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BACKGROUND AND AIMS: Most studies validating the Alcohol Use Disorders Identification Test (AUDIT) have either assessed its factor structure and/or test-retest reliability, or used diagnostic interviews as validators of current alcohol use disorders. The aim of the present study was to determine whether AUDIT and AUDIT-Consumption (AUDIT-C) scores are associated with subsequent risk of hospital admission for alcohol-related disorders and diseases (ARDDs).DESIGN: Historical cohort study. Using national registers, survey respondents were tracked from September 1, 2011 to hospitalization for an ARDD, emigration, death, or December 31, 2018, whichever occurred first SETTING: Denmark.PARTICIPANTS: Respondents (N=4,522) from a Danish national survey conducted in autumn 2011.MEASUREMENTS: Outcome was incident ARDD admission recorded in the National Patient Register. Predictors were AUDIT and AUDIT-C scores, and covariates were age, gender, highest level of education, and previous psychiatric disorder.FINDINGS: During the study period, 56 respondents had a first-time ARDD admission. Respondents who scored above the 8-point AUDIT cutoff and respondents who scored above the 5-point AUDIT-C cutoff had a significantly increased risk of being admitted for an ARDD compared with respondents who scored below the cutoffs, (AUDIT: hazard ratio (HR)=4.72, 95% confidence interval (CI) = 2.59-8.60; AUDIT-C: HR=7.97, 95% CI 3.66-17.31) CONCLUSIONS: Scores above Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-Consumption (AUDIT-C) cutoffs are associated with an increased risk of long-term alcohol-related hospital admissions. At widely-used cutoffs, the AUDIT-C is a better predictor of alcohol-related hospitalizations among members of the general population than the full AUDIT.

Implementation science is a useful tool to consider ways in which we can introduce improvements to burn services in low-and-middle income countries (LMICs), where the majority of the burden of burn injury is now experienced. This paper outlines the development of the Delivery Assessment Tool (DAT), a method for facilitating quality improvement in burn services in LMICs. We used a participatory approach that ensured that local clinicians and experts were fully involved in piloting the tool. The DAT is based on internationally agreed operational standards for burn care service delivery and has undergone an iterative process of improvement and refinement through an initial three-year project in Nepal and Bangladesh. The DAT, a 50-item tool organised into 10 subsections, is used to assess a service through a participatory focus group discussion (FGD) with a mixed, multidisciplinary team of staff working at the burn service, typically 6-10 participants. This usually lasts 2 to 3hours. The staff in the unit then select priority areas for quality improvement programmes that are within their control to achieve, which starts a cycle of audit and review. The final version of the tool was used in a further three-year project to evaluate 11 hospitals in Nepal and Bangladesh. Education and training are key components of this work; both were provided by Interburns as part of on-going support for the clinical teams. At the end of the project a >19% improvement in scores was demonstrated using the final version of the DAT in both Nepal and Bangladesh; this achievement is remarkable given the continued difficulties in service provision where patient numbers far outstrip the resources available to care for them. As a result of this work, we have made a digital version of the tool available free of charge.

Introduction: As the therapeutic options in the management of type 2 diabetes increase, there is an increase confusion among health care professionals, thus leading to the phenomenon of therapeutic inertia. This is the failure to escalate or de-escalate treatment when the clinical need for this is required. It has been studied extensively in various settings, however, it has never been reported in any studies focusing solely on primary care physicians with an interest in diabetes. This group is increasingly becoming the focus of managing complex diabetes care in the community, albeit with the support from specialists. Methods: In this retrospective audit, we assessed the prevalence of the phenomenon of therapeutic inertia amongst primary care physicians with an interest in diabetes in UK. We also assessed the predictive abilities of various patient level characteristics on therapeutic inertia amongst this group of clinicians. Results: Out of the 240 patients reported on, therapeutic inertia was judged to have occurred in 53 (22.1%) of patients. The full model containing all the selected variables was not statistically significant, p = 0.59. So the model was not able to distinguish between situations in which therapeutic inertia occurred and when it did not occur. None of the patient level characteristics on its own was predictive of therapeutic inertia. Conclusion: Therapeutic inertia was present only in about a fifth of patient patients with diabetes being managed by primary care physicians with an interest in diabetes.

Purpose: The aims were to: (1) determine 1-year mortality rates for hip fracture patients during the first UK COVID-19 wave, and (2) assess mortality risk associated with COVID-19. Methods: A nationwide multicentre cohort study was conducted of all patients presenting to 17 hospitals in March-April 2020. Follow-up data were collected one year after initial hip fracture (‘index’) admission, including: COVID-19 status, readmissions, mortality, and cause of death. Results: Data were available for 788/833 (94.6%) patients. One-year mortality was 242/788 (30.7%), and the prevalence of COVID-19 within 365 days of admission was 142/788 (18.0%). One-year mortality was higher for patients with COVID-19 (46.5% vs. 27.2%; p

Background The Joint Committee on Surgical Training (JCST) have published a series of quality indicators (QIs) which act as a benchmark against which the quality of surgical training can be assessed. This audit aims to compare core surgical training (CST) rotas in our region against the JCST QI 10's minimum standard of 5 consultant supervised training sessions per week. Methods Core surgical trainees in one training region were contacted requesting their on-call rotas from rotations undertaken during the 2019/20 academic year. Rotas were analysed in a protocolised manner, with the number of potential training sessions available calculated and compared against the JCST QI 10 minimum recommendation. Results Twenty-four rotas were assessed across 17 hospitals. Only six (25%) of rotas achieved the JCST QI 10 standard. There was a mean deficit of 18.5 (±29.5) training sessions per 6-month rotation. Rotas compliant with JCST QI 10 used a mean rota pattern of 1 in 11 compared to 1 in 9 for those failing to meet the target. Further analysis, comprising of the addition of expected consultant led training whilst on call, led to an improvement in compliance to 9 (38%) and 13 (54%) of rotas when there was an addition of 0.5 h and 1 h of consultant supervised training time per on-call session respectively. Conclusion Many core surgical trainee rotas in the region are non-compliant with JCST QI 10, indicating a lack of regular consultant-led training opportunities. A move to a reduced on-call commitment with the use of supporting medical practitioners could be considered to improve this.

Background Pre-triage emergency department (ED) waiting times can be lengthy when presentation numbers are high. Queuing is random, affecting flow management and patient care. We investigated pre-triage wait times and barriers to triage access at an Australian ED. Methods A reviewer conducted a retrospective audit of triage reception security video camera footage (February–March, 2020). The reviewer manually documented self-presenting patients’ wait-to-be-seen times and barriers to patient flow. Results The audit identified three main topics: lengthy pre-triage wait times, pre-triage queuing and observed barriers to triage. Median pre-triage wait time was 12 min (IQR = 5–21; n = 141), with no apparent relationship between patients’ wait time and time of arrival. During peak or busy periods, multiple random queues formed at the triage reception area. Triage nurses could not concurrently triage and provide queue control during busy periods. Conclusions Unrecorded pre-triage wait times may exceed 20 min. This unseen time may extend beyond the estimated post-triage wait times suggested by the Australasian Triage Scale (ATS). There was a degree of disorder in patient queueing, reducing effective door-to-triage productivity. Larger studies could determine these findings’ external replicability, with additional research addressing potential benefits of pre-triage queuing processes or a departmental concierge.

Objectives Concerns have been raised about the quantity and quality of research conducted during the COVID-19 pandemic, particularly related to the mental health and wellbeing of healthcare workers (HCWs). To understand the volume, source, methodological rigor and degree of overlap in COVID-19 studies conducted amongst HCWs in the United Kingdom (UK). Study Design Mixed methods approach, literature review and audit. Methods First, a literature review of published research studies and second, an audit of studies HCWs have been invited to complete. For the literature review, we searched Medline, PsycINFO and Nexis, webpages of three medical organisations (Royal Society of Medicine, Royal College of Nursing and British Medical Association), and the YouGov website. For the audit, a non-random purposive sample of six HCWs from different London NHS Trusts reviewed email, WhatsApp and SMS messages they received for study invitations. Results The literature review identified 27 studies; the audit identified 70 study invitations. Studies identified by the literature review were largely of poor methodological rigor: only eight studies (30%) provided response rate, one study (4%) reported having ethical approval and one study (4%) reported funding details. There was substantial overlap in the topics measured. In the audit, volunteers received a median of 12 invitations. The largest number of study invitations were for national surveys (n = 23), followed by local surveys (n = 16) and research surveys (n = 8). Conclusion HCWs have been asked to complete numerous surveys which frequently have methodological shortcomings and overlapping aims. Many studies do not follow scientific good-practice and generate questionable, non-generalisable results.

Medical errors were largely concealed prior to the landmark report "To Err Is Human". The purpose of this systematic scoping review was to determine the extent pediatric surgery defines and studies errors, and to explore themes among papers focused on errors in pediatric surgery.The methodological framework used to conduct this scoping study has been outlined by Arksey and O'Malley. In January 2020, PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Oxford Level of Evidence was assigned to each study; only studies rated Level 3 or higher were included.Of 3,064 initial studies, 12 were included in the final analysis: 4 cohort studies, and 8 outcome/audit studies. This data represented 5,442,000 aggregate patients and 8,893 errors. There were 6 different error definitions and 5 study methods. Common themes amongst the studies included a systems-focused approach, an increase in errors seen with increased complexity, and studies exploring the relationship between error and adverse events.This study revealed multiple error definitions, multiple error study methods, and common themes described in the pediatric surgical literature. Opportunities exist to improve the safety of surgical care of children by reducing errors. Original Scientific Research Type of Study: Systematic Scoping Review Level of Evidence Rating: 1.

IntroductionSevere maternal morbidity (SMM)—an unexpected pregnancy-associated maternal outcome resulting in severe illness, prolonged hospitalisation or long-term disability—is recognised by many, as the preferred indicator of the quality of maternity care, especially in high-income countries. Obtaining comprehensive details on events and circumstances leading to SMM, obtained through maternity units, could complement data from large epidemiological studies and enable targeted interventions to improve maternal health. The aim of this study is to assess the feasibility of gathering such data from maternity units across Canadian provinces and territories, with the goal of establishing a national obstetric survey system for SMM in Canada.Methods and analysisWe propose a sequential explanatory mixed-methods study. We will first distribute a cross-sectional survey to leads of all maternity units across Canada to gather information on (1) Whether the unit has a system for reviewing SMM and the nature and format of this system, (2) Willingness to share anonymised data on SMM by direct entry using a web-based platform and (3) Respondents’ perception on the definition and leading causes of SMM at a local level. This will be followed by semistructured interviews with respondent groups defined a priori, to identify barriers and facilitators for data sharing. We will perform an integrated analysis to determine feasibility outcomes, a narrative description of barriers and facilitators for data-sharing and resource implications for data acquisition on an annual basis, and variations in top-5 causes of SMM.Ethics and disseminationThe study has been approved by the Mount Sinai and Hamilton Integrated Research Ethics Boards. The study findings will be presented at annual scientific meetings of the Society of Obstetricians and Gynaecologists of Canada, North American Society of Obstetric Medicine, and International Network of Obstetric Survey Systems and published in an open-access peer-reviewed Obstetrics and Gynaecology or General Internal Medicine journal.

Paediatric spontaneous pneumothorax (PSP) management continues to lack paediatric-specific guideline recommendations. There have been increasing reports of paediatric retrospective case studies supplemented by important well designed RCT (predominantly) adult studies. Taken together, these suggest that conservative management may have an increasing role to play in the management of PSP and that aspiration may have limited utility as a first line intervention. Our local experience, as part of a multicentre retrospective analysis and subsequent audit of management since, corroborates recent published data: it highlights an increasing trend towards conservative management in spontaneous pneumothorax with similar rates of recurrence, compared to intervention, and low use of aspiration with similarly low success rates. We have therefore updated our local practice guidelines and share these with readers. Specifically, we have removed aspiration in the management of primary spontaneous pneumothorax and reserved intervention for children who are clinically unstable or show evidence of increasing air leak irrespective of pneumothorax size. Whilst the success of this change in clinical practice will need to be reviewed in the next 5–10 years, the overall low incidence of the condition, demands a multicentre, and probably multinational, collaborative approach to allow the best chance of obtaining definitive evidence to guide clinical paediatric management.

All units managing hypertensive pregnant women should maintain and review uniform departmental management protocols and conduct regular audits of maternal & fetal outcomes. The cause(s) of pre-eclampsia and the optimal clinical management of the hypertensive disorders of pregnancy remain uncertain; therefore, we recommend that every hypertensive pregnant woman be offered an opportunity to participate in research, clinical trials and follow-up studies.

Bronchiectasis refers to both a clinical disease and a radiological appearance that has multiple causes and can be associated with a range of conditions. Disease heterogeneity and the absence of standardised definitions have hampered clinical trials of treatments for bronchiectasis and are important challenges in clinical practice. In view of the need for new therapies for non-cystic fibrosis bronchiectasis to reduce the disease burden, we established an international taskforce of experts to develop recommendations and definitions for clinically significant bronchiectasis in adults to facilitate the standardisation of terminology for clinical trials. Systematic reviews were used to inform discussions, and Delphi processes were used to achieve expert consensus. We prioritised criteria for the radiological diagnosis of bronchiectasis and suggest recommendations on the use and central reading of chest CT scans to confirm the presence of bronchiectasis for clinical trials. Furthermore, we developed a set of consensus statements concerning the definitions of clinical bronchiectasis and its specific signs and symptoms, as well as definitions for chronic bacterial infection and sustained culture conversion. The diagnosis of clinically significant bronchiectasis requires both clinical and radiological criteria, and these expert recommendations and proposals should help to optimise patient recruitment into clinical trials and allow reliable comparisons of treatment effects among different interventions for bronchiectasis. Our consensus proposals should also provide a framework for future research to further refine definitions and establish definitive guidance on the diagnosis of bronchiectasis.

Introduction Magnetic Resonance Imaging (MRI) can be a challenging examination, particularly for children. The aim of this Clinical Perspective is to outline early experiences, based upon a service evaluation (defined as an assessment of how well the intended aims are achieved), of the Playful Magnetic Resonance Imaging Simulator (PMRIS) (Domed, Lyon, France) in reducing the number of children requiring general anaesthetic (GA) in order to undergo Magnetic Resonance Imaging (MRI). Methods Baseline data from an audit of children undergoing MRI under GA in 2017 had previously been captured as part of the funding bid for the PMRIS. Estimation of costs associated with anaesthesia were made, then combined with the overall numbers of MRI under GA to estimate projected anaesthetic related cost-savings based on the reported effectiveness of the PMRIS. Once the PMRIS was in place, data were collected for children attending a Play Specialist supervised session. The number and age of children proceeding directly to MRI without requiring a GA was determined. The associated cost benefit was calculated and compared with the projections made in the initial funding bid. Results Over a 7 month period 36 children, average age 6 years, age range 4 to 11 years, who had initially been triaged for MRI under GA, attended a Play Specialist led session on the PMRIS. Of these, 30, average age 6 years, age range 4 to 11 years proceeded directly to MRI without a GA. Based on the costings used for the initial funding bid, this equates to a gross cost-saving of £9,000 over 7 months. Discussion This service evaluation shows a positive impact of Play Specialist sessions using the PMRIS with 30 out of 36 children having a successful awake MRI as a result. There are limitations to this evaluation, particularly that whilst all these children had been triaged for MRI under GA it cannot be known how many might have had an awake MRI with different preparation. Nevertheless, according to the local referral pathways these children would otherwise have had MRI under GA. Conclusion This service evaluation has shown that the number of GAs required for children having MRI has reduced for this particular service through the use of the PMRIS, with Play Specialist support, with associated reduction in risk and cost savings.

This study aimed to highlight the value and key findings of on-site proton audits.The authors performed 38 on-site measurement-based peer reviews of proton centers participating in National Cancer Institute-funded clinical trials. The reviews covered beam calibration, lateral and depth measurements, mechanical checks, treatment planning and clinical practice, and quality assurance (QA) practices. Program deficiencies were noted, and recommendations were made about ways institutions could improve their practices.Institutions received an average of 3 (range, 1-8) recommendations for practice improvements. The number of deficiencies did not decrease over time, highlighting the continued need for this type of peer review. The most common deficiencies were for Task Group-recommended QA compliance (97% of centers), computed tomography number (CTN) to relative linear stopping power conversion (59%), and QA procedures (53%). In addition, 32% of institutions assessed failed at least 1 lateral beam profile measurement (90% of pixels passing 3% [global]/3 mm; 10% threshold), despite passing internal QA measurements. These failures occurred for several different plan configurations (large, small, shallow, and deep targets) and at different depths in the beam path (proximal to target, central, and distal). CTN to relative linear stopping power conversion curves showed deviations at low, mid, and high CTNs and highlighted areas of inconsistency between proton centers, with many centers falling outside of 2 sigma of the mean curve of their peers. All deficiencies from the peer review were discussed with the institutions, and many implemented dosimetric treatment planning and practice changes to improve the accuracy of their system and consistency with other institutions.This peer review program has been integral in confirming and promoting consistency and best practice across proton centers for clinical trials, minimizing deviations for outcomes data.

Background Large-scale quarantine facilities staffed with non-healthcare workers (NHCW) were instrumental in preventing community spread of COVID-19 (coronavirus disease of 2019). The objective of this study was to determine the effectiveness of a newly developed procedural skills training framework in ensuring personal protective equipment (PPE) compliance of PPE-naïve NHCWs. Materials and methods We developed a PPE procedural skills training framework for NHCWs using the Learn, See, Practice, Prove, Do, and Maintain (LSPPDM) framework and international guidelines on PPE for healthcare workers. The NHCWs underwent PPE training using this framework, conducted by a team of Infection Prevention nurses, prior to being stationed within the CCF. Effectiveness of the LSPPDM PPE training framework was assessed using: 1) competency assessment scores for NHCWs, 2) PPE compliance rates from daily audit findings, and, 3) healthcare-associated COVID-19 infection rates of NHCWs. Results A total of 883 NHCWs had completed the PPE training and demonstrated competency in PPE compliance, fulfilling 100% of the checklist requirements. Mean PPE compliance of all NHCWs during the 11-week study period was noted to be >96%. The post-implementation improvement was statistically significant when the compliance was expressed in 3-days blocks) and in bed management staff (P = < 0.05). None of the 883 NHCWs who underwent PPE training via the LSPPDM framework were diagnosed with healthcare-associated COVID-19 infection. Conclusions An evidence-based skills training framework is effective in PPE training of large numbers of NHCWs, resulting in high compliance of appropriate PPE use and prevention of healthcare-associated COVID-19 infection.

The utility of any database or registry depends on the completeness and accuracy of the data it contains. This report documents the validity of data elements within DataDerm, the clinical registry database of the American Academy of Dermatology. An external audit of DataDerm, performed by a third-party vendor, involved the manual review of 1098 individual patient charts from calendar year 2018 from 8 different dermatology practices that used 4 different electronic health records. At each site, 142 discrete data fields were assessed, comparing the data within DataDerm to the source data within the electronic health record. Audited data included 3 domains of data elements (diagnoses, medications, and procedures) and a performance measure ("Biopsy Reporting Time-Clinician to Patient"), which is 1 of several measures used by DataDerm as a Qualified Clinical Data Registry. Overall completeness of data was 95.3%, with a range among practices of 90.6% to 98.5%. Overall accuracy of data was 89.8%, with a range of accuracy among practices of 81.2% to 94.1%. These levels of completeness and accuracy exceed the rates in the literature for registries that are based on data that is extracted from electronic health records; and therefore, this audit validates the excellent quality of data in DataDerm.

INTRODUCTION Guidelines of the World Federation of Hemophilia support the provision of equitable, optimal care for people with hemophilia (PWH). However, limited research exists examining the lived experiences of PWH or the barriers to care they may encounter. The primary objective of this exploratory study was to describe the experiences of men with hemophilia in Canada. METHODS We conducted a qualitative descriptive study using a semistructured interview guide and analyzed transcribed interviews using inductive thematic content analysis. Inclusion criteria were: age ≥18 years, English-speaking, and confirmed diagnosis of inherited hemophilia A or B. RESULTS A total of 11 participants were interviewed. Median age was 39 years old (29-73 years old), and diagnoses included severe hemophilia A (n = 5), mild hemophilia A (n = 2), and severe hemophilia B (n = 4). Three primary themes arose: (1) impact on identity and daily life; (2) dynamic changes in treatment; and (3) barriers to care and identified needs. Major subthemes included chronic pain and activity limitation, psychosocial burden, and symptom normalization. Multidisciplinary care, coordinated surgical care, improved emergency care, and clear care plans were identified as ongoing needs. DISCUSSION Men with hemophilia described significant symptom burden and areas of ongoing need. Collaborative efforts between hematologists, emergency room physicians, and surgeons to establish hospital-specific testing, treatment and referral guidelines, and regular hemophilia treatment center audits may help address these care gaps, providing more person-centered, equitable care. Future work is required to implement these strategies and monitor their effects.

Refereed/Peer-reviewed Clinical relevance: Establishing the level of appropriateness and barriers to glaucoma care delivery by Australian optometrists are important first steps in developing tailored interventions aimed at improving glaucoma care delivery. Background: To determine the appropriateness of and barriers to glaucoma care by optometrists. Methods: A mixed method study was conducted. Phase I was a retrospective cross-sectional medical record audit that assessed glaucoma care appropriateness against 37 clinical indicators from a nationally representative sample of 42 optometry practices. In Phase II, focus groups and interviews involving 31optometrists explored audit findings to identify barriers to appropriate glaucoma care. Barriers were analysed by deductive and inductive qualitative analysis. Saliency analysis was used to identify key domains that influence glaucoma care. Results: Appropriate glaucoma care was delivered for 63% (95% CI 61%, 64%) of the 420 patient encounters audited. Appropriate care was delivered above 80% for most (57%) indicators, while 14(38%) indicators were delivered below 60% appropriateness. Good compliance to appropriate care was noted for key indicators of intraocular pressure measurement (90%, 95% CI 87%, 93%) and optic nerve head/retinal nerve fibre layer imaging (78%, 95% CI 74%, 82%). Important barriers identified were beliefs about expected outcomes, lack of perceived relevancy, time constraints, poor organisational culture, knowledge gaps, focusing on some aspects of glaucoma care to the detriment of others, the complexity of glaucoma care, information recall, and social norms. Conclusion: Glaucoma care was appropriate in most patient encounters, with opportunity to improve some aspects of history taking and physical examinations. Barriers to glaucoma care were diverse, existing at both the practitioner and organisational levels. These findings provide direction for the development of a tailored improvement intervention.

Background Early identification and treatment of serious infections improves clinical outcomes. Previous studies have found that septic patients without fever are more likely to die than those with fever, due to delay in antibiotic administration. Aim To determine whether antibiotic treatment and mortality differed in afebrile adult patients presenting to the Emergency Department with bacteraemia, compared with those with a history of fever. Methods Retrospective six-month audit of all adult patients with positive blood cultures taken in the Emergency Department (ED) of a single tertiary hospital. Outcomes included receipt of antibiotics within 4 and 24 h of ED arrival, in-hospital mortality and 30-day mortality. Results 227 patients with clinically significant bacteraemia were identified, of which 38 (16.7%) were afebrile in ED. There was no statistically significant difference in the proportion of afebrile or febrile patients receiving antibiotics within 4-h (44.7% vs 55.6%, p = 0.222) or 24-h (89.5% vs 95.2%, p = 0.163) of arrival at ED. Inpatient mortality was not statistically different in the afebrile and febrile groups 15.8% vs 6.9%, p = 0.070), but 30-day mortality was higher among afebrile patients (27.6% vs 10.1%, p = 0.010). Conclusions There was no significant difference in receipt of antibiotics within 4 h or 24 h ED arrival between the febrile and afebrile groups. However, afebrile patients experienced higher 30-day mortality. While most bacteraemic patients received antibiotics within 24 h, only half received antibiotics within 4 h, representing a key area for improvement. This article is protected by copyright. All rights reserved.

Background The provision of equitable and affordable health care has become increasingly challenging as advanced technology is introduced, particularly in developing countries. We explored the hypothesis that focused, small-scale mini–public-private partnerships have a potential role in providing equitable and affordable access to advanced technology for the benefit of all patients in developing nations, particularly middle-income countries. Methods A clinician-led financial plan was developed at the University of Malaya to create the Centre for Image Guidance and Minimally Invasive Therapy (CIGMIT) to provide an integrated platform for high-end care for Malaysian patients of all ages, both public and private, requiring complex neurosurgical and spinal procedures and stereotactic and intensity-modulated radiotherapy. The challenges faced during development of the plan were documented together with an audit of patient throughput and analyses of financial risk and return. Results CIGMIT opened in 2015. Patient throughput, both public and private, progressively increased in all facilities. In 2015–2019, 37,724 patients used the Centre’s facilities. CIGMIT has become progressively more profitable for the University of Malaya, the public and private hospitals, and the investor. CIGMIT has weathered the challenges posed by coronavirus disease 19. Conclusions Focused, small-scale mini–public-private partnerships have a potential role in providing advanced technology for the benefit of patients in developing nations, particularly middle-income countries, subject to an approach that balances equity of access between public and private health care systems with fair reward.

Background Medical emergency teams use medications to rescue deteriorating patients. Medication management is the system of steps and processes, including prescribing, distribution, administration, and monitoring, to achieve the best outcomes from medication use. Systems or standards for medication management by medical emergency teams have not been defined. Objectives The aim of the study was to propose potential solutions to improve medical emergency team medication management by evaluating medication supply and related medication management practices during medical emergency team activations and understanding clinicians' perceptions about medical emergency team medication management in acute hospitals. Methods A prospective multicentre audit of intensive care unit–equipped hospitals in Victoria, Australia, was conducted. After advertisement and invitation via scheduled email newsletters to hospitals, a representative of the medical emergency team from each hospital self-administered an online audit tool during December 2019 and January 2020. Audit data were analysed descriptively, and perceptions were analysed using content analysis. Results Responses were received from 32 of the 44 (72.7%) eligible hospitals. At 17 of the 32 (53.1%) hospitals, arrest trolleys provided medications for medical emergency team activations, in addition to arrest calls. At 15 of the 32 (46.9%) hospitals, separate, dedicated medical emergency team medication supplies were used to care for deteriorating patients. Dedicated medical emergency team supplies contained a median of 20 (range = 8–37) medications, predominantly cardiovascular (median = 8, mode = 7, range = 4–16) and neurological medications (median and mode = 6, range = 0–11). Variation was observed in all storage and other supply-related medication management practices studied. The four most frequent categories of clinicians' perceptions described systematic challenges with availability of the right medication in the right place at the right time. Conclusions Current supply and related medication management practices and clinicians' perceptions demonstrated further development is necessary for medication management to meet the needs of medical emergency team clinicians and their patients.

Aims To assess differences in estimated cardiovascular disease (CVD) risk among rheumatoid arthritis (RA) patients from different world regions and to evaluate the management and goal attainment of lipids and blood pressure (BP). Methods and results The survey of CVD risk factors in patients with RA was conducted in 14 503 patients from 19 countries during 2014–19. The treatment goal for BP was Conclusion We revealed considerable geographical differences in estimated CVD risk and preventive treatment. Low goal attainment for LLT was observed, and only half the patients obtained BP goal. Despite a high focus on the increased CVD risk in RA patients over the last decade, there is still substantial potential for improvement in CVD preventive measures.

Objective: Compression therapy is the mainstay of treatment for venous leg ulceration. Several studies have evaluated leg ulcer management and compression in the community. However, little is known about the leg ulcer population and use of compression therapy in the hospital setting, where it is not often part of inpatient care. This study aimed to evaluate the proportion of inpatients with leg ulceration eligible for compression therapy. Method: A point prevalence audit was undertaken using three methods: patient electronic live report; a leg ulcer audit form; and an electronic record search. The following data were retrieved: patient age, sex, primary reason for admission, diabetes, mobility status, history of dementia, Clinical Frailty Scale score and presence of oedema. Ankle-brachial pressure index was measured to determine patients' eligibility for compression therapy. Results: The audit identified 80/931 (8.5%) inpatients as having confirmed, active leg ulceration. A total of 36/80 (45%) inpatients were assessed for eligibility for compression, of whom 25/36 (69.4%) were eligible for full compression, 2/36 (5.6%) reduced compression and 9/36 (25%) were not eligible for compression therapy. Conclusion: The audit demonstrated that a significant proportion of hospital inpatients with leg ulcers were eligible for compression therapy and that this patient population were heterogenous in terms of comorbidity profile, mobility, frailty and dementia, among other factors. Further research is required to explore the most feasible and effective compression options for inpatients with leg ulcers.

Background Propofol is a drug of diversion because of its high-volume use, lack of prescribed control mechanisms, and accessibility. As a result, intensive care unit nurses and other health care professionals are placed at unnecessary risk. Decreasing the risk of drug diversion can save lives, licenses, and livelihoods. Local Problem Objectives were to reduce the risk of drug diversion and diminish the environmental impact of medication discarded down the sink. Disposing of residual propofol into activated carbon pouches was successful and sustainable in operating rooms at the study institution. Literature findings supported this intervention because of propofol’s potential for abuse, ongoing diversion events, ease of access, poor control mechanisms, lack of standardization, excessive waste, and ecological impact. Methods The intensive care unit with the highest propofol use was selected to replicate the propofol disposal process used in the operating rooms. Activated carbon pouches and bottle cap removal tools were located in each intensive care unit room at the nurses’ workstation for ease of use. Audits of unsecured waste bins and staff surveys of institutional policy awareness, disposal processes, barriers, and concerns were completed before and after the intervention. Results Survey results determined significant concern for drug diversion risk. The pilot project displayed success: 44.1% of propofol bottles in waste bins were full before the intervention and 0% were full afterward. Conclusion Following institutional approval, this propofol disposal process was replicated in all intensive care units and the emergency department in the study institution.

Background It is important to examine perinatal deaths as part of a national mortality audit to identify risk factors. Implementing and re-evaluating recommendations from perinatal mortality audits completes the audit cycle, preventing similar deaths in the future. Lack of implementation results in recommendations recurring. Objectives In this study we examine national perinatal mortality audits’ methodology in four high-income countries (United Kingdom, New Zealand, Ireland, Netherlands) to highlight different approaches taken. We compare the recommendations made in these audits’ reports over the last five years, as well as review national initiatives and programmes addressing them. Study Design This study is an integrative review where two comprehensive literature searches were completed: on established national perinatal mortality audits in high-income countries; and on national initiatives addressing recommendations from these audits. Content analysis of the audits’ recommendations was performed organising them into themes according to topics these focused on. Results Though the methodology of the national perinatal mortality audits varied, all four were state-funded and had standardised online data collection forms to report deaths. The recommendations themes included: Raising public awareness of perinatal mortality risk factors, Detection of fetal growth restriction, Prevention of preterm birth, Resources for data collection and review. Only the UK had various initiatives addressing perinatal mortality risk factors directly. New Zealand included stakeholders in the audit recommendations’ development and provided updates on their implementation. The Netherlands developed a programme for audit recommendation implementation. Ireland created a group which is progressing some recommendations from the audit. Conclusions National perinatal mortality audits are important in identifying contributory factors and making recommendations to address these. Recurring recommendations suggest a failure to resolve the identified issues. This study shows how some challenges are common to high-income countries’ audits, highlighting the need for shared learning of successful initiatives.

usc Background: A significant proportion of the atrial fibrillation (AF) population attending Australian primary care is not receiving guideline-adherent oral anticoagulant (OAC) treatment. This study aimed to explore reasons for non-adherence to thromboprophylaxis guidelines in AF from the perspectives of general practitioners (GPs) and to map these reasons to the Capability, Opportunity, Motivation-Behaviour (COM-B) model to identify potential opportunities to support practice change. Methods: An exploratory qualitative descriptive study among GPs practising in Western Australia was conducted using semi-structured interviews, from November 2020 to February 2021. The Framework Method was employed to facilitate thematic analysis, using NVivo software. Interview responses were also mapped to the COM-B model. Results: Nine of the 10 GPs initially consented participated in the semi-structured interview (Male = 56%, median age = 52 years, data saturation reached with 6 participants). Two themes emerged from analysis of the interview transcripts: (1) GPs' decision-making process and (2) Patient refusal to take OACs. The COM-B model mapping identified behavioural factors that could impact adherence: capability (GPs' knowledge and understanding of AF guideline recommendations), opportunity (access to a cardiologist, and patients' refusal to take OACs), and motivation (using formal bleeding risk assessment tools). Conclusion: GPs identified various reasons contributing to non-adherence to thromboprophylaxis guidelines in patients with AF. Multifaceted interventions should consider behavioural opportunities to improve adherence, including education and training, electronic decision support, clinical audits by allied health professionals, partnership between general practices and local hospitals, and cardiologist-led interventions to support GPs. Further studies are needed to capture patients' reasons for refusing OACs. Refereed/Peer-reviewed

OBJECTIVES The aim of this project was to promote evidence-based best practice regarding hand hygiene among nurses in a pediatric blood and marrow transplantation (BMT) setting. INTRODUCTION Healthcare-associated infections (HAI) represent important complications of healthcare with potentially major impact on patient outcomes. Most HAI are transmitted through the hands of healthcare professionals (HCP) and therefore hand hygiene is the simplest, most effective and proven method for preventing HAI. However, the overall compliance rate of HCP with hand hygiene remains at a very low level. In this case, it is necessary to implement strategies to improve the compliance with hand hygiene of the HCP with the purpose of reducing HAI rates, mortality and costs, all the more so as it is known that patients with BMT have an increased risk of HAI. METHODS This best practice implementation project was based on the JBI methodological approach and included three phases of activity: a baseline audit, implementation of strategies and a follow-up audit. The project was conducted in the pediatric BMT setting of a large university hospital located in Bucharest, Romania, and the sample included 10 nurses and five relatives of pediatric patients from this ward. RESULTS As a result of the implementation of strategies, improvements were observed across seven audit criteria, given that for two audit criteria out of a total of nine audit criteria compliance was maximum (100%) since the baseline phase. Moreover, the post implementation audit showed a complete compliance (100%) for six audit criteria. However, for the other three audit criteria the compliance in follow-up audit was high: 92, 85 and 80%, respectively. CONCLUSION The strategies applied within this evidence implementation project were appropriate, so the project was a success. However, permanent actions are required to sustain changes in practice and improvements made.

Objective Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by inpatient advanced practice providers (APPs) on evaluation and management (E/M) charge capture, including outside of the global surgical package (GSP), and quality metrics including case mix index (CMI) and mortality index (MI). We hypothesized this clinical documentation initiative as well as improved coding of E/M services would result in increased reimbursement and quality metrics. Methods A documentation and coding initiative on the heart and vascular service line was initiated in 2016 with focus on improving inpatient E/M capture by APPs outside the GSP. Comprehensive training sessions and standardized documentation templates were created and implemented in the electronic medical record. Subsequent hospital care E/M (current procedural terminology codes 99231, 99232, 99233) from the years 2015 to 2017 were audited and analyzed for charge capture rates, collections, work relative value units (wRVUs), and billing complexity. Data were compared over time by standardizing CMS values and reimbursement rates. In addition, overall CMI and MI were calculated each year. Results One year following the documentation initiative, E/M charges on the vascular surgery service line increased by 78.5% with a corresponding increase in APP charges from 0.4% of billable E/M services to 70.4% when compared with pre-initiative data. The charge capture of E/M services among all inpatients rose from 21.4% to 37.9%. Additionally, reimbursement from CMS increased by 65% as total work relative value units generated from E/M services rose by 78.4% (797 to 1422). The MI decreased over the study period by 25.4%. Additionally, there was a corresponding 5.6% increase in the cohort CMI. Distribution of E/M encounter charges did not vary significantly. Meanwhile, the prevalence of 14 clinical comorbidities in our cohort as well as length of stay (P = .88) remained non-statistically different throughout the study period. Conclusions Accurate clinical documentation of E/M care and ultimately inpatient acuity is critical in determining quality metrics that serve as important measures of overall hospital quality for CMS value-based payments and rankings. A system-based documentation initiative and expanded role of inpatient APPs on vascular surgery teams significantly improved charge capture and reimbursement outside the GSP as well as CMI and MI in a consistently complex patient population.

Summary Additional variables for a nationwide hip fracture registry must be carefully chosen to prevent unnecessary registry load. A registry pilot in seven hospitals resulted in recommending polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for development of quality indicators. Purpose Clinical registries help improve the quality of care but come at the cost of registration load. Datasets should therefore be as compact as possible; however, variables are usually chosen empirically. This study aims to evaluate potential variables with additional value to improve the nationwide Dutch Hip Fracture Audit (DHFA). Methods An expert panel selected eleven new variables for the DHFA, which were tested in a prospective cohort of all hip fracture patients treated in 2018 and 2019 in seven pilot hospitals participating in the DHFA. The association of these eleven variables with complications, mortality, and functional outcomes at 3 months was analyzed using multivariable logistic regression analysis. Based on the results, a proposal for variables to add to the dataset of the DHFA was made. Results In 4.904 analyzed patients, three tested variables had significant associations (p Conclusion This study assesses potential new variables for a hip fracture registry. Based on the results of this study, we recommend polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for the development of quality indicators. Incorporating these variables in the DHFA dataset may contribute to better and clinically relevant quality indicators.

BACKGROUND: In industrial towns, the dangers of each industry also poses a threat to other industries due to the proximity of different industries to each other. So there is a need for a safety management system. OBJECTIVE: This study was conducted to introduce a management system for managing the safety of industrial towns. METHOD: This cross-sectional and qualitative study was conducted in three main phases: (1) Identify the elements of the safety management systems using literature review, (2) screening and determining useful elements using Delphi technique and (3) determining the structure of safety management system. RESULTS: Participation of the industries and their compliance with the standards were considered as the system foundation. The networks of safety information of the industries, accident’s database, safety training, contractors, emergency management and management of the changes were placed on the foundation as the system columns. The Industrial Town’s Safety Management (ITSM) system as the system roof was placed on the columns. This structure was placed within a two-line framework including the trade secrets and program audit. CONCLUSIONS: The ITSM system consists of a set of factors that can help manage the safety of the industrial towns. This system will increase the safety level of industrial towns by incorporating some safety principles. However, the safety management of an industrial town is very complex and requires a great deal of efforts.

BACKGROUND: The structure of buildings is in degradation over time, monitoring their safety status and providing timely warnings is crucial. Therefore, an efficient visual inspection of the building’s safety has intrinsic value to give early warnings to owners and managers. OBJECTIVE: This study aimed to provide an audit tool for evaluation of the administrative in-operation buildings’ safety status. METHODS: Factors affecting the administrative buildings’ safety status was determined based on the National Building Regulations of Iran (NBRI) and other studies. Checklist items and their guidelines were prepared. Face validity (quantitative and qualitative), Content Validity Ratio (CVR), and Content Validity Index (CVI) were calculated for the checklist. The Intra-class Correlation Coefficient (ICC) used for inter-rater reliability and Cronbach’s α was used to evaluate internal consistency of the checklist. RESULTS: Forty-seven items related to in-operation building safety were extracted from literature review. Based on the results of the psychometric analysis, 5 items were removed and 42 items remained. The values of different psychometric indices for the other items indicated their acceptable validity (α= 0.82, ICC≥0.75). CONCLUSION: The designed checklist had a good level of validity and reliability for inspecting architectural, technical services, and managerial safety aspects of administrative in-operation buildings. Stakeholders can use it for quick and comprehensive assessment of building safety. Use of this checklist are expected to give early warnings about the safety of buildings to the stakeholders.

Low anterior resection syndrome (LARS) is a collection of symptoms that can occur as a result of a low anterior resection for bowel cancer. Transanal irrigation (TAI) can be used to manage these symptoms. This article describes a retrospective audit of 15 patients who were using TAI to manage symptoms of LARS. The aim of the audit was to ascertain whether the use of TAI improved outcomes for these patients. The data suggest that TAI has reduced both the frequency of bowel movements and episodes of faecal incontinence. Those patients using higher volumes of water seem to have experienced more benefit than those patients using lower volumes of water. These findings are consistent with current literature around TAI for LARS and suggest research into optimum volume of water would be beneficial.

Current recommendations for management of patients with axial spondyloarthritis (axSpA) include regular collection of validated disease activity outcomes. This study aimed at evaluating the proportion of patients for whom validated outcome measures were available on their electronic medical reports (EMR), and the factors associated with the presence of such information on the EMR. We performed a cross-sectional monocentric observational study, including patients with an axSpA diagnosis who attended an outpatient visit between February, 2018 and February, 2019. Patients (demographics, disease characteristics, treatment) and physician characteristics (age, gender) and the disease activity outcome measures (BASDAI, CRP and ASDAS, and the items allowing to calculate them) were retrieved from the EMR. The proportion of patients in which disease activity outcome measures were available in the EMR was calculated, and the association between the presence of such outcomes and patients and physician's characteristics was evaluated. 320 EMR of axSpA patients seen in the outpatient clinic were examined. Among them, 131 (41%) and 123 (38.4%) had a BASDAI + CRP and an ASDAS reported, respectively, but at least one was available in 178 (55.6%) of the EMR. The most frequently reported disease activity items were duration of morning stiffness (n = 230, 72%) and CRP (n = 224, 70%). Only previous participation on a systematic holistic review was independently associated with a reported disease activity outcome. Thus, implementation of recommendations with regard to regularly collecting disease activity outcome measures is not optimal. The participation in educational programs including self-assessment educational programs might be a key to improve such implementation.

BACKGROUND AND AIMS: Unhealthy alcohol use (UAU) is one of the leading causes of global morbidity. A machine learning approach to alcohol screening could accelerate best practices when integrated into electronic health record (EHR) systems. This study aimed to validate externally a natural language processing (NLP) classifier developed at an independent medical center. DESIGN: Retrospective cohort study. SETTING: The site for validation was a midwestern United States tertiary-care, urban medical center that has an inpatient structured universal screening model for unhealthy substance use and an active addiction consult service. PARTICIPANTS/CASES: Unplanned admissions of adult patients between October 23, 2017 and December 31, 2019, with EHR documentation of manual alcohol screening were included in the cohort (n = 57 605). MEASUREMENTS: The Alcohol Use Disorders Identification Test (AUDIT) served as the reference standard. AUDIT scores ≥5 for females and ≥8 for males served as cases for UAU. To examine error in manual screening or under-reporting, a post hoc error analysis was conducted, reviewing discordance between the NLP classifier and AUDIT-derived reference. All clinical notes excluding the manual screening and AUDIT documentation from the EHR were included in the NLP analysis. FINDINGS: Using clinical notes from the first 24 hours of each encounter, the NLP classifier demonstrated an area under the receiver operating characteristic curve (AUCROC) and precision-recall area under the curve (PRAUC) of 0.91 (95% CI = 0.89-0.92) and 0.56 (95% CI = 0.53-0.60), respectively. At the optimal cut point of 0.5, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 0.66 (95% CI = 0.62-0.69), 0.98 (95% CI = 0.98-0.98), 0.35 (95% CI = 0.33-0.38), and 1.0 (95% CI = 1.0-1.0), respectively. CONCLUSIONS: External validation of a publicly available alcohol misuse classifier demonstrates adequate sensitivity and specificity for routine clinical use as an automated screening tool for identifying at-risk patients.

INTRODUCTION AND AIMS As directed by the WHO, antenatal care providers have good opportunities to identify and refer mothers who are struggling with psychosocial problems. In Ethiopia, the pooled prevalence of perinatal depression is 25.8%, which is almost two-fold of the pooled global prevalence. Though this is an indication of the need for prompt interventions, there is no assessment targeted to this population. Therefore, the aim of this project was to promote an antenatal psychosocial assessment practice among midwives. METHODS Using the Joanna Briggs Institute Practical Application of Evidence System, 66 first visit antenatal care assessment opportunities were observed in both baseline and follow-up audit using three audit criteria. Fourteen midwives were interviewed for the first criterion. On the basis of the results, the gaps and barriers were analyzed using Getting Research into Practice strategies. RESULT The baseline audit result revealed a 0% compliance rate for all evidence-based antenatal psychosocial assessment audit criteria. This scenario disclosed that there had not been psychosocial problem assessment practice at antenatal clinic. However, the postimplementation result showed that an average 91.5% practice of evidence-based antenatal psychosocial assessment was applied as per standards. CONCLUSION Carrying out discussions on evidence summary with providers, on-the-job training, using local leaders' opinions, and involving relevant stakeholders appeared to be the key methods in improving compliance to best available evidence in antenatal psychosocial assessment.

This paper using Scottish audit data found that frailty was associated with longer waiting times at almost all stages of the preoperative emergency general surgical pathway. Frailty and ASA fitness grade were also good indicators of mortality in this cohort.

To assess and improve pain management practices for hospitalized children in an urban tertiary pediatric teaching hospital. Methods Health Quality Ontario Quality Improvement (QI) framework informed this study. A pre (T1) – post (T2) intervention assessment included chart reviews and children/caregiver surveys to ascertain pain management practices. Information on self-reported pain intensity, painful procedures, pain treatment and satisfaction were obtained from children/caregivers. Documented pain assessment, pain scores, and pharmacological/non-pharmacological pain treatments were collected by chart review. T1 data was fed back to pediatric units to inform their decisions and pain management targets. Results At T1, 51 (58% of eligible participants) children/caregivers participated. At T2, 86 (97%) chart reviews and 51 (54%) children/caregivers surveys were completed. Most children/caregivers at T1 (78%) and T2 (80%) reported moderate to severe pain during their hospitalization. A mean of 2.6 painful procedures were documented in the previous 24 h, with the most common being needle-related procedures at both T1 and T2. Pain management strategies were infrequently used during needle-related procedures at both time points. Conclusion No improvements in pain management as measured by the T1 and T2 data occurred. Findings informed further pain management initiatives in the participating hospital.

PURPOSE A recent nationwide medical record audit of optometry practices has identified an evidence-to-practice gap in primary diabetic eyecare delivery. This study aimed to explore the determinants (barriers and enablers) to appropriate diabetic eyecare delivery in Australia. METHODS A qualitative study involving focus-group discussions and interviews of a purposeful sample of Australian optometrists was conducted. Participants were asked about the perceived barriers to adherence to four underperforming clinical indicators related to primary diabetic eyecare identified by the recent national optometry practice audit. The Theoretical Domain Framework was used for thematic analysis and coding salience to identify key behavioural determinants. RESULTS Optometrists participated in eight focus groups (n = 27) and individual interviews (n = 4). The most salient barriers were related to Environmental resources (e.g., limited chair time); Beliefs about consequences (e.g., lack of perceived importance); Knowledge (e.g., poor understanding); Professional role/identity (e.g., the perceived role of optometry in care process); Social influences (e.g., the influence of senior optometrists) and Intentions (e.g., apathy). Key enablers were Environmental resources (e.g., electronic record system and practice aids); Knowledge (e.g., keeping up with knowledge/professional development); reinforcements (e.g., fear of legal actions) and behavioural regulations (e.g., self-monitoring/audit). CONCLUSIONS This study shows that the evidence-to-practice gap in primary diabetic eyecare delivery in Australia can be attributed in part to several interconnected factors related to optometrists' individual capability and motivation as well as the social and practice environment within which they sit. These behavioural determinants will inform the design of an intervention to improve the appropriateness of primary diabetic eyecare delivery.

Wound bed preparation has come into sharper focus over the past decade, with strategies identified to improve wound condition. This article focuses on implementing a wound cleansing policy and measuring, through audits, how this change affected rates of wound infection. From 2016 onwards, the Skin Integrity Team at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust took steps to revise and improve wound care practices. This resulted in the introduction of a wound cleansing pathway incorporating a surfactant-based cleanser in place of saline, with subsequent staff training and other changes made to practice. This study details the steps taken to implement the new pathway, which brought a reduction in wound infections of 84.3% between 2017 and 2019.