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Rationale, Aims and Objectives: Emergency hospital readmissions within 30 days of discharge from hospital are considered a marker for the quality of hospital care, patient experience, the discharge process and integration with community services. This paper describes the frequency and variations in cause of emergency readmissions at 30 and 90 days following discharge after acute stroke from two stroke units. Methods: Retrospective data collection of Hospital Episodes Statistics (HES) and Sentinel Stroke National Audit Programme (SSNAP) of consecutive acute stroke hospital discharges over 24 months from 2017 to 2019 from two specialist stroke units in England. HES data were used to calculate the Charlson comorbidity index (CCI). Covariates were analysed for their association with readmission rate, including: age; gender; CCI; length of stay for first stroke admission; living alone; discharge to a care home; discharge receiving stroke specialist early supported discharge (ESD) rehabilitation and stroke severity as determined by National Institute for Health Stroke Scale on stroke admission. Results: From 2017 to 2019 there were 1999 live discharges with a primary diagnosis of stroke. Both hospitals had a trend of increasing readmission rates with increasing stroke severity and comorbidity. Longer length of stroke admission, especially for patients with increasing stroke severity, and patients receiving ESD rehabilitation after discharge reduced 90‐day readmissions. This association was stronger at 90 days than at 30 days. Different readmission event rates were found at 30 and 90 days and when events were compared between the two hospitals. Conclusion: Understanding differences in readmission event rates between hospitals at 30 and 90 days can support local planning of patient needs in the first weeks after stroke discharge and to investigate ways for hospital to reduce the impact of readmission. It is recommended that stroke services use both 30 and 90‐day readmissions to inform service evaluation and improvement. [ABSTRACT FROM AUTHOR]

Abstract: Rationale, aims, and objectives: Whilst many dose omissions cause no patient harm, inappropriate dose omissions have been associated with increased length of hospital stay, risk of sepsis, and mortality. This study aimed to comprehensively describe the prevalence and nature of omitted doses overall and of high risk medication dose omissions in an organization using an electronic Medication Management System. Methods: A retrospective cross‐sectional study was undertaken in an Australian tertiary referral health service. All routinely documented electronic inpatient dose administration records from 1st July 2014 to 30th June 2015 were included. Period prevalence and characteristics of dose omissions overall and of high‐risk medication dose omissions were determined. Results: During the study period, 3.3 million inpatient doses were scheduled for administration, with doses endorsed as “not given” comprising 6.2% of all scheduled doses. Non‐valid dose omissions (medication not available or no justification documented) comprised 1.2% of scheduled doses. Patient refusal accounted for one third of all dose omissions, while for 12% no explanation was provided and 7% were endorsed “medication not available”. High‐risk medications accounted for 20% of all dose omissions. One in 20 antimicrobial doses scheduled were omitted, and of these, 17% were due to patient refusal. Conclusion: The period prevalence of dose omissions in this large study after electronic Medication Management System implementation is similar to that found when paper charts were used. Although most dose omissions appear appropriate, many orders were not given due to patient refusal or with no documented justification. Interventions to minimize unintentional dose omissions are indicated. [ABSTRACT FROM AUTHOR]

This paper deals mainly with health services peer accreditation in Italy, but a preliminary brief description of governmental accreditation is done, inasmuch as peer initiatives must take into account - and build upon - institutional accreditation requirements and practices. In Italy, no independent agency, such as the 'Commission for Health Improvement' or the 'Health Advisory Service' is operating. In the field of mental health services, two major peer accreditation programmes have been carried out. The paper focuses on the most original features of both programmes and reports examples of standards belonging to the more recent accreditation manual. In the manual, because of a lesser need to reach a consensus between services with widely different outlook, professional standards are more detailed and the importance that they should be based on the principle of evidence-based mental health is more stressed. The Italian peer accreditation approach in mental health may raise interest also in other countries. [ABSTRACT FROM AUTHOR]

Rationale This paper reports an initiative which promoted evidence-based practice in pressure risk assessment and management among home nursing clients in Melbourne, Australia. Aim and objectives The aim of this study was to evaluate the introduction and uptake of the Australian Wound Management Association Guidelines for the Prediction and Prevention of Pressure Ulcers. Method In 2007 a pilot study was conducted. Nurse perspectives (n=21) were obtained via survey and a client profile (n=218) was generated. Audit of the uptake and continued use of the pressure risk screening tool, during the pilot study and later once implemented as standard practice organizational wide, was conducted. Results Nurses at the pilot site successfully implemented the practice guidelines, pressure risk screening was adopted and supporting resources were well received. Most clients were at low risk of pressure ulcer development. The pilot site maintained and extended their pilot study success, ensuring more than 90% of clients were screened for pressure risk over the 18 months which followed. All other sites performed less well initially, however subsequently improved, meeting the pilot sites success after 18 months. Two years later, the organization continues to screen more than 90% of all clients for pressure risk. Conclusion Implementation of clinical practice guidelines was successful in the pilot project and pressure risk screening became a well-adopted practice. Success continued following organizational wide implementation. Pilot study findings suggest it may be prudent to monitor the pressure ulcer risk status of low risk clients so as to prevent increasing risk and pressure ulcer development among this group. [ABSTRACT FROM AUTHOR]

Background Performance feedback is one of a number of strategies used to improve clinical practice among students and clinicians. Objectives The aims of this paper were to examine conceptual underpinnings and essential components for audit and feedback strategies, to assess the extent to which recently published audit and feedback interventions include these components and to recommend future directions for feedback to improve its educational and behavioural impact. Methods Based on the actionable feedback model, we examined the presence of four theoretical constructs - timeliness, individualization, lack of punitiveness and customizability - in studies published during 2009-2010 which included a feedback intervention. Results There was wide variation in the definition, implementation and outcomes of 'feedback' interventions, making it difficult to compare across studies. None of the studies we reviewed included all of the components of the actionable feedback model. Conclusions Feedback interventions reported to date, even when results are positive, often fail to include concepts of behaviour change. This may partially explain the large variation in approaches and in results of such interventions and presents major challenges for replicating any given intervention. If feedback processes are to be successfully used and disseminated and implemented widely, some standardization and certainly more clarity is needed in the specific action steps taken to apply behavioural theory to practice. [ABSTRACT FROM AUTHOR]

Rationale Little scrutiny has been applied to how 'cost per fall' values have been calculated and applied. This paper presents discourse discussing how the cost of fall statistic could potentially be misleading when applied to inpatient health or residential care settings and provides estimates of the cost of falls and cost of falls per person. Method Burden of disease was estimated using a decision tree approach. Data informing the decision tree were drawn from a retrospective audit of 545 falls in a residential care facility, a visual observation study of 46 residents from the same facility and a cohort study of 186 residents from nine different facilities in Australia. Acute care and transportation costs were extracted from the retrospective audit using incident reports and care note review. The distribution of falls per person and associations between falls, fractures and change in resident mobility were extracted from the cohort study. The association between resident mobility and the amount of time required to perform toileting, transfer and dressing activities was extracted from the visual observational study. Results The minimum 'cost per fall' was estimated to be $AUD 841 and the maximum was $AUD 1024. The 'cost of falls per person' estimate was $AUD 1887 (2008 base year). Conclusions This cost per fall estimate was substantially lower than three previous internationally derived estimates possibly as a consequence of how fall data were collected and modelled in these studies. Cost of falls per person may be a preferable statistic for future use. [ABSTRACT FROM AUTHOR]

Background Research indicates that multifaceted practice development (PD) interventions are more effective than single strategies. However, models of education in health care need to consider cost-effectiveness. Objectives This paper presents a research-based, PD theory called the Individual Practice Development Theory. It argues that programmes that use the Individual Practice Development Theory to tailor PD support to the learning needs of practitioners will result in more engagement in PD and will target PD resources efficiently. Methods The in-depth qualitative, multi-method realistic evaluation was of a multifaceted, organization-wide PD programme in one National Health Service Mental Health and Learning Disabilities Trust. Semi-structured interviews, practice observation and documentation audit were used to gather data from occupational therapists. Findings Results indicated that environmental contexts, particularly the support of the immediate team, and the participant's personal circumstances affected PD behaviour change. Six mechanisms acted as catalysts. These were: Building Confidence, Finding Flow, Accumulating Reward, Conferring with Others, Constructing Knowledge Know-how and Channelling Time. Four stages of PD characterized as: 'In the Hangar', 'On the Runway', 'Take-off' and 'In the Air' were identified. The research also illustrated the interconnectivity between outcome levels, contextual circumstances and activating mechanisms. Discussion The findings suggested that PD interventions need to be more individually tailored to achieve optimum learning outcomes. The identification of four discernable stages permits rapid understanding of PD support needs in order to focus PD support. Conclusion With a systematic and individualized approach to PD in health care, more target PD supports can be put in place. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Little is known about the quality of occupational health care provided to National Health Service (NHS) staff. We designed the first national clinical audits of occupational health care in England. We chose to audit depression and back pain as health care workers have high levels of both conditions compared with other employment sectors. The aim of the audits was to drive up quality of care for staff with these conditions. The object of this paper is to describe how we developed an audit methodology and overcame challenges presented by the organization and delivery of occupational health care for NHS staff. Methods We designed two retrospective case note audits which ran simultaneously. Sites submitted up to 40 cases for each audit. We used duplicate case entry to test inter-rater reliability and performed selection bias checks. Participants received their site's audit results, benchmarked against the national average, within 4 months of the end of the data entry period. We used electronic voting at a results dissemination conference to inform implementation activities. Results Occupational Health departments providing services to 278 (83%) trusts in England participated in one or both audits. Median kappa scores were above 0.7 for both pilot and full audits, indicating 'good' levels of inter-rater reliability. In total, 79% of participants at a dissemination conference said that they had changed their clinical practice either during data collection (52%) or following receipt of their audit results (27%). Conclusions Clinical audit can be conducted successfully in the occupational health setting. We obtained meaningful data that have stimulated local and national quality improvement activities. Our methodology would be transferable to occupational health settings outside the NHS and in other countries. [ABSTRACT FROM AUTHOR]

Abstract: Rationale, aims, and objectives: Process evaluation can be used to understand the factors influencing the impact of knowledge translation (KT) interventions. The aim of this mixed methods process evaluation was to evaluate the processes and perceived outcomes of eight KT interventions that were used with healthcare aides (HCAs) to introduce a mobility innovation into their daily care practices. The study examined the perceived effectiveness of various KT interventions in sustaining daily performance of the sit‐to‐stand mobility innovation by HCAs with residents in long‐term care. Method: In‐person interviews were conducted with four leaders across three long‐term care facilities. Seven focus groups with 27 HCAs were conducted across the three facilities. All participants were asked to rank the eight interventions involved in the trial according to their perceived effectiveness and, for the leaders, their perceived ease of implementation. Focus group and interview questions asked participants to discuss the relative merits of each KT intervention. Two research assistants coded all of the transcripts independently using content analysis. Results: Both HCAs and their leaders perceived reminders, followed by discussion groups, to be the most effective KT interventions to sustain practice change. Healthcare aide champions were deemed least effective by both leaders and HCAs. Leaders identified both the focus group discussion and audit and feedback posters in the study as the most difficult to implement. Participants valued interventions that were strategically visible, helped to clarify misconceptions about the new care innovation, supported teamwork, and made visible the resident benefits of the care innovation. Logistical issues, such as staff scheduling and workload, influenced the perceived feasibility of the various KT interventions. Conclusions: Understanding how care staff in long‐term care settings perceive KT interventions can inform the choice of future use of these interventions to move research evidence into practice. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Healthcare systems worldwide devote significant resources towards collecting data to support care quality assurance and improvement. In the United Kingdom, National Clinical Audits are intended to contribute to these objectives by providing public reports of data on healthcare treatment and outcomes, but their potential for quality improvement in particular is not realized fully among healthcare providers. Here, we aim to explore this outcome from the perspective of hospital boards and their quality committees: an under‐studied area, given the emphasis in previous research on the audits' use by clinical teams. Methods: We carried out semi‐structured, qualitative interviews with 54 staff in different clinical and management settings in five English National Health Service hospitals about their use of NCA data, and the circumstances that supported or constrained such use. We used Framework Analysis to identify themes within their responses. Results: We found that members and officers of hospitals' governing bodies perceived an imbalance between the benefits to their institutions from National Clinical Audits and the substantial resources consumed by participating in them. This led some to question the audits' legitimacy, which could limit scope for improvements based on audit data, proposed by clinical teams. Conclusions: Measures to enhance the audits' perceived legitimacy could help address these limitations. These include audit suppliers moving from an emphasis on cumulative, retrospective reports to real‐time reporting, clearly presenting the "headline" outcomes important to institutional bodies and staff. Measures may also include further negotiation between hospitals, suppliers and their commissioners about the nature and volume of data the latter are expected to collect; wider use by hospitals of routine clinical data to populate audit data fields; and further development of interactive digital technologies to help staff explore and report audit data in meaningful ways. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Clinical practice guidelines (CPGs) are significant tools for evidence‐based health care quality improvement. The CPG program at King Saud University was launched as a quality improvement program to fulfil the international accreditation standards. This program was a collaboration between the Research Chair for Evidence‐Based Healthcare and Knowledge Translation and the Quality Management Department. This study aims to develop a fast‐track method for adaptation of evidence‐based CPGs and describe results of the program. Methods: Twenty‐two clinical departments participated in the program. Following a CPGs awareness week directed to all health care professionals (HCPs), 22 teams were trained to set priorities, search, screen, assess, select, and customize the best available CPGs. The teams were technically supported by the program's CPG advisors. To address the local health care context, a modified version of the ADAPTE was used where recommendations were either accepted or rejected but not changed. A strict peer‐review process for clinical content and methodology was employed. Results: In addition to raising awareness and building capacity, 35 CPGs were approved for implementation by March 2018. These CPGs were integrated with other existing projects such as accreditation, electronic medical records, performance management, and training and education. Preliminary implementation audits suggest a positive impact on patient outcomes. Leadership commitment was a strength, but the high turnover of the team members required frequent and extensive training for HCPs. Conclusion: This model for CPG adaptation represents a quick, practical, economical method with a sense of ownership by staff. Using this modified version can be replicated in other countries to assess its validity. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Local health administrators implemented chronic obstructive pulmonary disease and heart failure admission order sets to increase guideline adherence. We explored the impact of these order sets on workflows and guideline adherence in the internal medicine specialty in two Canadian teaching hospitals. Methods: A mixed methods study combined shadowing care providers (250 h), meeting observation and interviews (11 h), and patient medical chart audits for heart failure (n = 120) and chronic obstructive pulmonary disease (n = 120) patients. The chart audits analysed details of the admission process and 14 guideline elements associated with heart failure (nine) and chronic obstructive pulmonary disease (five). Results: A subset (10/14) of the evaluated guideline elements were included in the heart failure or chronic obstructive pulmonary disease order sets. Order set use significantly increased adherence to some (4/10) of these elements. However, our qualitative work uncovered a perception that use of these two order sets increased order duplication. Our chart audits supported this perception. Order set use increased order duplication for heart failure (92% vs 43%) and chronic obstructive pulmonary disease (75% vs 43%). Conclusion: It is unclear whether, for these two hospitals, the gains brought by implementation of chronic obstructive pulmonary disease and heart failure admission order sets were worth their associated organisational shortcomings. Problems with order set implementation appeared to stem from poor integration with pre‐existing complex organisational systems. Health administrators and clinicians interested in implementing order sets within their own hospitals need to remain cognizant of how these tools will fit into existing systems and practices. [ABSTRACT FROM AUTHOR]

Background: Regular, routine, multimodal analgesia provides better pain relief following Caesarean section than reliance on "as required" opiate dosing. This quality improvement report describes the effective use of an education programme coupled with a highlighted, preprinted medication chart, employing "Nudge Theory" principles to achieve significant improvements in the administration of analgesic medications to patients after Caesarean section operations. Problem An acute pain service audit identified a serious deficiency with delivery of regular postoperative analgesic medications to patients following Caesarean section operations. Methods: An audit of pain medication delivery to patients following Caesarean section demonstrated that postoperative analgesia was not being administered in line with local prescribing guidelines. Two interventions were planned: Education sessions for anaesthetic recovery and ward staff.Introduction of a new preprinted and highlighted medication chart. A postintervention audit was then conducted. Results: There were statistically significant improvements in all medications administered to patients following the two interventions. For analgesic medications, the rate of administration of drugs in compliance with guidelines rose from 39.6% to 89.9% (P < 0.001 using 2‐sample z test). Each subgroup of medications also showed statistically significant improvements in administration compliance. Conclusion: A combined approach, including application of "Nudge Theory" to the administration of analgesic medication after Caesarean section, considerably improved delivery of medications prescribed for postoperative analgesia. [ABSTRACT FROM AUTHOR]

Abstract: For older adults with osteoporosis, a fall resulting in hip fracture is a life‐changing event from which only one‐third fully recover. Current best evidence argues strongly for elderly patients to bear weight on their repaired hip fracture immediately after their surgery to maximize their chances of full or nearly full recovery. Patient stakeholders in Canada have argued that some surgeons fail to issue “weight‐bearing‐as‐tolerated” (WBAT) orders in all eligible cases, protecting their bony repair but contributing to increased mortality and long‐term disability rates. In collaboration with a national stakeholder organization, Bone and Joint Canada, we interviewed 20 orthopedic surgeons across Canada who perform hip fracture repair surgery, with the aim of understanding their attitudes and behavior toward patient management regarding weight bearing. Qualitative content analysis, in which themes are identified and agreed by multiple coders, suggested that both patient characteristics and surgeon factors influence surgeons' postoperative weight‐bearing orders. While almost all respondents agreed that weight bearing as tolerated is indeed therapeutic for most hip fracture repair or replacement patients, surgeons also described certain patient characteristics that would diminish the value of immediate weight bearing, including poor bone quality and certain types of fracture pattern. Surgeon factors that affect postoperative mobilization orders include choice of construct, previous experience of construct failure, and lack of local audit data regarding past weight‐bearing decisions and patient outcomes. Thus, although familiar with best practice guidelines, surgeons also have “rules to break the rules.” In an era when “good” medicine leans toward science rather than art, the role of individual experience in decision making with regard to hip fracture care continues to be important and would benefit from being discussed openly. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives Adverse events (AEs) are a major concern in surgery, but the evidence in cardiac surgery is limited, especially on the contributory factors. According to the data of the National Outcomes Program, a unit was selected to conduct a mixed methods investigation into the incidence, type, and cause of AE, given its mortality rate that was double the national average on coronary artery bypass grafting, valve reparation, and replacement. Methods A retrospective investigation on the performance of a cardiac surgery, combining the routinely collected data on process and outcome measures with a 2-stage structured review of 280 medical records performed by 3 expert clinicians, with the support of a methodologist. Results At least one risk had been verified in 137 of 280 cases (48.9%, 95% CI, 43.1-54.8). The total number of AE was 42, with an incidence of 15% (95% CI, 10.8-20.2) and a preventability of 80.9% (95% CI, 69.1-92.8). In 11.9% of AE, the consequence is death, disability in 40.5%, and extended hospital stay in 69% of the cases. Adverse events are associated with problems in care management at the ward (89/137, 64.9%, 95% CI, 56.9-72.9), followed by surgical complications (46/137, 33.6%, 95% CI, 25.7-41.5) and infection/sepsis (32/137, 23.4%, 95% CI, 16.3-30.4). An active error was made by the health care workers in 31 of 42 cases with AE, either during the decision making or during the execution of an action. A total of 36 AEs were due to deficiencies attributed to organizational factors and 31 were linked to poor teamwork. Conclusions The mixed methods approach demonstrated how a deep understanding of AE and poor performance may emerge thanks to the combination of routinely available data and experts' evaluations. The main limitation of this study is its focus on the cardiac surgery rather than on the entire process of care. The evaluation could have been integrated with on-site observations and the analysis of reported incidents. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The Hospital Federation of Vaud ( Switzerland) used a Breakthrough Collaborative with the aim of reducing adverse drug events ( ADEs) by 20% in 10 participating hospitals. Methods A set of interventions (covering patient identification, high-alert medication and medication preparation in the ward) was deployed over 18 months starting in October 2010. All hospitals monitored discrepancies between drugs prescribed and those prepared for administration, as well as the occurrence of ADEs using the ADE Trigger Tool for 18 months (cohort 1). A subset of five hospitals continued this monitoring for 12 additional months (cohort 2). Results In cohort 1, pill box discrepancies were present in 5.9% of doses ( n = 9772) in 2011 and in 5.8% ( n = 2251) in the first 3 months of 2012 (no statistical significance). There were no significant differences in the rate of ADEs/1000 doses across time (1.2 in 2010, 1.0 in 2011 and 1.0 in 2012). In cohort 2, pill box discrepancies were reduced from 6.5% ( n = 4846 doses) in 2011 to 4.4% ( n = 7355) in 2012 ( P < 0.001) to 3.0% for the first 3 months of 2013 ( n = 2251; P = 0.004). The rate of ADEs/1000 doses decreased (1.8 in 2010, 1.1 in 2011 and 0.6 in 2012/13 ( P = 0.008 for 2010-2011, and P < 0.001 for 2011-2012/2013). Conclusions Reductions in drug discrepancies and ADEs occurred in the cohort with the longer monitoring duration. Factors contributing to success may include the strategic status of the project, executive support, perseverance in post-intervention measurement, and institution-wide rather than partial deployment. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives There is evidence that health and well-being of the National Health Service ( NHS) workforce affects organizational and patient outcomes. A Cochrane review of the effectiveness of clinical audit to improve quality of care has shown great variation between studies, depending on the design and intensity of support offered. This study evaluates the effectiveness of an organizational audit methodology with (1) action-planning workshops and follow-up and (2) audit feedback alone, to support the implementation of the National Institute for Health and Care Excellence ( NICE) workplace guidance. Methods Two rounds of audit using a self-administered online questionnaire were conducted. An overall implementation score was devised for each trust. Following round 1, interviews were conducted with a cohort of trusts with high scores. The interviews used a theory-based framework to identify predictors of and barriers to successful implementation. From this, the content for action-planning workshops was devised and workshops held with lower scoring trusts. The remaining trusts received only written feedback on their audit results. Changes in the implementation score between rounds 1 and 2 were compared within and between cohorts. Results The median improvement in scores between rounds 1 and 2 was statistically significant except where baseline score was high. The improvement for trusts who received workshops was very much better than those who did not ( P < 0.001). This difference remained after adjustment using stratification by baseline score ( P = 0.001). Conclusions Audit, combined with action-planning workshops and follow-up, appears to be more effective in improving implementation of NICE workplace health and well-being guidance than audit with feedback alone. [ABSTRACT FROM AUTHOR]

Rationale aims and objectives This study sought to evaluate potential reductions in risk associated with midazolam injection, a sedating medication, following a UK National Patient Safety Alert. This alert, 'Reducing risk of overdose with midazolam injection in adults', was sent to all National Health Service organizations as a Rapid Response Report detailing actions services should take to minimize risks. Method To evaluate any potential changes arising from this alert, a number of data sources were explored including reported incidents to a national reporting system for health care error, clinician survey and audit data, pharmaceutical purchasing patterns and feedback from National Health Service managers. Results Prior to the Rapid Response Report, 498 incidents were received by the National Patient Safety Agency including three deaths. Post-implementation of the Rapid Response Report ( June 2009), no incidents resulting in death or severe harm had been received. All organizations reported having completed the Rapid Response Report actions. Purchase and use of risk-prone, high-strength sedating midazolam by health care organizations decreased significantly as did the increased use of safer, lower strength doses (as recommended in the Rapid Response Report). Conclusions Organizations can achieve safer medication practices, better knowledge, awareness and implementation of national safer practice recommendations. Risks from inadvertent overdose of midazolam injection were reduced post-implementation of national recommendations. Ongoing monitoring of this particular adverse event will be required with a sustained patient safety message to health services to maintain awareness of the issue and reduction in the number of midazolam-related errors. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives A prototype diagnostic clinical decision support system ( CDSS) was developed to assist primary care clinicians (general practitioners) in clinical decision making, aimed at reducing diagnostic errors. The prototype CDSS showed some promise with high levels of validity and reliability; however, issues regarding the underlying Bayesian belief network ( BBN), small sample size and use of radiological imaging as a gold standard measure were highlighted that required further investigation before considering clinical testing. Methods The prototype CDSS was reviewed and updated based on computer science literature and expert (orthopaedic consultant) opinion. The updated CDSS was tested by comparing its diagnostic outcome against the diagnosis of 93 case studies as determined by expert opinion combined with arthroscopy findings or radiological imaging. Results The updated CDSS showed significant high levels of sensitivity (91%), specificity (98%), positive likelihood ratio (53.12) and negative likelihood ratio (0.08) with a kappa value of 0.88 to a confidence level of 99% compared with expert diagnosis combined with arthroscopy findings or radiological imaging. Conclusions The results suggest that the updated CDSS has addressed the issues highlighted from the initial research while maintaining high levels of validity and reliability. The updated CDSS is now ready for clinical testing. [ABSTRACT FROM AUTHOR]

Rationale In nephrology, the NEOERICA project assessed the feasibility of the diagnosis scheme based on a general practice database. This approach opened a new area where routinely collected data could be used for purposes other than patient management, such as epidemiological analysis and professional practice evaluation. In Lyon, the TIRCEL network is made up of a coordination team and an online database. In 2008, a total of 468 professionals participated and 983 patients were in the database corresponding to 4114 consultations and 9250 biological assessments. Objective To investigate the impact of a quality control process on the data from operational databases. Methods We set up a quality control process and we described the impact of this process on data. We also specifically investigated the role of measurement scales in error frequency and we studied the impact of data quality on variables which could be used for professional practice evaluation. Results Quality control allowed us to detect as inconsistent data 7.5% of tested data. This rate is linked to the parameters and varied from less than 1% (weight, diastolic blood pressure and urinary sodium) to more than 30% (serum iron and ferritin). Quality control led mainly to the validation of the identified data for 80.4%, a direct correction was realized for 12.9%, 5.6% by the lab and only 1.2% were set to missing. Average proteinuria was modified with the quality control process (2.09 g per 24 hours vs. 0.82 g per 24 hours); however, the median remained stable (0.21 g per 24 hours). Conclusion Specialty databases such as TIRCEL could not be used for epidemiological research or for the extraction of indicators for professional practice evaluation without strict quality control or the set-up of data-entering limits and alarms. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Minor Illness and Injury Units (MIUs) are becoming a key element in the Urgent Care strategies of Primary Care Trusts. They are intended to both improve access to primary care and to reduce the workload of hospital emergency departments. Their efficiency in resolving patients' needs for health care has been questioned. We sought to describe subsequent health care utilisation among people attending two MIUs in Sunderland, UK. Method Audit of all patients who attended the MIUs during two separate week-long blocks with General Practitioner (GP) case note review of those who had been either treated and discharged or referred to their GP. Results A total of 1995 patients from 38 practices attended during the study period. 1262 (63.3%) were treated and discharged and 281 (14.1%) referred to the GP. In the subsequent 7 days 336 (21.8%) attended their GP, 37 (2.4%) attended an emergency department and 18 (1.2%) reattended the MIU. Overall, 855 (42.9%) of all attenders required further care, and in 265 (29.9%) this was unscheduled. Conclusion Although most people attending Minor Illness and Injury Units are treated and discharged, subsequent use of health care services is common and in a third of cases is unscheduled. This calls into question the effectiveness of MIUs as an alternative to general practice but may reflect a need for better signposting of patients to the service best suited to their needs. [ABSTRACT FROM AUTHOR]

Background In 2002, the US Preventive Services Task Force recommended routine osteoporosis screening for women aged 65 years or older. However, studies have indicated that osteoporosis remains underdiagnosed, and various methods such as the use of health information technology have been tried to increase screening rates. We investigated whether we could boost the low rates of bone mineral density testing with implementation of a point-of-care clinical decision support system in our primary care practice. Methods We retrospectively reviewed the medical records of female patients eligible for osteoporosis screening who had no prior bone mineral density test who were seen at our primary care practice sites in 2007 or 2008 (before and after implementation of a point-of-care clinical decision support system). Results Overall, screening rates were 80.1% in 2007 and 84.1% in 2008 ( P < 0.001). Of patients who did not have osteoporosis screening before the visit, 5.87% completed the screening after the visit in 2007, compared with 9.79% in 2008 (when the clinical support system was implemented), a 66.7% improvement ( P = 0.025). Conclusion Clinical decision support for primary care doctors significantly improved osteoporosis screening rates among eligible women. Carefully designed clinical decision support systems can optimize care delivery, ensuring that important preventive services such as osteoporosis screening for patients at risk for fracture are performed while unnecessary testing is avoided. [ABSTRACT FROM AUTHOR]

Background and aims Emergency admissions of frail older people in care homes, many of whom have dementia, are critical events which should be avoided if possible. To identify and influence factors related to emergency admissions and place of death. Method Design of study: Completed audit cycle. Setting: Jenner Health Centre patients in six local care homes. Data collection over 12 months in 05/6, repeated in 08/9. Emergency admissions, admitting health professional, assessment prior to admission, length of hospital stay, annual visit workload and place of death. Results Admission numbers fell from 91 (194 patients) in 05/6 to 52 (183 patients) in 08/9, related to a fall in admissions by general practitioners (GPs) and out of hours (OOH). The proportion of admissions by care home staff doubled. There was a highly significant difference ( P < 0.001), between GPs and OOH in patients visited prior to admission in 05/6 which persisted in 08/9 ( P < 0.01). A hospital stay >72 hours was significantly more likely if patients were visited prior to admission. In 05/6, 55% of deaths occurred in the care home rising to 75.5% in 08/9 (total numbers deaths unchanged). There was a highly significant difference ( P < 0.001 05/6 and 08/9), between deaths in nursing compared with residential homes. GP visits to nursing home patients rose by 10.3% but visits to residential home patients fell by 5.4%. Conclusions The aims of the audit were achieved with a 43% reduction in emergency admissions and a 45% reduction in deaths in hospital but at the expense of a 12% increase in visits. Improved anticipatory planning and increased medical and nursing support for patients and staff in residential homes may help to further reduce emergency admissions and deaths in hospital in future. [ABSTRACT FROM AUTHOR]

Objective To evaluate the implementation of clinical practice guidelines in the initial stages of treatment of first episode psychosis, through use of a care pathway within one area mental health service. Methods A fidelity audit was undertaken using data from local Early Psychosis Care Pathway documents, completed for the cohort of clients with early psychosis seen in the first 2 years of an integrated early psychosis programme model, at St Vincent's Mental Health Service, Melbourne, Australia. Results The utilisation of a care pathway greatly supported both the documentation of clinical process and fidelity to clinical guidelines in early psychosis treatment. Excellent adherence (over 80%) was achieved for therapeutic alliance with the client, conducting a comprehensive bio-psychosocial assessment, medical investigations, reduction of client trauma and increased orientation to the service and the mental health systems of care, and for contact with family. Good adherence (over 70%) was achieved for client re-integration to the community and promotion of carer well-being; the service plans to focus on these areas in future service improvement initiatives, along with a focus on physical health assessment and enhancing primary care liaison. Conclusions The process of formally operationalizing and implementing clinical guidelines utilizing a care pathway within an area mental health service has proved to be an effective way to ensure fidelity with standard agency practices and protocols. The integrated approach, supported by quality assurance initiatives, provides an excellent goodness-of-fit within an established area mental health service. [ABSTRACT FROM AUTHOR]

Recent UK policy has promoted routine monitoring of the performance of cancer services. Clinical databases are one method of collecting the detailed data required for clinically relevant analyses and of supplementing that collected by cancer registries. To describe characteristics of patients, their treatment and surgical care recorded in the North Thames Prospective Audit of Colorectal Cancer database compared with the Thames Cancer Registry database between 1999 and 2004. We defined the geographical area served by the prospective audit and extracted a registry dataset for the same area. We compared the numbers, age, sex, cancer site and staging of patients in each database. The proportions recorded as receiving surgery, radiotherapy and chemotherapy were compared over time, and clinical standards recorded for preventing post-operative complications and for specialist care were determined from the clinical database. Clinical and registry databases differed in case mix. The clinical database began to capture data on a larger number and wider range of patients over time, and generally included more complete staging data. Treatment trends differed between the databases, with the registry data showing lower proportions undergoing surgery and a slight increase in rectal cancer surgery over time. There was a suggestion that a higher proportion of men received radiotherapy and chemotherapy than women. Recording of surgical standards in the clinical database was generally poor, although decreased leak and infection rates and post-operative mortality were suggested in the initial years of the audit. The clinical database contributed some additional information on patient characteristics and the performance of services, but variable data quality and completeness prevented many planned analyses. Collecting additional data requires funded structures and quality assurance systems and such effort should focus on the data required to answer the most pressing clinical questions. [ABSTRACT FROM AUTHOR]

To validate the Patients Assessment of Chronic Illness Care (PACIC) among patients with chronic disease in the Australian context and to examine the relationship between patient-assessed quality of care and patient and practice characteristics. Cross-sectional analysis of baseline data in two independent health service intervention studies that involved patients with type 2 diabetes, ischaemic heart disease and/or hypertension in general practice. The first study involved 2552 patients from 60 urban and rural general practices. The second involved 989 patients from 26 practices in Sydney. Patients were mailed a questionnaire, which included the PACIC and Short Form Health Survey. Factor analysis was performed and the factor scores and total PACIC were analysed using multi-level regression models against practice and patient characteristics. Factor analysis revealed a two-factor solution with similar loading of PACIC items in both studies: one for shared decision making and self-management and the other for planned care. Practice characteristics were not related to PACIC scores. Scores were related to patient characteristics - education, retirement, type and number and duration of conditions. The two-factor structure of the PACIC found in these Australian studies is different from the five-factor structure found in the US and the European studies. This may be related to differences in the way patients interact with the health system especially the use of Team Care plans. The association of total scores with patient characteristics was consistent with those found in other studies including a lack of association with gender, age and ethnicity. These findings should be taken into consideration when comparing patient-assessed quality of care between countries using this tool. [ABSTRACT FROM AUTHOR]

Leadership and innovation are currently seen as essential elements for the development and maintenance of high-quality care. Little is known about the relationship between leadership and culture of innovation and the extent to which quality improvement methods are used in general practice. This study aimed to assess the relationship between leadership behaviour, culture of innovation and adoption of quality improvement methods in general practice. Self-administered postal questionnaires were sent to general practitioner quality improvement leads in one county in the UK between June and December 2007. The questionnaire consisted of background information, a 12-item scale to assess leadership behaviour, a seven-dimension self-rating scale for culture of innovation and questions on current use of quality improvement tools and techniques. Sixty-three completed questionnaires (62%) were returned. Leadership behaviours were not commonly reported. Most practices reported a positive culture of innovation, featuring relationship most strongly, followed by targets and information but rated lower on other dimensions of rewards, risk and resources. There was a significant positive correlation between leadership behaviour and the culture of innovation ( r = 0.57; P < 0.001). Apart from clinical audit and significant event analysis, quality improvement methods were not adopted by most participating practices. Leadership behaviours were infrequently reported and this was associated with a limited culture of innovation in participating general practices. There was little use of quality improvement methods beyond clinical and significant event audit. Practices need support to enhance leadership skills, encourage innovation and develop quality improvement skills if improvements in health care are to accelerate. [ABSTRACT FROM AUTHOR]

Drug errors are a common and persistent problem in health care and are also associated with serious adverse events. Reporting has become the cornerstone of learning from errors, but is not without its imperfections. The aim of this study is to improve reporting and learning from drug errors through investigating the contributory factors in drug errors and quality of reporting in an acute hospital. A retrospective, random sample of 991 drug error reports from 1999 to 2003 were subjected to quantitative and qualitative analysis. This was followed by 40 qualitative interviews with a volunteer, multi-disciplinary sample of health professionals. The combined analysis has been used to develop a knowledge base for improved drug error reporting. The quality of reports varied considerably, and 27% of reports lacked any contributory factors. Documentary analysis revealed a focus on individuals, sometimes culminating in blame without obvious justification. Doctors submitted few reports, and there were notable differences in reporting according to clinical location. Communication difficulties commonly featured in causation, and high workload and interruptions were predominant contributory factors in the interview data. Interviewees viewed causation as multifactorial, including cognitive and psychosocial factors. Organizational orientation to error was predominantly perceived by interviewees as individual rather than systems-based. Staff felt obliged to report but rarely received feedback. Drug errors are multifactorial in causation. Current reporting schemes lack a theoretical basis, and are unlikely to capture the information required to ensure learning about causation. Health professionals have reporting fatigue and some remain concerned that reporting promotes individual blame rather than an examination of systems factors. Reporting can be strengthened by human error theory, redesigned to capture a range of contributory factors, facilitate learning and foster supportive actions. It can also be feasible in routine practice. Such an approach should be examined through multi-centred evaluation. [ABSTRACT FROM AUTHOR]

Laboratory monitoring has been increasingly recognized as an important area for improving patient safety in ambulatory care. Little is known about doctors' attitudes towards laboratory monitoring and potential ways to improve it. Six focus groups and one individual interview with 20 primary care doctors and nine specialists from three Massachusetts communities. Participants viewed laboratory monitoring as a critical, time-consuming task integral to their practice of medicine. Most believed they commit few laboratory monitoring errors and were surprised at the error rates reported in the literature. They listed various barriers to monitoring, including not knowing which doctor was responsible for ensuring the completion of laboratory monitoring, uncertainty regarding the necessity of monitoring, lack of alerts/reminders and patient non-adherence with recommended monitoring. The primary facilitator of monitoring was ordering laboratory tests while the patient is in the office. Primary care doctors felt more strongly than specialists that computerized alerts could improve laboratory monitoring. Participants wanted to individualize alerts for their practices and warned that alerts must not interrupt work flow or require too many clicks. Doctors in community practice recognized the potential of computerized alerts to enhance their monitoring protocols for some medications. They viewed patient non-adherence as a barrier to optimal monitoring. Interventions to improve laboratory monitoring should address doctor workflow issues, in addition to patients' awareness of the importance of fulfilling recommended therapeutic monitoring to prevent adverse drug events. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Service provision and clinical outcomes for patients admitted with chronic obstructive pulmonary disease remain unacceptably variable despite guidelines and performance feedback of national audit, data. This study aims to assess the impact of mutual peer review on service improvement. The initial phase of this study was to assess the feasibility and determine the practicalities of delivering such a peer review programme on a large scale. Methods All UK acute hospitals were invited to participate in a reciprocal peer review programme administered by a central team from three UK health organizations. Hospitals with the most resources were paired with those with the least (as defined in a baseline survey) and pairs randomized on a 3:2 basis into intervention or control groups. A number of key quality indicators were derived to measure service levels at the beginning and end of the study. Peer review teams included clinicians and managers from acute and primary care organizations and when possible a patient representative. Visits were focussed on four key areas of chronic obstructive pulmonary disease service. Teams were to agree service improvements and submit plans signed off by participants. Monthly change diaries were to be used to record progress towards agreed goals. Results A total of 100 hospitals participated in the programme. Overall, 52 of 54 peer review visits took place within a 4-week time frame and all units submitted service improvement plans within an agreed time frame. Secondary care representatives participated in all visits, primary care in 30 but patients in only 17. The mean number of diaries returned was 2, but 94% of units returned initial and final versions. Conclusions It is possible to deliver successful large-scale mutual peer review using a limited but focussed programme. Participation of patients and use of change diaries requires further evaluation. [ABSTRACT FROM AUTHOR]

The randomized controlled trial (RCT) is considered the gold standard methodology for determining the efficacy and tolerability of new treatments. However, RCTs cannot provide information on the effectiveness of interventions as they are used in real life. This study was conducted to investigate the effectiveness of montelukast, a leukotriene receptor antagonist, in the real-world management of asthma, through a large-scale, retrospective, observational study: the National Montelukast Survey. In order to ensure a robust methodology for the National Montelukast Survey we performed three pilot studies involving a total of almost 400 patients. During the pilots, the design of the study was extensively modified from a simple prescriber questionnaire used in the first pilot to the ‘triangulated’ methodology encompassing the perspectives of patient, prescriber and independent observer used in the National Montelukast Survey. Good levels of interobserver agreement confirmed the robustness of the final methodology. Achieving a robust methodology was dependent on the extensive piloting. It is possible to collect reliable observational data relating to treatment outcomes. We believe our methods are likely to have more widespread applicability and offer a potential improvement over postmarketing surveillance. [ABSTRACT FROM AUTHOR]

Audit has been a major part of attempts to improve patient care in Britain, with substantial resources devoted to it since the 1990 National Health Service reforms. Systematic reviews have considered audit to be of variable, but often moderate, effectiveness. However, these have included few studies from British primary care, and as quality improvement activities may be context specific, it is hard to judge how effective audit has been here. A search for audits published in peer-reviewed journals revealed 48 two-stage projects carried out in British general practice, of which 27 principally concerned chronic disease management and nine prescribing. Most audits showed some improvements in performance, and those using controls showed 27/56 (48%) parameters had changed significantly ( P < 0.05). This review adds further evidence that audit can often be moderately effective. However, it is frequently used as one of a complex set of interventions making precise evaluation difficult. Those responsible for clinical governance will need to choose carefully the subjects they audit in order to use their limited resources to maximum effect. These projects are illustrative examples but once again do not identify any ‘magic bullets’ that would be highly likely to improve professional performance. [ABSTRACT FROM AUTHOR]

To audit the performance of hospitals in evidence-based prescribing. All hospitals in England were invited to participate. The audit was completed in 62 hospitals. Prescribing and clinical data were collected on 100 consecutive medical inpatients aged ≥ 65 years at each site, enabling evaluation of eight prescribing indicators before and after intervention. The data were collected using a specifically designed database. The results of the first audit were available immediately from the software and a national report with locally identifiable information was returned to hospitals. Hospitals were encouraged to design and deliver their own intervention strategy. A questionnaire was sent to all hospitals to document prioritization of indicators. Generic names were used for 36 061 (82.6%) in 1999 and 39 188 (86.4)% in 2000. In 1999, 50% (3074) of patients had documentation of allergy status. This increased to 60% (3684) in 2000. For 21.2% of patients prescribed paracetamol in 1999 and 18.1% in 2000, the prescription was written such that it was possible to exceed the maximum recommended dose of 4 g in 24 hours. Long-acting hypoglycaemic drugs were prescribed to 29 patients in 1999 and 20 patients in 2000. Anti-thrombotics were used appropriately for 54% (520/966) of patients in atrial fibrillation in the first audit and 57% (579/1019) in the second audit. The appropriate use of aspirin increased from 91% (595/651) to 94% (725/772) and the appropriate use of benzodiazepines dropped from 49% (537/1088) to 47% (460/966) between the audits. For three indicators, the allocating of a high priority translated into a bigger improvement between the audits. Local ownership of data and the quality improvement process, and provision of national benchmarking data did not result in a significant improvement in prescribing in the second audit. [ABSTRACT FROM AUTHOR]

Variation in quality of local services is of great concern to the government and public. National audit is an important means of providing data of comparative performance but is hampered at local level by poor methodology including audit design, standard setting and data collection tools. A pilot audit of the hospital care of patients ad-mitted with acute chronic obstructive pulmonary disease (COPD) was performed in preparation for a national audit programme and was designed and supported by experts. It was hoped to overcome these barriers. We report a prospective evaluation of the practical issues involved in local participation of hospital audit of COPD care within a national framework. Hospitals were recruited to the study by random selection and voluntary participation. A clinical audit study was completed over an 8-week period immediately followed by a survey of clinicians and audit staff to identify positive and negative issues of participation and the process required to achieve a successful outcome. Forty-one hospitals were invited to participate, 26 (63%) accepted, and four others volunteered to meet the target of 30 enrolled centres. Reasons cited for non-participation were of inadequate resources amongst either clinicians or audit departments or prior engagement in other national or local audit schemes. Following completion of the audit most (81%) participating units reported it was a useful exercise and were willing to be involved in future audits. Negative aspects of involvement included the lack of dedicated time and manpower for audit, poor information technology and inadequate systems for identifying patient diagnoses either at admission or at discharge and incomplete case note entries. Methodological issues such as study design and data collection tools were not cited as important barriers to participation. There is local willingness to be involved in national audit of hospital care of COPD and central provision of expert design of methods and tools may reduce some audit barriers. Nevertheless, priority must be given to improving resources identified to support audit and in improving methods and systems for data capture. These issues appear to be important in most units and represent a potentially serious barrier to achieving widespread local involvement in a national audit programme of COPD care and may also apply to other national audits designed to provide comparative assessment of National Health Service services. [ABSTRACT FROM AUTHOR]