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PubMed2004

Prospective audit of bacteraemia management in a university hospital ICU using a general strategy of short-course monotherapy.

OBJECTIVE: As optimal antibiotic therapy for bacteraemia remains unknown, different strategies have evolved. Routine practice in the University College London Hospitals intensive care unit (ICU) is to use short-course (5-6 days) monotherapy, unless specifically indicated (e.g. endocarditis, osteomyelitis). We decided to assess this approach for treating community-, hospital-, and ICU-acquired bacteraemia by monitoring clinical response, relapse rate and patient outcome. DESIGN: Six-month prospective observational study from February to July 2000. SETTING: Mixed medical-surgical tertiary referral ICU. PATIENTS: All 713 patients admitted to the ICU over the study period. MEASUREMENTS AND RESULTS: In total, 102 bacteraemic episodes occurred in 84 patients. Eight (57%) of 14 community-acquired bacteraemias, 22 (79%) of 28 hospital-acquired bacteraemias, and 48 (80%) of 60 ICU-acquired bacteraemias (in 49 patients) were treated with short-course monotherapy. Compared with previous reported studies, these patients had a low rate (23.8%) of death directly attributable to the bacteraemia and a satisfactory clinical response in 72%. Of six relapses (all Gram-negative), four had received combination therapy for severe deep-seated infections. ICU-acquired multidrug-resistant Gram-negative bacteraemias (6.5%) and fungaemias (3%) were also uncommon. No patient discharged from ICU subsequently developed a new bacteraemia relapse, or any long-term complication such as osteomyelitis. CONCLUSIONS: Our general strategy of short-course antibiotic monotherapy for treating bacteraemia in the critically ill appears to provide a satisfactory clinical response, low relapse rate and no long-term complications in a well-defined group of patients. Multicentre studies are warranted to compare short versus long course therapy, and monotherapy versus combination therapy.

Anti-Bacterial Agents↗
PubMed2006

Adult choledochal cysts: an audit of surgical management.

BACKGROUND: Choledochal cysts are rare congenital cystic dilatations of the biliary tree. Surgical management has evolved with regards to timing and surgical procedure of choice. We conducted a retrospective review of clinical presentation and surgical management of adult choledochal cysts. METHODS: Thirty-two patients with choledochal cysts who underwent surgery between April 1991 and January 2005 were reviewed. There were 27 Todani Type I, 2 Type II, 2 Type IVA and 1 Type V cysts. Eighty-four per cent of patients underwent complete cystectomy and hepaticojejunostomy. Seven patients had revision surgery comprising completion cystectomy and hepaticojejunostomy. RESULTS: There were no perioperative mortalities. Perioperative morbidity rate was 44% and the commonest complication perioperatively was wound infection (19%). Malignancy was noted in one histological specimen. This patient was disease free for 1 year postoperatively and was subsequently lost to follow up. No further malignancy was found on median follow up of 3.9 years (range, 1-14 years) for the other 31 patients. CONCLUSION: Adult choledochal cysts are rare and are often non-specific in their clinical presentation. In managing patients with choledochal cysts, it is important to first treat complications such as sepsis and pancreatitis before imaging of the biliary tree with endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography to evaluate the full extent and type of choledochal cyst. Surgical management should be planned single-stage surgery comprising complete cyst resection, cholecystectomy and Roux-en-Y hepaticojejunostomy and should be carried out by hepatobiliary specialists. Excellent perioperative morbidity and mortality results are possible with this strategy. Malignancy is rare and was only noted in 3% but close follow up is warranted.

Adolescent↗
PubMed1991

An audit of the management of ectopic pregnancy.

OBJECTIVE: To estimate the local incidence of ectopic pregnancy and to review the management of ectopic pregnancy with reference to those misdiagnosed at presentation. To establish management guidelines to be applied to all possible ectopic pregnancies. DESIGN: A review of all ectopic pregnancies presenting over a 2-year period, and of emergency gynaecological admissions during 4 months. SETTING: A teaching hospital. RESULTS: The local rate of ectopic pregnancy was similar to that seen in other UK studies. Nineteen (13%) women with ectopic pregnancies were sent home with an incorrect diagnosis. Eight were recalled but eight required emergency admission and one died at home. Undue confidence in ultrasound reports and failure to follow up inconclusive histology results were a feature in cases where patients were not recalled. A set of simple management guidelines has been drawn up. Amongst general gynaecological admissions 1 in 12 of all first trimester complications was an ectopic pregnancy. Amongst apparently true uterine miscarriages 20% of histological examinations were inconclusive and histology and ultrasound examinations failed to confirm a uterine miscarriage in 14% of apparently true missed miscarriages. CONCLUSIONS: Ectopic pregnancy is common amongst first trimester complications. Adherence to simple management guidelines would minimize the number of patients requiring emergency admission, though up to 20% of patients with apparently true uterine miscarriages would also require further investigation.

Abortion, Spontaneous↗
PubMed1989

An audit of the management of 250 patients with chest trauma in a regional thoracic surgical centre.

Two hundred and fifty patients with chest trauma admitted consecutively over a 6-year period to the Royal Surrey County Hospital were reviewed. This is a large series by British standards. The cause and nature of their chest and associated injuries were studied, together with the management, complications and outcome. The aim of this study was to find areas where diagnosis and treatment could be improved. It was found that where there was no lung contusion, flail chest injuries could be managed without ventilation. The review suggests that even small traumatically induced pneumothoraces should be drained. It illustrates the need for an awareness of the wide range of concurrent problems in patients with chest injuries and the variety of possible complications.

Accidents, Traffic↗
PubMed2004

An audit of obstetricians' management of women potentially infected with blood-borne viruses.

OBJECTIVE: To assess obstetricians' current antenatal screening practices for blood-borne viruses (hepatitis B, hepatitis C and HIV) and how they manage pregnant women infected with a blood-borne virus. DESIGN AND PARTICIPANTS: National cross-sectional survey conducted between September 2002 and January 2003. All obstetricians (n = 767) registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) were mailed a questionnaire assessing their antenatal screening practices and knowledge of management of women potentially infected with a blood-borne virus. OUTCOME MEASURES: Concordance of clinical practice with RANZCOG recommendations and current evidence-based guidelines. RESULTS: 523 obstetricians (68% response rate) completed the questionnaire. Fifty-one per cent of respondents said they would always offer HIV screening and 60% would always offer HCV screening. For HIV-infected women, 36% of obstetricians would always recommend elective caesarean section and 33% would always avoid rupture of membranes. Despite a lack of evidence, 34% of obstetricians advise patients that the risk of HBV transmission is increased with breastfeeding, and 47% give the same advice about HCV transmission. CONCLUSION: There is some discordance between the RANZCOG antenatal screening recommendations for HCV and HIV and current practice. Knowledge about the management of HIV-infected women could be improved, and more obstetricians need to be aware that current evidence suggests there is no increased risk of transmission of HBV or HCV with breastfeeding.

Australia↗
PubMed1992

Medical audit: the differing perspectives of managers and clinicians.

The objectives of this study were to gauge the attitudes and perceptions of managers and clinicians to medical audit, and to identify differences which might be barriers to the effective implementation of audit. A questionnaire survey of consultants and health service managers in one health district was conducted prior to the introduction of medical audit. Replies were received from 113/144 (78%) clinicians and 53/70 (76%) managers. Managers and clinicians concurred about the potential benefits of audit but had divergent opinions regarding its disadvantages. Seventy-one per cent of clinicians thought that audit would interfere with clinical work and 41% that audit would consume resources that could be better used on patient care. Only one in eight managers shared these views. Clinicians were divided on the threats to clinical autonomy and were three times more likely than managers to agree that audit would enable managers to influence medical practice. Most clinicians considered that audit would require one session a week, while 49% of responding managers thought audit could be performed within existing timetables. Although managers and clinicians are broadly in favour of the introduction of audit, they differ in their assessment of the time required and the opportunity costs. Appreciation of these differing perspectives should facilitate the effective introduction of audit.

Attitude↗
PubMed2002

Audit of primary care angina management in Sandwell, England.

This audit aimed to assess the identification and treatment of coronary risk factors, lifestyle advice given and use of drug therapy, among patients with angina in Sandwell. It was designed to help general practices evaluate their angina management, and highlight areas where practice could be improved. Criteria were based on Sandwell's published angina audit and local clinical guidelines. Each participating practice was asked to identify all patients with angina, from which a 10% sample was randomly selected. The notes of each selected patient were examined for evidence showing whether agreed standards of care had been achieved. Fifteen practices took part, and contributed data on a total of 358 patients. Of patients without contraindications, 66.5% were taking aspirin, 62.1% were prescribed short-acting nitrates and 58.4% were prescribed beta-blockers. Non-white patients were significantly less likely to receive short-acting nitrates (p < 0.001) and women were significantly less likely to receive beta-blockers (p < 0.01). A total of 83.5% of patients had received smoking cessation advice, 75.1% had weight advice, 75.1% were advised about alcohol use and 64.5% about exercise. Overall, 77.4% had a blood pressure check within the previous twelve months, 40.5% had their cholesterol measured and 33.5% had their blood glucose measured. Non-white patients were significantly less likely to receive smoking cessation, weight, exercise and alcohol advice and were less likely to have their blood pressure checked (all p < 0.0001). Patients aged 65 and over were significantly less likely to receive a cholesterol check (p < 0.0001). None of the auditable standards were actually met. This study shows that there is considerable scope to improve the management of angina patients, with particular regard to aspirin. We recommend that practices develop systems to ensure that the appropriate treatment, advice and checks are given to all patients with angina, paying particular attention to those from ethnic minority backgrounds.

Angina Pectoris↗
PubMed2000

Surgical management of intractable epistaxis: audit of results.

We have audited our results after changing the management practice in patients with intractable epistaxis. These patients are offered trans-nasal endoscopic sphenopalatine artery diathermy with or without anterior ethmoid artery diathermy instead of conventional surgical procedures. During the first year after the change in practice, 145 patients were treated as inpatients for epistaxis. Ten patients (seven per cent) required a surgical procedure under general anaesthesia due to the recurrent nature of bleeding. All 10 patients had endoscopic sphenopalatine artery diathermy, whereas in four patients anterior ethmoid artery diathermy was also performed concurrently. The post-operative hospital stay ranged from one to three days (mean 2.1 days). The mean follow-up was 10 months. The epistaxis recurred in one patient and this was managed conservatively. There were no complications related to surgery. In the previous year, 132 patients were admitted for epistaxis and eight patients had surgical procedures, which included septoplasty, nasal packing and external carotid artery ligation. The post-operative stay ranged from three to six days (mean 3.9 days). Our audit shows that endoscopic sphenopalatine artery diathermy is a safe, successful and effective management option for patients with refractory epistaxis. The morbidity is reduced and the hospital stay is shortened. The sphenopalatine artery diathermy can be combined with anterior ethmoid surgery, when necessary.

Aged↗
PubMed1991

The need for standards for audit of coronary surgery and angioplasty.

The purpose of auditing is to improve clinical practice, but there is little point in auditing the management of a single patient or a series of patients unless the correct management has been established. Auditing should involve comparing case management with a standard and should not be based on individual opinion. This review considers how standards for auditing of coronary artery surgery and angiography can be defined, and it describes recent publications of different types that potential auditors should consider before beginning their task. These publications include series of patients, registers, committee statements, and ratings of "appropriateness."

Angioplasty, Balloon, Coronary↗
PubMed2001

Audit of acute pancreatitis management: a tale of two hospitals.

BACKGROUND: A case note audit of existing practices in the management of acute pancreatitis (AP) at a district general hospital (DGH) and a teaching hospital was undertaken to determine if practices were in accordance with published UK guidelines. METHODS: Casenotes of all adults admitted with AP over a period of one year at the two hospitals were reviewed. RESULTS: Ninety-five patients were treated for AP at the teaching hospital and 52 at the DGH. The age, sex and aetiological distributions at the two hospitals were similar. Fifteen (15.8%) patients at the teaching hospital and eight (15.3%) at the DGH had severe AP. Four patients died at each hospital. Prognostic Glasgow criteria tests (excluding LDH) were completed within 48 hours in 43% patients at the teaching hospital and 48% at the DGH. Five of the twenty-five cholecystectomies at the teaching hospital and 4/18 at the DGH were performed within four weeks after admission with AP. CONCLUSION: Audit of current practice has highlighted deficiencies at many levels compared with current evidence-based guidelines, although this has not resulted in unexpected mortality. It remains to be seen whether new measures to aid compliance with guidelines will result in improvement in morbidity and mortality.

Adolescent↗
PubMedDate not supplied

An audit of cardiac arrest management by extended trained ambulance crew.

OBJECTIVE: To audit the use of extended skills by South Glamorgan Ambulance crew in attempted resuscitations from out-of-hospital cardio-respiratory arrest, in terms of successful discharge of patients from hospital and the accuracy with which agreed protocols were applied. Design-Retrospective analysis of ambulance report forms, electrocardiograph rhythm strips, casualty cards and discharge summaries during 26 months (1st May 1987-30th June 1989). SETTING: A mixed urban and semi-rural area of 187 square miles with a population of 396,000. RESULTS: There were 274 attempted resuscitations. Seven patients (2.5%) were managed for primary respiratory arrest and 3 were discharged. In 98 patients (35.8%) the initial resuscitation protocol was for ventricular fibrillation: 26 were admitted and 17 were discharged. In 169 patients (61.7%) the initial resuscitation protocol was for asystole or electromechanical dissociation: 11 were admitted and 1 discharged. The majority of patients who were successfully discharged from hospital were those in ventricular fibrillation who responded to defibrillation alone (13 survivors). Drug administration may have played a role in the successful resuscitation of the remainder. Endotracheal intubation was successful in 94.7% and vein cannulation in 87.7% of attempts. There were deviations from the ventricular fibrillation protocol in 27 cases (27.5%) and from the asystole protocol in 27 cases (16.0%). CONCLUSION: Survival rates for ventricular fibrillation managed by these personnel were satisfactory with early defibrillation. Defibrillation alone was responsible for the majority of successful resuscitations. The additional benefit of drug administration appears small, though potentially important. The majority of patients were in asystole by the time the ambulance arrived. IMPLICATIONS: Extended trained crews use their skills effectively. The most important skill is defibrillation. Further studies are required to explain the high proportion of patients found in asystole. The performance of individual ambulance personnel should be assessed prospectively, because agreed resuscitation protocols are not always followed.

Ambulances↗