of the clinical management of adult tetanus admitted in 1994 to 2001 to the Korle-bu Teaching Hospital. METHODS: Data extracted from the admission and discharge books of the Fevers' Unit of Korle-bu Teaching Hospital, Accra and patient case notes were examined and analysed. RESULTS: Case fatality rate (CFR) varied from 25 % in 1999 to 72.7% in 2001. There was no gender difference in the case fatality. There was no significant difference in the mean age of those who died and those who survived, however, the CFR rose with age. The presence of neck and a dirty wound were associated with increased CFR. The CFR correlated with the severity of tetanus and increased when an expected treatment action, wound debridement, administration of antibiotics and/or immunoglobulin, was not performed. The administration of anti-tetanus toxin was associated with an increased CFR. CONCLUSION: The high case fatality rate in Accra was due to inappropriate management with most of the patients not treated with immunoglobulin and antibiotics and had inadequate wound care.

Adolescent↗
PubMed2003

An audit of the management of soft tissue sarcoma within a health region in the UK.

AIMS: Soft tissue sarcomas are rare and heterogeneous tumours only occasionally seen by most individual clinicians. Early recognition, appropriate referral and timely investigations markedly improve outcomes. Our aim was to retrospectively assess the referral patterns, investigation, surgery and outcomes of patients with soft tissue sarcoma in the Trent region of the UK. METHODS: Two hundred and four patients with soft tissue sarcoma registered with the Trent Cancer Registry in 1995-1997 were first studied. Clinical details, tumour characteristics, presentation, management and follow-up were recorded from the case notes and analysed.A further group of 40 patients referred to a single cancer centre in 1999 were audited to establish whether there had been any improvements/changes over the 2 years, since the completion of the first audit. RESULTS: In the first audit, 49.5% were first referred to general surgeons and 16% to orthopaedic surgeons. Only 15% of patients fit for surgery were referred to a surgeon with a specialist sarcoma interest prior to definitive exploration. Of the deep tumours, 64% had a preoperative biopsy and only 68% had a scan before biopsy or definitive surgery. Tumour grade, completeness of excision and site of the sarcoma influenced survival. The second audit performed on patients treated in 1999 showed only a marginal improvement in management when compared to the first audit.

Abdominal Neoplasms↗
PubMed1995

An audit of the management of acute otitis externa in an ENT casualty clinic.

The management of acute otitis externa is variable, despite the fact that it is one of the commonest otological emergencies. We formed the impression that many patients attending our ENT casualty clinic with otitis externa were being treated and followed up inappropriately. To test this hypothesis we performed a retrospective pilot study on our practice which revealed a lack of uniformity in the management and follow-up of these patients. And as a result of this, guidelines were developed to improve our management of otitis externa and decrease the number of unnecessary review visits. Our practice was then audited prospectively over a six-month period with the guidelines in place. An improvement in the overall management and a rationalization of follow-up for otitis externa was seen by applying basic audit principles to this common clinical problem.

Acute Disease↗
PubMed2005

A criteria-based audit of the management of severe pre-eclampsia in Kampala, Uganda.

OBJECTIVE: To improve the quality of clinical care for women with severe pre-eclampsia. METHODS: A criteria-based audit was conducted in a large government hospital in Uganda. Management practices were evaluated against standards developed by an expert panel by retrospectively evaluating 43 case files. Results of the audit were presented, and recommendations developed and implemented. A re-audit was conducted 6 months later. RESULTS: The initial audit showed that most standards were rarely achieved. Reasons were discussed. Guidelines were produced, additional supplies were purchased following a fundraising effort, labor ward procedures were streamlined, and staffing was increased. In the re-audit there were significant improvements in diagnosis, monitoring, and treatment. CONCLUSION: Criteria-based audit can improve the quality of maternity care in countries with limited resources.

Female↗
PubMed1981

'Do as I say and not as I do'? An audit of clinical management in teaching compared with service work.

The work of five principals in a teaching general practice was audited to examine differences in prescribing, investigation and follow-up between teaching and service work over a 3-week period. The patients seen in clinical teaching were found to be representative of those consulting in normal service sessions for both morbidity and age. Some big differences in clinical management were found including a strong tendency to prescribe less but investigate and follow up more when teaching. The prescribing differences were variable between morbidity groups. It is suggested that large differences correlated with areas where the doctors were least confident in their behavior, such as the use of antibiotics for respiratory illness and the use of tranquillizers for problems without a psychological diagnosis. It is concluded that while reductions in prescribing probably reflect better patient care, increases in investigations are more for the students' benefit.

Drug Prescriptions↗
PubMed1994

A district audit on the management of polymyalgia rheumatica and giant cell arteritis.

Twenty-one hospital consultants, representing 20% of the hospital specialists and 54 general practitioners representing 22% of the general practitioners in the Norwich Health District were circulated a questionnaire on the management of polymyalgia rheumatica and giant cell arteritis, as part of a departmental audit. The wide variations in the diagnosis and treatment of these two common conditions are shown in this study. Appropriate recommendations have been made for these two common conditions in the hope of providing a useful guideline for more uniform and effective therapy. We intend to repeat this study at a later date to assess if any of the recommendations have been undertaken successfully.

Family Practice↗
PubMed1992

An audit of the management and outcome of hospital inpatients with diabetes: resource planning implications for the diabetes care team.

In order to assess the outcome of hospitalized diabetic patients in an urban health district the notes of a cohort identified from a survey of all inpatients on a single day in spring 1990 were reviewed. One hundred and ten cases were reviewed (8.4% of all inpatients); median age 73 years (range 26-99), 59 female. Fifty-five percent were medical patients (general or geriatric) and 16% were general surgical. Six remained inpatients after 6 months. Sixteen died, of whom 10 had macrovascular disease. Median length of stay was 22 days (2-300), significantly above the district average in all specialties (< 10 days). Of 15 patients with foot problems, 5 died and 3 had major amputations. Only 23% of all patients had documented evidence of screening for diabetic complications. The discharge diagnoses failed to acknowledge diabetes in 54 cases (including 10 deaths). Only 10% had formal advice from the diabetes team and subsequent audit revealed that metabolic management was commonly suboptimal in non-physician units. These data suggest that inpatient diabetes is costly and carries a high mortality. The incidence is substantially underestimated by conventional episode statistics. The evidence from this cohort of diabetic inpatients suggests that improved communication and recognition of the importance of diabetes could usefully contribute to the quality of care achieved.

Aged↗
PubMed2001

An audit of perioperative management of autistic children.

BACKGROUND: Autistic children are very difficult to manage in the hospital setting because they react badly to any change in routine. METHODS: We have developed a unique management program for autistic children admitted for medical and surgical procedures requiring a general anaesthetic. Details of each patient managed according to this program have been prospectively entered into an Autistic Register. RESULTS: An audit of this database shows that we have administered anaesthesia on 87 occasions for 59 autistic children over 4 years. CONCLUSIONS: There is great variation in the severity of autism and hospital needs of these children. The focus is on early communication with the patient's families, flexibility to individualize the admission process and anaesthetic plan with admission and early discharge on the day of surgery whenever possible. Oral midazolam is an effective premedication for the milder cases and oral ketamine is the most reliable for moderate and severe cases. Comparison of oral midazolam and ketamine shows no significant different postoperative recovery and hospital discharge times. Routine intravenous fluids and antiemesis prophylaxis with removal of the i.v. cannula before return to the ward are also seen as important steps to decrease stress and smooth the postoperative phase. This program has also successfully been extended to the management of problem children due to other causes.

Adolescent↗
PubMed1998

An audit of the management of thyroid cancer in a district general hospital.

OBJECTIVE: Thyroid cancer is the commonest endocrine malignancy yet it appeared to present infrequently to the endocrinologists at this large District General Hospital. The management of well-differentiated thyroid cancer remains controversial with a wide variation in clinical practice. The aim of this survey was to determine the characteristics of the patients diagnosed with thyroid cancer and whether any deficiencies existed in the management of subjects diagnosed with thyroid cancer over a five-year period using standards of care based upon long-term outcome data and recently published USA guidelines. DESIGN AND PATIENTS: Retrospective case-note survey of all patients newly registered with thyroid cancer from 1990 to 1994 in North Staffordshire (estimated total population 450,000). RESULTS: The annual incidence of all thyroid cancer was two per 100,000 of which well-differentiated tumours comprised 70%. Medical records were obtained in 48 new cases (91% of total) identified. Fifteen subjects who presented as surgical emergencies received only palliative treatment and had a poor outcome. Two patients presented with metastatic medullary thyroid carcinoma (3% of total). Thirty-one patients (97% of whom presented with a thyroid nodule) were referred electively to either surgical (n = 22), ENT (n = 2) or endocrinology (n = 7) outpatients with well-differentiated papillary (n = 17) and follicular (n = 14) tumours. Thirteen patients (42%) had fine-needle aspiration cytology performed preoperatively. Of the 22 tumours (71%) greater than 1.5 cm, five (27%) had a total thyroidectomy and two (9%) also had radioiodine ablation. There was inadequate serum thyrotrophin suppression postoperatively in 12 patients (39%) and only five (16%) were being monitored for recurrence with serum thyroglobulin measurements. CONCLUSIONS: Deficiencies in the optimum management of small, well-differentiated thyroid cancers were identified. Improved communication between specialties has led to the development of an agreed management protocol to increase the quality of care offered to patients with thyroid cancer and for auditing the coordinated service in the future.

Adult↗