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AIM Benefits of mothers' own milk (MOM) for premature and sick neonates are well documented. To increase access, many neonatal units have a lactation consultant (LC) on staff. This study aimed to assess the impact of a permanent LC on (i) maternal access to LC support; (ii) staff confidence in providing Breast Feeding (BF) education and (iii) provision of MOM. METHODS Study included a staff survey and chart audit. Questions provided feedback on access to lactation support and meeting maternal needs. Audit data included: gestational age, birthweight, intention to breastfeed, documentation of LC appointment, provision of MOM at 12 hours, days 3, 7, 28 and discharge. Student's t-tests were used for numerical data and chi-squared tests for categorical variables. RESULTS Ninety-one staff surveys were returned, (pre 35/75 (47%), post 56/85 (66%) with staff reporting organising an LC appointment was significantly easier (P

Absconding from inpatient psychiatric care is a complex problem with significant and broad ranging effects for patients, staff, family/carers, and the broader community. Absconding includes leaving the ward without permission and failing to return from leave at an agreed time. This study is a retrospective chart audit of a data set of absconding events from 11 psychiatric wards in a metropolitan Australian city. The data set included both quantitative and qualitative data. The focus of this study is analysis of the qualitative data documenting what happened during events, with quantitative data provided to contextualize the qualitative analysis. A total of 995 absconding events by 488 patients were reported between January 2016 and June 2018, representing a rate of 1.6 per 100 admissions. Two themes were identified in the qualitative analysis. 'Having things to do' encompassed opportunistic absconding and volitional absconding. 'Something changed' represented predisposing events that affected the absconding behaviour, such as being stepped down in care (moving from a more acute to a less acute psychiatric unit), receiving bad news, or interpersonal conflict either between patients or between nursing staff and patients. Results highlight the importance of harm minimization strategies to reduce the incidence of absconding.

New multiple agency recommendations have encouraged the early introduction of peanut protein (PP) in high-risk children to decrease peanut allergies. However, many providers are hesitant to use these recommendations. Our objective was to increase the recommendation of new guidelines by providers during routine infant care and evaluate caregiver acceptance of early PP introduction.This QI project focused on changing providers' knowledge and attitudes as a means to change practice using the "Plan-Do-Study-Act" model. Following provider educational sessions in 4 clinical sites providers and caregivers were questioned about instruction on the introduction of PP. Pre and post educational intervention data were collected from providers using chart audit and caregivers' report through the modified Promoting Healthy Development Survey (PHDS).The educational intervention was effective in increasing provider knowledge (p .05), providers' dissemination of knowledge to caregivers through provider report (p .001) and caregiver report (p .05).Education increased providers' knowledge about the safety and importance of early introductions of PP, and allayed fears about initiating an allergic reaction. The increased provider recommendation to caregivers was validated by both provider and caregiver report. Caregivers felt comfortable initiating peanut protein.Provider education led to increased recommendation to caregivers on early introduction of PP and increased caregiver comfort introducing PP.

The prevalence of security guards in health care settings is growing worldwide. There is a need to explore and understand their role and actions to inform policy and training and support least restrictive practices in health care. The aim of this study was to conduct a retrospective chart audit of security guard logs to investigate security guard involvement in Code Blacks, called in emergency situations of personal threats including patient and/or visitor violence, in medical and surgical wards in a large metropolitan health network in South Australia. Security guards attended 1664 Code Blacks (0.63% of admissions) over the 2.5-year study period. Events were more frequently reported in medical than surgical wards. The most common reasons for security guard attendance were patients threatening/harming staff and patients threatening/harming themselves. The most frequent security guard actions were "Attend only/standby," "Physical restraint," and "Patient located and returned to the ward." The most frequent outcomes were physical restraint, chemical restraint, and de-escalation respectively. Results highlight the imperative that health services maintain and increase efforts to support least restrictive practice through policy directives and staff training.

BACKGROUND Clozapine is the most effective in treatment-resistant schizophrenia. Neutropenia is an adverse effect of the drug requiring treatment discontinuation. This study related treatment continuation with little or no interruption after a neutropenia episode. The study contrasted from rechallenge studies after an extended treatment interruption. METHODS This retrospective chart audit examined 37 patients with an episode of neutropenia. It described characteristics of patients continuing treatment with minimal interruption. FINDINGS Thirty-one patients continued treatment after an initial treatment interruption for less than 3 days. A probable cause for neutropenia other than clozapine was identified in 14 patients. Twelve patients continued treatment with a change in the absolute neutrophil counts threshold to 1000/μL to determine treatment cessation. Most patients recovered from the index episode of neutropenia within 2 days. They also frequently presented with recurring benign episodes of low neutrophil cell counts during treatment than a comparative group. IMPLICATIONS The study recommends modifying clozapine treatment protocol absolute neutrophil count thresholds to less than 1000/μL to determine treatment cessation. Consideration of other probable causes for neutropenia, diurnal variations in cell counts, and laboratory errors reduced preemptive discontinuation of treatment. A risk-benefit approach supports continuing clozapine treatment after an episode of neutropenia.

To improve nurses' comfort in helping laboring woman void on a bedpan after initiation of epidural analgesia, to increase the frequency of bedpan use in the labor and birth unit, and to decrease the use of continuous indwelling Foley catheters during the intrapartum period.Quality improvement project.A single large, midwestern U.S. hospital (3,000 births annually), where bedpans are infrequently used after epidural placement.Registered nurses on a labor and birth unit.A 20-minute educational presentation that included current urinary catheter evidence-based practice, preferential use of bedpans, and methods to help women void successfully was taught to all registered nurses in the author's labor unit. Nurses rated on a scale of 0 (not comfortable at all) to 10 (extremely comfortable) their comfort level at helping a woman with a bedpan. Primary data were collected through a convenience sample of anonymous surveys (n = 52) completed by registered nurses regarding their experience with bedpan and catheter use during labor and their comfort level helping women be successful with voiding. This was followed by a retrospective chart audit for women with term, singleton pregnancies who labored with epidural analgesia.Nurses' comfort levels increased from an average of 5.7 to 7.2 (p = .067). Postepidural bedpan use increased from 5.5% (n = 12) to 19% overall (n = 20; p .001), with five women using bedpans exclusively. When assisted with bedpan use, 38% (n = 12) of women were able to void 34 of the 53 times it was offered (64%). Use of continuous indwelling Foley catheters decreased from 61.7% (n = 137) to 54.7% (n = 58), and use of intermittent catheterization increased from 30.6% (n = 68) to 37.7% (n = 40).When assisted by nurses educated in and comfortable with different voiding techniques, women may be able to avoid medically unnecessary use of urinary catheters during labor.

Objective: To examine the impact of a clinical toxicology service on toxicology patients admitted to an intensive care departmentMethods: The authors performed a retrospective chart audit of all pa...

Introduction The development of effective interventions in hand and upper extremity rehabilitation is critically important; yet even the most promising interventions may not successfully be implemented in practice. Occupational and physical therapists who provide specialized hand and upper extremity rehabilitation services (“hand therapists”) can face extensive, multi-level barriers when attempting to use research findings in real-world settings, widening the long-standing research-to-practice gap. Concepts from the field of implementation science can be leveraged to address this gap and expedite the application of research discoveries that can maximize treatment outcomes of the musculoskeletal upper extremity client. As the intersection of hand and upper extremity rehabilitation and implementation science draws growing attention, there is a great need for researchers and clinicians to infuse implementation science into the hand and upper extremity rehabilitation research and practice contexts. Purpose The purpose of this article is to define implementation science and synthesize several studies from the hand and upper extremity rehabilitation field that have examined the effect of implementation strategies (eg, chart audit and feedback techniques; implementation teams) on implementation outcomes (eg, acceptability, fidelity). We also present recommendations for how (1) hand and upper extremity rehabilitation researchers can design studies to examine both patient outcomes and implementation outcomes relative to interventions for the musculoskeletal upper extremity and (2) hand and upper extremity rehabilitation specialists and administrators can develop implementation teams to facilitate the use of evidence in practice. Conclusion Collaboration between researchers and clinicians has great potential to advance the entirety of the hand and upper extremity rehabilitation profession, especially when such collaborations are guided by the implementation science field.

Background:An examination of invasive procedure cancellations found that the lack of pre-procedural oral screening was a preventable cause, for children with congenital heart disease. The purpose of this study was to implement an oral screening tool within the paediatric cardiology clinic, with referral to paediatric dental providers for positive screens. The target population were children aged ≥6 months to Methods:The quality implementation framework method was used for this study design. The multi-modal intervention included education, audit and feedback, screening guidelines, environmental support, and interdisciplinary collaboration. Baseline rates for oral screenings were determined by retrospective chart audit from January 2018 to January 2019 (n = 211). Provider adherence to the oral screening tool was the outcome measure. Positive oral screens, resulting in referral to the paediatric dental clinic, were measured as a secondary outcome. Provider adherence rates were used as a process measure.Results:Data collected over 14 weeks showed a 29% increase in documentation of oral screenings prior to referral, as compared to the retrospective chart audit. During the study period, 13% of completed screenings were positive (n = 5). Provider compliance for the period was averaged at 70% adherence.Conclusion:A substantial increase in pre-procedural oral screenings by paediatric cardiologists was achieved using the quality implementation framework and targeted interventions.

INTRODUCTION Specialists in a Maintenance of Certification program are required to participate in assessment activities, such as chart audit, simulation, knowledge assessment, and multisource feedback. This study examined data from five different specialties to identify variation in participation in assessment activities, examine differences in the learning stimulated by assessment, assess the frequency and type of planned changes, and assess the association between learning, discussion, and planned changes. METHODS E-portfolio data were categorized and analyzed descriptively. Chi-squared tests examined associations. RESULTS A total of 2854 anatomical pathologists, cardiologists, gastroenterologists, ophthalmologists, and orthopedic surgeons provided data about 6063 assessment activities. Although there were differences in the role that learning played by discipline and assessment type, the most common activities documented across all specialties were self-assessment programs (n = 2122), feedback on teaching (n = 1078), personal practice assessments which the physician did themselves (n = 751), annual reviews (n = 682), and reviews by third parties (n = 661). Learning occurred for 93% of the activities and was associated with change. For 2126 activities, there were planned changes. Activities in which there was a discussion with a peer or supervisor were more likely to result in a change. CONCLUSIONS AND DISCUSSION Although specialists engaged in many types of assessment activities to meet the Maintenance of Certification program requirements, there was variability in how assessment stimulated learning and planned changes. It seems that peer discussion may be an important component in fostering practice change and forming plans for improvement which bears further study.

Objective To better understand the impact of alcohol consumption on the clinical management of chronic diseases in a regional general practice setting. Methods A retrospective chart audit was undertaken of individual patient records at two large group general practices in Townsville, a regional Australian city. Three common indicator chronic diseases were selected that have clear management guidelines for general practice: type 2 diabetes; chronic obstructive pulmonary disease; and chronic kidney disease. The audits were analysed using SPSS software to examine the association between alcohol consumption on acquisition of clinical management targets and primary disease intermediate outcomes (haemoglobin A1c fraction; per cent of normal forced expiratory volume at one second; and estimated glomerular filtration rate). Results A total of 457 records were audited. Higher‐risk alcohol consumption is associated with reduced ability of patients to reach management targets (F[3,453]=3.68; p=0.012) and decreased standardised primary disease outcome (F[3,403]=2.86; p=0.037). Conclusion Higher‐risk alcohol consumption is associated with reduced attainment of chronic disease management targets and worse chronic disease outcomes. Implications for public health Alcohol consumption should be assessed frequently in people with chronic disease, especially when there is difficulty acquiring management targets or worsening of disease outcomes without a clear explanation. Better education about the potential associations between alcohol use and chronic disease would benefit those managing these complex conditions, both clinicians and patients.

This study described psychotropic prescription patterns among adults referred to a psychiatric outpatient clinic for individuals with intellectual disability and determined demographic, clinical, and organization-level predictors of receipt of three or more psychotropic medications concurrently (psychotropic polypharmacy).To identify predictors of psychotropic polypharmacy, a retrospective chart audit was conducted for patients with intellectual disability referred (N=517) to a specialized psychiatric outpatient clinic between 2005 and 2013.Seventy percent of patients were prescribed at least one psychotropic medication, and 22% received psychotropic polypharmacy. Women, those living in supervised residential settings, and those with a psychiatric diagnosis in two or more diagnostic categories were more likely to receive psychotropic polypharmacy.Polypharmacy is a significant concern for adults with intellectual disability seeking specialized psychiatric services, with multiple contributors to prescribing practices. Both psychiatrists and family physicians can play a role in the judicious use of medications for this vulnerable population.

Background: The majority of individuals who have had a mild stroke are discharged home from acute care. Yet, the proportion who are assessed for driving ability and given related recommendations is unknown. Objective: To describe acute care practice related to driving among individuals whose discharge location is home. Methods: A secondary analysis of data from a chart audit was realized in the Province of Quebec, Canada. Data were retrieved from the charts by trained extractors. Evaluation practice was described according to whether the driving assessment was specific or nonspecific to driving (cognitive, perceptual and visual functions). Descriptive statistics were used. Results: The sample consisted of 419 charts of individuals with a mean age of 70.5 ± 13.3 years old. Mean length of hospital stay was 10.3 ± 13.3 days. Specific driving assessment was documented among 26/419 (6.2%) charts while for seven of these, the assessment was considered full. Meanwhile, 92/419 (22.0%) were considered as problematic for driving a vehicle. Nonspecific driving assessment was documented among 70/419 (16.7%), 43/419 (10.3%) and 33/419 (7.9%) of charts for cognitive, perceptual and visual functions, respectively. Charts were characterized by several missing data relating to driving. Conclusion: The proportion of charts documenting driving restriction post-stroke in acute care was very low. Assuming that all driving discussions and referrals were captured in the charts (which may not be the case), our results would indicate an important gap in acute care practice as compared to best practices relating to driving post-stroke.

BackgroundOral dextrose gel is an evidence-based treatment that has been shown to reduce NICU admissions and support exclusive breastfeeding.PurposeWe summarize a knowledge translation project to introduce dextrose 40 percent oral gel to treat hypoglycemia or hyperglycemia. Implementation took place during the months of May, June, and July 2017.ResultsThrough chart audit, rates for NICU admissions and exclusive breastfeeding were measured for a three-month period before implementation and the three-month period after implementation.There were 234 doses indicated, 128 doses given, 93 doses missed, and 13 doses declined by parents in the first three months of implementation. Admission rates to the NICU for the groups audited were 13 percent in 2016 and 6 percent in 2017.Principles of knowledge translation were used to successfully introduce this change. Centers providing maternal newborn care should consider similar projects to enable introduction.

Background & aims: Prolonged temporary tube feeding places pediatric patients at risk of tube dependency. This chart audit aimed to identify current temporary tube feeding practice within an Australian tertiary hospital, risk factors of prolonged temporary tube feeding, and the likelihood of high risk patients receiving tube dependency preventative practices. Methods: A retrospective chart audit was conducted of the medical records of 187 pediatric inpatients who had temporary feeding tubes placed in an Australian tertiary hospital between November 2014 and March 2017. Information was collected on patient demographics and tube feeding practices. The Kaplan Meier estimate, Cox regression and logistic regression were used to determine the median time until feeding tube removal, predictors of prolonged temporary tube feeding, and the relationship between these predictors and utilization of preventative practices. Results: The Kaplan Meier estimate of median tube feeding duration was 6.43 months (95% CI: 5.17–7.90). Predictors of prolonged tube feeding were prematurity (p = 0.003), feeding difficulties requiring speech pathology referral (p = 0.002), and referral for long-term feeding tubes (p = 0.002). There was a low prevalence of preventative clinical practices including documentation of tube exit plans (5.3%, n = 10) and referral for long-term feeding tubes (27.3%, n = 51). Exhibiting risk factors for prolonged tube feeding did not increase the likelihood of receiving preventative clinical practices. Conclusions: The prolonged duration of temporary tube feeding within this sample highlights the need for improved utilization of tube dependency preventative practices within high risk groups.

Objective To educate nurses and physicians on changing practice from visual estimation of blood loss to quantification of blood loss (QBL) and to replace estimation of blood loss with QBL for at least 85% of vaginal births during a 3-month period. Design Quality improvement project. Setting/Local Problem A midwestern U.S. urban community hospital with 1,200 annual births, where postpartum blood loss was being measured by using visual estimation. Participants A convenience sample of 43 intrapartum nurses and 17 physicians. Intervention/Measurements A goal was set to use the QBL method for at least 85% of vaginal births for 3 consecutive months. Study participants were surveyed at baseline to assess their knowledge of the QBL method; they then received a 10-minute educational presentation by the clinical nurse specialist (CNS) on QBL. The CNS attended births on both 12-hour shifts to give support, evaluate correct use of the new drapes, and answer questions. Midway through the project, a brief survey was distributed to participants for their feedback. The CNS conducted a chart audit to determine the compliance rate for the QBL process. Results Data analysis indicated an average 89% compliance rate with the QBL process for the time period studied. Conclusion Education on the QBL method increased nurses’ and physicians’ awareness of the importance of using this method as the new standard of care for assessment of postpartum blood loss. Accuracy of postpartum blood loss measurement is critical to help prevent maternal morbidity and mortality. Nurses play a key role in the development and implementation of practice changes to use QBL measurement.

Objective To describe referral source, meal ordering patterns and the nutrient composition of meals from a regional Meals on Wheels (MOW) service. Methods Referral sources were obtained via retrospective chart audit and compared for 2008 and 2012. Nutrient content of the three most common meal combinations was compared against MOW recommendations of one-third daily energy and one-half daily protein requirements. Results There was a decline in overall uptake and referrals from hospitals. The "main meal" alone was the most popular meal choice, but did not meet energy requirements for men or women, nor protein requirements for men. The combination of a soup, main and dessert met the MOW recommendations for women only. Conclusions Investigation into how older people access MOW services is required. Innovative strategies are required to increase the nutrient content of meals, within the context of meal ordering preferences of consumers.

Perinatal care has been recognized as an integral part of ensuring quality health care in hospitals, and the focus on perinatal care quality is increasing. The previous hospital literature has focused much attention on measuring and improving quality of care generally, but recently there has been a call for a more comprehensive approach to measuring quality in the perinatal care setting. The perinatal literature is limited in addressing the association between organizational factors and perinatal quality. Using chart audit data for more than 10 000 maternity patients, we used multiple regression analysis to examine the association of organizational factors and perinatal quality of care. Findings show that ownership, setting (location), and hospital policy on infant feeding were statistically significant. Findings suggest that it is important that hospital boards and leaders develop and implement organizational policies to enhance perinatal quality of care.

Background Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. Methods A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. Results In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. Conclusion After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.

OBJECTIVE: To investigate the association between a set of comprehensive factors across international literature and rehabilitation length of stay. METHOD: A chart audit of 197 Australian hospital rehabilitation unit orthopaedic inpatients (2016-2018) was conducted. Items significantly associated with length of stay throughout univariate regressions were entered into a subsequent hierarchical multiple regression analysis, where variables were regressed against length of stay in two steps. Items which were relevant prior to admission to the rehabilitation unit, or immediately upon admission, were regressed against length of stay during the first step, while variables which emerged during admission were entered during the second step. RESULTS: Having pressure injuries during rehabilitation (p

ObjectivesOpioid-related deaths continue to increase in North America, an epidemic that was initiated by high rates of opioid prescribing. We designed a multifaceted, theory-informed Opioid Self-Assessment (OSA) package, to increase adherence to the Canadian Opioid Guideline among family physicians. This study aimed to assess changes in Canadian family physicians’ knowledge and practices after completing the OSA package.DesignWe conducted a mixed-method evaluation using a pre-test and post-test design that involved the collection of both qualitative and quantitative data.SettingThis research was conducted in the primary care setting in Ontario, Canada.ParticipantsWe recruited a purposive sample of nine family physicians in Ontario who use long-term opioid therapy to treat patients with chronic pain.InterventionsThe OSA package included four components: an online knowledge test, an online learning programme, a safe medication practice self-assessment questionnaire and chart audit with feedback.Outcome measuresOur measures included changes in knowledge, opioid safety practices and physicians’ perspectives on the OSA package.ResultsWe found statistically significant improvements between pre-test and post-test knowledge scores at both baseline and 6-month follow-up. Physicians’ scores improved significantly on five of the seven core characteristics of the practice self-assessment questionnaire. On the chart audits, we observed an improvement in patient education between baseline and 6 months. Qualitative interviews showed that participants appreciated embedded resources in the OSA package. The completion of the package stimulated identification of gaps or deficits in practice and served as a useful reminder to discuss risk and safety with patients. Participants described the chart review as helpful in prompting discussions with their patients, identifying deficits and strengths and a ‘primary motivator’ for project participation.ConclusionsThe OSA package has the potential to improve medication safety practices in primary care related to opioid monitoring and adherence to current opioid guidelines.

Purpose The purpose of this EBP project was to align NG and OG tube placement and verification practices with evidence-based recommendations for children. Practice change An evidence-based NG/OG Tube Placement Algorithm was developed. The algorithm provided an individualized approach based on patient condition as well as a tiered approach that incorporated radiographs, tube measurement and marking, and pH testing. Methods A systematic appraisal of literature identified 40 studies supporting the development of the practice change. A 9-item questionnaire was administered to nurses across five pediatric units to assess current tube verification practices. Education was provided in participating units through a Competency Fair. Post-implementation evaluation included re-administering the practice survey and conducting a chart audit of NG/OG events occurring in the year following the practice change. Results Seventy-one nurses completed the pre-implementation survey; 64 nurses completed the post-implementation survey. Strategies for checking NG/OG placement varied across units prior to implementation; however, auscultation was the most likely to be used strategy and assessing pH was the least likely to be used strategy across units. Post-implementation, aspiration and checking pH were the most frequently endorsed assessment strategy, and auscultation was the least endorsed strategy. The post-implementation chart audit revealed that 73% of NG/OG tubes were checked for placement on insertion with radiograph or aspirate pH. Conclusions Implementation of an NG/OG Tube Placement Algorithm standardized NG/OG care across five pediatric units. Additional efforts are underway to further improve adherence to protocol in order to ensure safe, evidence-based practice for children with NG/OG tubes.

Aim: The present study aimed to assess the impact of a hospital-wide electronic medical record (EMR) on the way dietitians collect routine data for their assessments and its impact on their clinical documentation and service provision. Methods: Data were collected retrospectively from the following sources: interdepartmental chart audit, the EMR itself (nutrition diagnosis), National Health Roundtable database (admissions requiring nutrition events) and the hospital-wide Pressure Injury Prevention Audits (height, weight and malnutrition screening). Results: There were improvements in medical record accessibility (76.4% pre vs 100% post, P < 0.001), awareness of medical alerts (82.5% unaware pre vs 34.5% unaware post) and legibility of documentation (53.8% pre vs 99.2% post, P < 0.001). Improvements in accessing medical charts under 1 minute also occurred (65.8% pre vs 99.2% post, P < 0.001). The percentage of nutrition diagnoses resolved during admission increased from 20.0% in February 2016 to 34.0% in August 2017. A 72.0% increase in admissions requiring nutrition interventions was found with 4075 admissions pre- and 7035 post-EMR implementation. Time spent per nutrition event reduced by 22.0% (118 minutes pre and 92 minutes post). Hospital audit data revealed mean height and weight collected increased from 79.3 ± 3.8% (n = 8 audits totalling 3041/3834 patients) to 86.0 ± 2.6% (n = 5 audits totalling, 2544/2958 patients) post-EMR with malnutrition screening completion increasing from 57.5% to 74.0%. Conclusions: Findings indicate that EMR implementation has the potential to benefit the dietetic profession due to the potential to enhance the capacity and efficiency of dietetic departments.

ObjectivesCardiovascular magnetic resonance (CMR) imaging is the gold-standard test for the assessment of heart function. Despite its importance, many jurisdictions lack specific billing codes that can be used to identify patient receipt of CMR in administrative databases, limiting the ability to perform ‘big data’ CMR studies. Our objective was to identify the optimal billing code combination to identify patients who underwent CMR using administrative data in Ontario.DesignRetrospective cohort study.SettingQuaternary care academic referral centre in Ontario, Canada.ParticipantsWe tested all billing code combinations in order to identify the optimal one to determine receipt of CMR. The reference gold standard was a list of all cardiothoracic magnetic resonance scans performed at Sunnybrook Health Sciences Centre between 1 January 2014 and 31 December 2016, verified by chart audit. We assessed the diagnostic performance (accuracy, sensitivity, specificity, positive predictive value and negative predictive value) for all code combinations.ResultsOur gold-standard cohort consisted of 2339 thoracic MRIs that were performed at Sunnybrook Health Sciences Centre from 1 January 2014 to 31 December 2016. Of these, 2139 (91.5%) were CMRs and 200 (8.5%) were chest MRIs. We identified the most accurate billing combination for the determination of patient receipt of CMR. This combination resulted in an accuracy of 95.3% (95% CI 94.4% to 96.2%), sensitivity of 97.4% (95% CI 96.6% to 98.1%), specificity of 86.4% (95% CI 83.1% to 89.6%), positive predictive value of 96.9% (95% CI 96.1% to 97.6%) and negative predictive value of 88.4% (95% CI 85.4% to 91.5%).ConclusionsOur study is the first to verify the ability to accurately identify patient receipt of CMR using administrative data, facilitating more robust population-based CMR studies in the future.

ContextA rapid method of methadone conversion known as the Perth Protocol is commonly used in Australian palliative care units. There has been no follow-up or validation of this method and no comparison between different methods of conversion.ObjectivesThe primary objective of this study was to test the hypothesis that the achieved doses of methadone are independent of the conversion method (rapid vs slower). The secondary objectives included examining the relationship between calculated target doses, actual achieved doses and duration of conversions.MethodsThis is a retrospective chart audit conducted at two hospital sites in the Brisbane metropolitan area of Australia which used different methadone conversion methods.ResultsMethadone conversion ratios depended on previous opioid exposure and on the method of conversion used. The method most commonly used in Australia for calculating target doses for methadone when converting from strong opioids is a poor predictor of actual dose achieved. More appropriate conversion ratios are suggested.ConclusionFurther research is needed to refine the ratios used in practice when converting patients from strong opioids to methadone. Caution and clinical expertise are required. A palliative methadone registry may provide useful insights.

The aim of this study was to identify if patients presenting to a paediatric emergency department were due National Immunisation Program recommended vaccines in order to determine missed opportunities for vaccination or vaccination referral.A hospital chart audit assessed the documentation of an immunisation history, in comparison to the immunisation histories available from national and state immunisation databases to determine accuracy; to identify if patients were due vaccines as determined by the National Immunisation Program; and to identify factors associated with those due vaccines.Potential opportunities to vaccinate children due vaccines were missed (10/114, 8.8%); with less than half (4/10, 40%) correctly documented as due vaccines. Despite identification of due vaccines, no vaccines were administered. Almost one third of patients (34/114, 30%) had no immunisation history documented in the chart. 'Medically at risk' children (Odds Ratio [OR] 29.7, 95% CI 4.5-196, p0.001) were statistically more likely to be due vaccines. Likelihood of being due vaccines was higher, but not statistically significant, for those with no identified general practitioner (OR 4.5, 95% CI 0.96-20.6, p=0.08), and for those presenting with injury rather than illness (OR 2.0, 95%CI 0.51-8.1, p=0.48).Opportunities to vaccinate children presenting to the emergency department are currently being missed. A particular focus is needed for 'medically at risk' children and those with no identified general practitioner. Larger studies may confirm other risk factors. Further research is required into the attainment of an immunisation history during the hospital admission process and the accuracy of these methods.

Nurses on a neurological step-down unit were challenged to switch from documenting assessments by hand to documenting by using a highly technological, electronic format. Upon the switch to electronic documentation, it was discovered through a chart audit that neurological assessments were not being documented properly. The purpose of this project was to implement Care Organizer, an electronic nurse reminder tool, on a neurological step-down unit and to evaluate the tool's ability to assist RNs in documentation of neurological assessments. Fifty patients' charts were audited for documentation of neurological assessments. Thirty-two RNs completed an anonymous demographic survey and were provided with eight training sessions related to utilization of Care Organizer. The RNs were asked to complete an evaluation of the tool 2 weeks after training and again at 1 month after training. A second chart audit was conducted at 1 month to assess for improvement of documentation 1 month after training. Preimplementation/postimplementation chart audits revealed improvements in documentation of neurological assessments in seven of eight criteria examined. Nurses admitted discomfort with Care Organizer and verbalized concerns that it was not convenient and/or user-friendly. Most admitted that with collaboration between information technology department and nursing, the tool could be further developed to become more applicable to nurses.

During the 2009 H1N1 pandemic, 99 severe respiratory illness (SRI) cases were reported in Manitoba. The cause of illness was often not established. Many of these cases may have been unidentified pH1N1. We conducted a chart audit of all severe SRI cases and compared their demographic and clinical characteristics to severe pH1N1 cases. 73 of the 170 cases reviewed were confirmed pH1N1, 53 were SRI with an identified cause, and 44 were SRI with no identified cause. Unexplained SRI cases were similar to pH1N1 cases in terms of risk factors, geographic and temporal distribution, clinical presentation and outcomes. We found that unexplained SRI cases often resembled severe pH1N1 cases, suggesting that these cases were at least in part caused by undiagnosed pH1N1. The overall impact of the pandemic may have been underestimated, especially among the most severely affected indigenous and northern communities.

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and is a well-known cause of oropharyngeal, cervical, vaginal, vulvar, penile, and anal cancers. Despite the proven efficacy of the HPV vaccine, vaccination rates remain persistently low. Much literature has focused on attitudes toward the HPV vaccine; however, researchers have also investigated strategies clinicians can use to improve vaccination attitudes and acceptance. Such strategies include provider education, vaccine reminder/recall, and chart audit and feedback. The purpose of this integrative review is to uncover the best evidence-based practice interventions, with the aim of improving HPV knowledge, patient-provider conversations, and immunization uptake. This integrative review concludes that multicomponent interventions have a synergistic effect, resulting in increased provider vaccine support, improved patient/parental attitudes toward HPV vaccination, and increased immunization uptake. Such strategies hold much promise for today's pediatric providers as they work to combat current vaccination disparities.

Rehabilitation positively influences return to activities and social roles in people with aphasia. The cognitive-communication disorder (CCD) found following a right hemisphere stroke has been less extensively researched with rehabilitation access and outcomes yet to be determined.To document rehabilitation access and outcomes for people with CCD post-stroke; and compare outcomes based on presence (viz CCD; aphasia) or absence of communication impairment.A retrospective chart audit was completed for patients with first onset unilateral stroke, with a hospital length of stay (LOS) of at least two days and a communication assessment by a speech pathologist. Data extracted included presence and severity of communication impairment, access to and LOS in a rehabilitation unit, and functional outcome measures recorded at rehabilitation discharge.The majority of the 115 patients who met inclusion criteria were living independently (n = 112, 97.4%) at the time of stroke. CCD (66%) was diagnosed with similar frequency to aphasia (68%). The presence of communication impairment did not result in significant differences in rehabilitation LOS and discharge destination when compared to hemispheric strokes without communication impairment. Severity of CCD was an independent predictor of functional gain by rehabilitation discharge.People with CCD require comparable access to rehabilitation as people with aphasia, and severity of CCD should be considered in determining rehabilitation LOS. A large number of people are discharged with ongoing CCD which warrants exploration of potential participation restrictions created by the communication impairment.

Entrustable professional activities (EPAs) are complex tasks representing vital physician functions in multiple competencies, used to demonstrate trainee development along milestones. Managing a nephrology outpatient clinic has been proposed as an EPA for nephrology fellowship training.Retrospective cohort study of nephrology fellow outpatient clinic performance using a previously validated chart audit tool.Outpatient encounter chart audits for training years 2008-2009 through 2012-2013, corresponding to participation in the Nephrology In-Training Examination (ITE). A median of 7 auditors (attending nephrologists) audited a mean of 1,686±408 (SD) charts per year. 18 fellows were audited; 12, in both of their training years.Proportion of chart audit and quality indicator deficiencies.Longitudinal deficiency and ITE performance.Among fellows audited in both their training years, chart audit deficiencies were fewer in the second versus the first year (5.4%±2.0% vs 17.3%±7.0%; P0.001) and declined between the first and second halves of the first year (22.2%±6.4% vs 12.3%±9.5%; P=0.002). Most deficiencies were omission errors, regardless of training year. Quality indicator deficiencies for hypertension and chronic kidney disease-associated anemia recognition and management were fewer during the second year (P0.001). Yearly audit deficiencies ≥5% were associated with an ITE score less than the 25th percentile for second-year fellows (P=0.03), with no significant association for first-year fellows. Auditor-reported deficiencies declined between the first and second halves of the year (17.0% vs 11.1%; P0.001), with a stable positive/neutral comment rate (17.3% vs 17.8%; P=0.6), suggesting that the decline was not due to auditor fatigue.Retrospective design and small trainee numbers.Managing a nephrology outpatient clinic is an EPA. The chart audit tool was used to assess longitudinal fellow performance in managing a nephrology outpatient clinic. Failure to progress may be quantitatively identified and remediated. The tool identifies deficiencies in all 6 competencies, not just medical knowledge, the primary focus of the ITE and the nephrology subspecialty board examination.

Increasing demand for palliative care unit (PCU) admissions has led to a stronger focus on discharge planning. This has resulted in shorter inpatient length of stays (LOS), and stable patients not requiring specialist palliative care services being referred for placement in residential aged care facilities (RACFs). The process of placement is time-consuming and can be distressing to patients and families, so RACF placement should only be proposed in patients whose prognosis is relatively good (i.e., weeks to months).Our aim was to identify the outcomes of palliative care inpatients referred for residential aged care placement.A retrospective chart audit was conducted. The patients' outcomes (discharge or death and survival time) were recorded and analyzed using SPSS statistical software. Subjects were 100 consecutive inpatients from a 30-bed PCU who had been referred for RACF placement.Of the 100 patients referred for RACF placement 73 of 100 (73%) patients had a malignant diagnosis, whereas 27 (27%) had a noncancer diagnosis. Thirty-eight (38%) patients died before discharge, including 33 of 73 (45%) patients with cancer and 5 of 27 (13%) patients with nonmalignant conditions. In particular, 12 of 17 (71%) patients with metastatic non-small cell lung (NCSLC) cancer died before or soon after discharge.Over one-third of all patients died before discharge to an RACF could take place. The rate of death before discharge was higher among patients who had cancer. Patients suffering from NCSLC need to be more carefully selected for placement as only one-third of these patients survived to discharge.

The revised standard of care for breastfeeding infants at risk of developing hypoglycemia during transitioning to extrauterine life was developed using the American Academy of Pediatrics (AAP) 2011 hypoglycemia guidelines, the Academy of Breastfeeding Medicine protocol, and staff input. A pre/postimplementation chart audit indicated support of infant safety by glucose stabilization, breastfeeding within the first hour of life, and breastfeeding frequency without an increase in blood sampling, formula use, or admissions to the special care nursery.

OBJECTIVE. The Western Neuro Sensory Stimulation Profile (WNSSP) presents a hierarchy of items suggestive of a sequence of recovery. The aim of this study was to understand the sequence of recovery of neurobehavioral function in patients with brain injury and determine whether this sequence was consistent with the WNSSP test item order. METHOD. We conducted a retrospective clinical chart audit of 37 adult inpatients (mean age = 29 yr; 31 men, 6 women) with a diagnosis of traumatic brain injury and a minimum of two medical record entries on the WNSSP. The sequence of recovery was statistically derived from the content and structure of the WNSSP. RESULTS. Our analysis did not support the current item ordering of the WNSSP as a function of the sequence of recovery from coma, with the exception of the Arousal/Attention subscale. CONCLUSION. WNSSP item performance suggested a sequence of recovery; clinicians may consider a revised item order that reflects this observed order.

Objective Nutrition is an important part of recovery for hospitalized patients. The aim of this study was to assess the nutritional adequacy of meals provided to and consumed by patients prescribed a therapeutic diet. Methods Patients (N = 110) prescribed a therapeutic diet (texture-modified, low-fiber, oral fluid, or food allergy or intolerance diets) for medical or nutritional reasons were recruited from six wards of a tertiary hospital. Complete (24-h) dietary provisions and intakes were directly observed and analyzed for energy (kJ) and protein (g) content. A chart audit gathered demographic, clinical, and nutrition-related information to calculate each patient's disease-specific estimated energy and protein requirements. Provisions and intake were considered adequate if they met ≥75% of the patient's estimated requirements. Results Mean energy and protein provided to patients (5844 ± 2319 kJ, 53 ± 30 g) were significantly lower than their mean estimated requirements (8786 ± 1641 kJ, 86 ± 18 g). Consequently, mean nutrition intake (4088 ± 2423 kJ, 37 ± 28 g) were significantly lower than estimated requirements. Only 37% (41) of patients were provided with and 18% (20) consumed adequate nutrition to meet their estimated requirements. No therapeutic diet provided adequate food to meet the energy and protein requirements of all recipients. Patients on oral fluid diets had the highest estimated requirements (9497 ± 1455 kJ, 93 ± 16 g) and the lowest nutrient provision (3497 ± 1388 kJ, 25 ± 19 g) and intake (2156 ± 1394 kJ, 14 ± 14 g). Conclusion Hospitalized patients prescribed therapeutic diets (particularly fluid-only diets) are at risk for malnutrition. Further research is required to determine the most effective strategies to improve nutritional provision and intake among patients prescribed therapeutic diets.

Objectives: The objective of the current study was to provide a contemporary review of electroconvulsive therapy (ECT) practice in Far North Queensland, Australia. Method: Demographic, diagnostic and treatment characteristics were extracted from the hospital files of people who received ECT between 2011 and 2013. Data were quantitatively analysed and described. Results: Depressive illnesses were the most common indicator for treatment. However, psychotic illnesses also made up a large proportion of treated cases. The technical aspects of treatment were commensurate with previous Australian findings except for the higher incidence of bifrontal ECT and maintenance treatment. Conclusions: Further research is needed across Australia to determine whether the findings of the current study represent changes in Australian ECT practice.

In January 2009, registered dietitians (RDs) at St Michael's Hospital (Toronto, Ontario, Canada) were granted approval for nonmedication order entry of physician-approved nutrition-related orders for the patients to whom RDs provided care. The aim of this project was to document any changes in the numbers and types of diet order errors and time delays that were associated with this policy change. A retrospective chart audit was conducted to document the error rate in 672 nutrition-related orders placed before, and in 633 orders placed after, implementation of RD diet order entry on high-risk inpatient units. Error rates for all nutrition-related orders decreased by 15% after RD order entry access (P

Summary Background Out of hospital cardiac arrest is associated with a high rate of mortality, and poor neurological outcomes. Favourable neuro-protective effects are associated with induced hypothermia and international recommendations exist for therapeutic hypothermia. Objective This study reviews practice for therapeutic hypothermia for out of hospital cardiac arrest patients within one ICU. It aims to describe the level of adherence to the guideline, identify barriers to implementation and to improve adherence. Setting This project was conducted in an adult ICU which admits 2000 patients yearly. Methods A retrospective chart audit was used to document practice for a 12 month period. Results 33 patients were admitted to the ICU with a diagnosis of out of hospital cardiac arrest and met study inclusion criteria. From this sample of 33 patients, four patients (12%) were at the goal temperature of 32.5–33.5 °C, in the target time of 2 h. Nearly half ( n = 17) were not cooled at all. The length of time the patient was in the ICU prior to active cooling commencing varied from n = 15, 45%) to >3 h ( n = 5, 15%). Twenty-four percent ( n = 9) were cooled for the recommended length of time. There were medical orders stating a target temperature in nearly half of the cases ( n = 18), however, only 27% ( n = 9) were consistent with the ICU guidelines. A number of strategies have been initiated. They aim to improve communication and ready access to the required materials. Conclusions The audit indicated that less than a third of the patients experienced therapeutic induced hypothermia and only 12% were at goal temperature within the required 2 h. Strategies initiated to improve guideline implementation included; regular education sessions with ICU staff; placing a cooling blanket on the bed prior to admitting a patient post OOHCA; improving ready access to cooling agents and the addition of a care path for the induction and maintenance of therapeutic hypothermia to support and prompt clinicians when using the computerised patient record system.

We implemented an antimicrobial stewardship program at an urban, 60-bed long-term acute care hospital using a strategy of weekly postprescriptive chart audit with intervention and feedback. The results for the first 15 months demonstrated 80% acceptance of recommendations, a 21% reduction in use, and a 28% reduction in cost per patient-day.

Objectives To determine whether and to what extent simple screening tools might identify nursing home (NH) residents who are at high risk of becoming septic. Design Retrospective chart audit of all residents who had been hospitalized and returned to participating NHs during the study period. Setting and Participants A total of 236 NH residents, 59 of whom returned from hospitals with a diagnosis of sepsis and 177 who had nonsepsis discharge diagnoses, from 31 community NHs that are typical of US nursing homes overall. Measures NH documentation of vital signs, mental status change, and medical provider visits 0–12 and 13–72 hours prior to the hospitalization. The specificity and sensitivity of 5 screening tools were evaluated for their ability to detect residents with incipient sepsis during 0–12 and 13–72 hours prior to hospitalization: The Systemic Inflammatory Response Syndrome criteria, the quick Sequential Organ Failure Assessment (SOFA), the 100-100-100 Early Detection Tool, and temperature thresholds of 99.0°F and 100.2°F. In addition, to validate the hospital diagnosis of sepsis, hospital discharge records in the NHs were audited to calculate SOFA scores. Results Documentation of 1 or more vital signs was absent in 26%–34% of cases. Among persons with complete vital sign documentation, during the 12 hours prior to hospitalization, the most sensitive screening tools were the 100-100-100 Criteria (79%) and an oral temperature >99.0°F (51%); and the most specific tools being a temperature >100.2°F (93%), the quick SOFA (88%), the Systemic Inflammatory Response Syndrome criteria (86%), and a temperature >99.0°F (85%). Many SOFA data points were missing from the record; in spite of this, 65% of cases met criteria for sepsis. Conclusions NHs need better systems to monitor NH residents whose status is changing, and to present that information to medical providers in real time, either through rapid medical response programs or telemetry.

An audit of second stage caesarean section (C/S) at a tertiary hospital was undertaken to compare the frequency of perinatal and maternal complications between first and second stage C/S and to evaluate the training level of physicians.A prospective chart audit of all women who underwent emergency C/S over a 7-month period at a tertiary hospital was conducted. The patients' hospital records were assessed on a daily basis and all relevant information recorded on a structured data sheet categorising demographics, indications for C/S, level of training of decision-maker and surgeon, a consultant's presence, operative complications and neonatal outcome at 5 min post-delivery. The frequency of maternal and neonatal complications was the main outcome measures.There were 975 first stage and 116 second stage C/S. The commonest causes of second stage C/S were cephalo-pelvic disproportion, prolonged second stage and fetal distress. First stage C/S took a mean time of 35.5 min, while second stage C/S took an average time of 41.6 min to perform (p=0.001). There were 37 and 84 records of complications occurring in first and second stage C/S, respectively.Maternal complications were significantly higher in second stage C/S while neonatal complications were not significantly different between first and second stage C/S. There was little guidance from consultants at decision-making for second stage C/S.

Although palliative care services are becoming increasingly prevalent in acute care hospitals only a minority of patients who die in hospital or in the community have seen palliative care teams. There are large numbers of patients who might benefit from palliative care who are not receiving it. That said, identification of patients who are eligible for these services, and of those who would most benefit is problematic. Limitations in our ability to accurately predict prognosis as well as lack of universal agreement as to what constitutes a terminal illness, or "end of life" are important considerations. Another significant challenge faced by our health care systems is whether or not all "end-of-life" patients require specialized care by trained palliative care providers. Even if this were the ideal model of care, this would be unfeasible given the relatively small number of trained providers compared to the aging and dying population. Therefore it is critical that health care systems begin to standardize their approach to the identification of patients who are most in need of, and/or most likely to benefit from interventions by interdisciplinary palliative care teams. Institutions that are planning to develop new services, or expand their current services will require some method/tool to assess specific population needs at their site. The Hamilton Chart Audit (H-CAT) was developed at our institution to help identify potential palliative care needs of patients and their families. We report on development of the tool and use of the tool for a retrospective audit of 222 patients who died at our institution.

Background Recommendations for postoperative antibiotics for appendicitis were published by the American Pediatric Surgical Association (APSA) in 2010. However, implementation of practice recommendations often takes years. We measured compliance of pediatric surgeons (who receive reminders every 6months from the Division Chief) with the APSA recommendations. Methods With Research Ethics Board approval, we completed a retrospective review of children who underwent appendectomy since 2010. Compliance with APSA recommendations was analyzed descriptively. Agreement between pediatric surgeons and pathologists was analyzed by kappa. Results We reviewed 242 charts. Patients were excluded for missing data ( n =5) and diagnosis other than appendicitis ( n =27), resulting in 210 patients with appendicitis (119 acute, 91 perforated). Agreement of perforation status between surgeons and pathologists was good ( κ =0.75; 95% CI: 0.66–0.83). Many patients with nonperforated appendicitis received antibiotics in excess of the APSA recommendations (62/119 (52%)), as did those with uncomplicated perforated appendicitis (52/84 (62%)). Conclusions Despite the availability of published recommendations, surgeons continue to prescribe postoperative antibiotics for appendicitis in excess of the recommendations. Overtreatment leads to potential medication errors and increased length-of-stay/medication costs. An intensive implementation program with ongoing education/monitoring may improve compliance with established recommendations to decrease the use of excess postoperative antibiotics and their associated costs/risks.

Purpose: To examine (1) the frequency and types of painful procedures, (2) the frequency and types of analgesic/sedative use, and (3) the frequency of documented pain assessments that infants experience during the five days following a diagnosis of necrotizing enterocolitis (NEC).Design: A retrospective descriptive cohort design.Sample: Thirty-nine infants from one tertiary care unit diagnosed with stage II NEC.Main Outcome Variable: Painful procedure data were classified into highly invasive procedures and moderately invasive procedures and were collected for five days following the diagnosis of NEC. Frequency and types of analgesic/sedative administration and frequency of documented pain assessments during each of the five days following the NEC diagnosis were collected.Results: The average number of painful procedures was 16.3 per day, with documented PIPP scores performed on 30–60 percent of the infants during each of the days following the diagnosis of NEC. At no time were more than two PIPP scores per infant documented in a 24-hour period. Analgesics were used in 52–76 percent of infants during the first three days following the diagnosis of NEC, but use decreased gradually on the fourth and fifth days. No correlation between painful procedures and analgesic/sedative administration on any day was found. Similarly, no correlation between documented PIPP scores and analgesic/sedative use on any day was found.

Summary Radiation oncology charts containing medical information and treatment details are the major methods of communication between the various personnel involved in delivering radiation therapy to the patient. It is paramount to good patient care for this communication to be clear, precise and accurate in detail. A regular chart audit should be a part of the quality assurance programme of every radiation oncology department. The primary aim of this study was to develop and assess an objective and quantitative programme for reviewing radiation oncology charts, thereby improving the quality of communication and hence patient management. A secondary aim was to compare the charts of radically treated patients with those treated palliatively. A pilot study using a new chart review tool, developed at the Perth Radiation Oncology Centre, was carried out over an 8-month period. A sample of charts, representing 25% of our treatment group, were assessed using the tool on a monthly basis. A total of 156 charts were reviewed during this time period. Fifty-six per cent were radical treatments and 44% were palliative. The overall mean chart scores significantly improved over the time of this study (P

Two emergency nurses, an emergency physician, an information services specialist, and a patient registrar began working on the problem early in 1998. Information Services generated a report of patients with 6 or more ED visits in the previous calendar year, including discharge diagnosis and actual visit dates for each patient. We conducted an extensive chart audit and narrowed the list of potential patients to those with multiple monthly ED visits for the same complaint or those who specifically requested narcotics for pain. As the team leader, I contacted each person’s primary physician to discuss entering the patient into the program. Ironically, many physicians were unaware of how often their patients came to the emergency department for pain medication and had no system to track ED visits. From the beginning, most physicians were very receptive to involvement in the program. Internists and family practice physicians serve as primary providers for most patients in the program, although a physician specializing in pain manages some of the frequently visiting patients. Patients without a

Effective obesity care will not be accomplished without the implementation of a well-planned, office-based organizational system designed to address the assessment, evaluation, and treatment of the overweight and obese patient. Completing an office audit, as shown in Table 1, should be useful for triggering quality improvement opportunities regarding obesity care. Similarly, the chart audit in Table 4 can be used to assess current and future practice behavior. This article has reviewed the key office-based components for the delivery of obesity care. The strategies and techniques used for treatment are addressed in the remaining articles in this issue.

The goal of this study was to establish patients' perspectives on the acceptability of wait times, the impact of wait times on their health and the possibility of using electronic consultations (eConsultations) to avoid visits to specialists. A 2-stage patient survey (self-administered and with a follow-up telephone call) and a chart audit was conducted on a sequential sample of patients attending their initial consultations in a tertiary diabetes and endocrinology centre. Patients' perspectives on actual and ideal wait times, the impact of waiting for access, the effectiveness of the referral-consultation process and attitudes toward eConsultations as an alternative to traditional referral-consultations were collected. The study involved 101 patients (22% for diabetes, 78% for endocrinologic conditions), whose comments were collated and categorized. Of the 101 patients who completed the survey, 61 also completed telephone interviews. The average wait time was 19 weeks; the median 10 weeks. More than 30% of patients waited longer than 6 months and 6% waited longer than 1 year. Overall, 90% of patients thought that the maximum wait time should be less than 3 months. While waiting, 58% of patients worried about a serious undiagnosed disease, 30% found their symptoms had affected their daily activities and 24% had to miss work or school due to symptoms. Of the patients, 46% considered eConsultation a viable alternative to face-to-face visits. Excessive wait times for specialist care remain barriers and have negative impacts on patients. Wait times significantly exceeded times patients considered acceptable. eConsultations provide acceptable alternatives for many patients, and they reduced the number of patients requiring traditional consultations.

Purpose To evaluate rehospitalizations and develop a strategy to reduce the number of individuals sent back to the hospital within 30 days of admission from postacute care services including skilled care, long-term care, and home care. Design Using the Plan, Do, Study, Act (PDSA) format outlined by the Institute for Healthcare Improvement, we implemented and evaluated a quality improvement project. Methods The number of rehospitalizations was calculated and chart audit was used to determine the reasons. Interventions were designed to decrease the number of reasons individuals had to return to the hospital. Findings Five rehospitalizations were deemed preventable. Interventions were designed to improve staff knowledge. Conclusions The effectiveness of interventions and rehospitalization rates continue to be monitored. The rehospitalization rates from these agencies are low. Low rehospitalization rates are good for clients and improve desirability as a source for care posthospitalization. Clinical Relevance Understanding causes for rehospitalization, providing skills and knowledge aimed at the root causes of hospitalization, and reducing the rate of rehospitalization improves nursing practice and reimbursement.

Objectives To evaluate quality of care delivered to patients presenting to the emergency department (ED) with pain and managed by emergency nurse practitioners by: 1Evaluating time to analgesia from initial presentation 2Evaluating time from being seen to next analgesia 3Measuring pain score documentation Background The delivery of quality care in the emergency department (ED) is emerging as one of the most important service indicators being measured by health services. Emergency nurse practitioner services are designed to improve timely, quality care for patients. One of the goals of quality emergency care is the timely and effective delivery of analgesia for patients. Timely analgesia is an important indicator of ED service performance. Methods A retrospective explicit chart review of 128 consecutive patients with pain and managed by emergency nurse practitioners was conducted. Data collected included demographics, presenting complaint, pain scores, and time to first dose of analgesia. Patients were identified from the ED patient information system (Cerner log) and data were extracted from electronic medical records. Results Pain scores were documented in 67 (52.3%; 95% CI: 43.3–61.2) patients. The median time to analgesia from presentation was 60.5 (IQR 30–87) minutes, with 34 (26.6%; 95% CI: 19.1–35.1) patients receiving analgesia within 30 minutes of presentation to hospital. There were 22 (17.2%; 95% CI: 11.1–24.9) patients who received analgesia prior to assessment by a nurse practitioner. Among patients who received analgesia after assessment by a nurse practitioner, the median time to analgesia after assessment was 25 (IQR 12–50) minutes, with 65 (61.3%; 95% CI: 51.4–70.6) patients receiving analgesia within 30 minutes of assessment. Conclusions The majority of patients assessed by nurse practitioners received analgesia within 30 minutes after assessment. However, opportunities for substantial improvement in such times along with documentation of pain scores were identified and will be targeted in future research.