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Background:The clinical profile of Aboriginal and Torres Strait Islander adults admitted to hospital with neurological injury is not well documented. Understanding these profiles may enable health professionals to provide more culturally responsive health care for this patient group. This study aimed to report the clinical profile of Aboriginal and Torres Strait Islander adults admitted to a regional Queensland hospital due to stroke or traumatic brain injury (TBI).Method:A 2-year retrospective medical record review of Aboriginal and Torres Strait Islander adults (≥18 years) admitted to a regional Queensland hospital with principal diagnoses of stroke or TBI.Results:There were 132 Aboriginal and Torres Strait Islander adult stroke (51.5%) or TBI (48.5%) admissions. The mean ages were 56.7 years for stroke and 42.7 years for TBI. The majority of patients (83.3%) were of Aboriginal descent with others identifying as Torres Strait Islander only, or both Aboriginal and Torres Strait Islander. Patients were from 26 diverse home locations across northern Australia, primarily Outer Regional or Remote/Very Remote geographical locations. All patients’ language backgrounds were documented as English only. Over 90% of stroke and 50% of TBI patients presented with medical co-morbidities.Conclusions:Patients had diverse geographical locations and cultural backgrounds, with many likely impacted by dislocation from home and country, as well as potential delays in receiving treatment. Despite this diversity, English was documented in patients’ medical records as their only language. The majority of patients also presented with multiple medical co-morbidities. Health professionals should consider these factors to ensure patients receive optimum and culturally responsive health care.

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.

A pre- post-chart audits of 50 asthmatics assessed provider documentation for asthma classification and treatment according to national guidelines. Once baseline electronic medical records (EMR) audit was conducted the healthcare providers and clinic staff received training on the use of asthma diagnosis and treatment national guidelines. A post-training EMR chart audit (3-months after the training) was conducted for a pre-post-training comparison.

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.

Objective: To move closer to achieving the third target of the UNAIDS 90-90-90 goals, we prospectively implemented a viral load (VL) champion (VLC) program aimed at enhancing VL monitoring and recognition of treatment failure. Design: Three clinics in eThekwini, Kwa-Zulu Natal (low-, medium- and high-volume, encompassing 9184 patients overall) were each assigned a VLC. We employed a descriptive analysis (chart audit) to compare the pre-intervention period to a 1-year post-intervention period. The number of patients with a VL test performed 6 and 12 months after the intervention was calculated as a proportion of VL tests due at those time points (VL completion rate). Results: The pre-implementation VL completion rate at the three sites was respectively 68% (140/205 patients), 54% (84/155 patients) and 64% (323/504 patients), and the 6-month post-implementation completion rate increased to 83% (995/1194 patients), 90% (793/878 patients) and 99% (3101/3124 patients) (P 90% across all facilities. Conclusion: We demonstrate a successful, multifaceted, quality-improvement intervention centered on a clinic-level VLC which, taken to scale, has important implications for attaining the third UNAIDS 90-90-90 target.

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.

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: We retrospectively investigated COVID-19 patients on anticoagulation or antiplatelet medications as their home medication or used as inpatient treatment to evaluate if they exhibited lower levels of D-dimer and lower rates of embolic events and mortality. METHODS: This correlational retrospective study evaluated n=319 COVID-19 patients admitted to acute inpatient services across the Mercy Health Youngstown hospitals. A retrospective chart audit included home medications and admission medications, hospital and ICU length of stay, days on the ventilator, initial and follow-up labs (D-dimer), and thromboembolic events after diagnosis of COVID-19. We constructed a composite index for any embolic events occurring in inpatient: MI, DVT, PE, stroke, and cardiac arrest. The prevalence of these embolic events was 23.5% (n=75/319). For propensity modeling, comorbidities, initial D-dimer, demographics, days from a positive COVID-19 test result to admission, and a summative index of comorbidities were entered in a binary logistic regression model to predict embolic events. RESULTS: The rate of any embolic events among COVID inpatients was 23.5% (n=75/319). Initial D-dimer was 1648±1702 ng/mL among patients experiencing any embolic events and was lower among patients without embolic events, 1009±1205 ng/mL (t=3.638, p < 0.001). In iterative forward selection, logistic modeling retained in the model for embolic events were age, initial D-dimer, past medical history of ESRD, and ethnicity, which correctly classified 75% of embolic events in patients (AUC=0.702). The addition of home medications, antiplatelets and anticoagulants to the propensity model did not significantly improve AUC (0.704) which indicates that neither home use of anticoagulation nor antiplatelets was associated with inpatient embolic events in a propensity adjusted model. However, when inpatient anticoagulation therapy was initiated, statistically significant benefit in preventing embolic events was observed (AOR = 3.32 (95% CI 1.79-6.16);AUC 0.752 (p < 0.001)). Similarly, home use of antiplatelet and anticoagulation medications was not associated with mortality in COVID-19 patients, but in-hospital use of anticoagulation was statistically significant (p=0.036). CONCLUSIONS: Our study aimed to see if taking antiplatelet or anticoagulation medications as a home medication would have any effect on thromboembolic events and mortality in COVID-19 patients compared to when receiving antiplatelet or anticoagulation agents during hospitalization. We found that being on an antiplatelet or anticoagulation medication at home (before hospitalization) did not prevent COVID-19 patients from thromboembolic events or improve mortality. However, after adjusting for baseline risk of embolic events, in-hospital anticoagulation had a statistically significant benefit in preventing embolic events and mortality. CLINICAL IMPLICATIONS: It has been established that COVID-19 patients are at higher risk for embolic events that have been linked to increased mortality. In our current study using a composite index model to predict embolic events in COVID-19 patients, the use of anticoagulation agents during hospitalization revealed a significant reduction in embolic risks and mortality while patients on home antiplatelet or anticoagulation medications did not show benefits in reducing the same risks. DISCLOSURES: No relevant relationships by Omotooke Babalola, source=Web Response No relevant relationships by Timothy Barreiro, source=Web Response No relevant relationships by David Gemmel, source=Web Response No relevant relationships by Oyidiya Osoka, source=Web Response No relevant relationships by Jeannie Ur, source=Web Response

Background Australians living in regional, rural, and remote areas face a myriad of complexities resulting in a trend to poorer health outcomes. Telehealth is being utilised as an alternative mode of service delivery to overcome such barriers. However, there is limited published information concerning the use of telehealth in perioperative medicine. Aims The purpose of this study was to review the performance of the telehealth pre-operative assessment service at Mater Hospital Brisbane to determine last-minute cancellation rates secondary to medical reasons. Methods A retrospective chart audit of all patients referred to perioperative medicine telehealth consultation services provided at Mater Hospital Brisbane. Results During a one-year period, 229 patients across 8 surgical subspecialties were referred for telehealth assessment (85 females, 144 males) with a median age of 67 years. Patients lived a median distance of 1597 kilometers from Brisbane. Of the 229 patients included in the study, 7 (3.1%) experienced last-minute cancellations. From this data, the last-minute cancellation rate due to medical reasons was 1.3%, which is consistent with the international average. Conclusion The Mater Hospital Perioperative Medicine telehealth Program is a means of providing comprehensive perioperative assessment to regional, rural and remote patients that result in reduced last-minute surgical cancellations and surgery within or below the national recommended guidelines.

Introduction: Choosing Wisely Nova Scotia (CWNS), an affiliate of Choosing Wisely Canada™ (CWC), aims to address unnecessary care and testing through literature-informed lists developed by various disciplines. CWC has identified unnecessary head CTs among the top five interventions to question in the Emergency Department (ED). Zyluk (2015) determined the Canadian CT Head Rule (CCHR) as the most effective clinical decision rule in adults with minor head injuries. To better understand the current status of CCHR use in Nova Scotia, we conducted a retrospective audit of patient charts at the Charles V. Keating Emergency and Trauma Center, in Halifax, Nova Scotia. Methods: Our mixed methods design included a literature review, retrospective chart audit, and a qualitative audit-feedback component with participating physicians. The chart audit applied the guidelines for adherence to the CCHR and reported on the level of compliance within the ED. Analysis of qualitative data is included here, in parallel with in-depth to contextualize findings from the audit. Results: 302 charts of patients having presented to the surveyed site were retrospectively reviewed. Of the 37 cases where a CT head was indicated as per the CCHR, a CT was ordered 32 (86.5%) times. Of the 176 cases where a CT head was not indicated, a CT was not ordered 155 (88.1%) times. Therefore, the CCHR was followed in 187 (87.8%) of the total 213 cases where the CCHR should be applied. Conclusion: Our study reveals adherence to the CCHR in 87.8% of cases at this ED. Identifying contextual factors that facilitate or hinder the application of CCHR in practice is critical for reducing unnecessary CTs. This work has been presented to the physician group to gain physician engagement and to elucidate enablers and barriers to guideline adherence. In light of the frequency of CT heads ordered EDs, even a small reduction would be impactful.

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.

© 2019, © 2019 Informa UK Limited, trading as Taylor & Francis Group. Background: Diabetes at the end of life (EoL) is characterized by blood glucose fluctuations that result from decreased oral intake, side effects of medications, altered physiology, and end-stage organ failure. With limited life expectancy and the presence of comorbidities, diabetes management can be challenging. While there is little clinical evidence to guide decision-makers, current practice depends on empiric and expert recommendations. Objective: To evaluate the current prescribing patterns and monitoring parameters in diabetes management at the EoL in patients at two palliative care inpatient units. Design: Retrospective clinical chart review. Setting/subjects: Adult patients attending the Palliative and Supportive Care Services at St Vincent's Private Hospital and Mater Adults Hospital, South Brisbane, Australia over a 24-month period, from October 2014 to October 2016. Results: A total of 145 charts were analysed. 139 patients were identified as having received glucose-lowering therapy (51% female, median age 71 years). Insulin therapy was used in 74 (51%) patients and oral and/or non-insulin therapies in 62 (43%). Blood glucose level monitoring was carried out a median of 4 times, range 1–6 times daily. Either continuously or at some stage of their treatment, 74 patients were receiving corticosteroids. Conclusion: Insulin therapy appears to be the safest and most effective approach, taking into consideration the patient needs and pharmacodynamic profile of each preparation. Without evidence-based guidelines on the optimal intervention to control diabetes at the EoL, therapy plans must be individualized to prevent symptomatic hyper- and hypoglycaemia with minimal patient discomfort and adverse drug reactions.

Background Unintended retained surgical sponges (URSSs) are preventable catastrophic events that occur in the surgical environment. Purpose A community hospital in the southern United States sought to reduce the occurrence of URSSs by implementing a quality improvement initiative. Methods We conducted a practice improvement project that incorporated safety-sponge technology preceded by education and training. Staff knowledge and practice expectations were assessed using a pre-post-intervention survey followed by internal audit. Results Staff knowledge significantly improved after the tailored education and training. A chart audit conducted 15 weeks after the intervention showed compliance with the technology was 99.4%, incorrect surgical counts went from 4% to 0.8%, and number of URSSs went from 2 to 0. Conclusion The project demonstrated a reduced risk of incorrect surgical counts and URSSs in the facility.

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

Background: Homelessness is a growing Canada-wide concern. Those with no fixed address have increased rates of emergency department (ED) utilization and increased healthcare spending compared to the general population, with higher rates of acute and chronic illnesses, as well as all-cause mortality. EDs are uniquely situated to act as an access point to the network of available community services, however referral rates from the ED is uncertain. To date, there has been no data collected on London, Ontario's homeless population, their health burden, and their utilization patterns of the ED. Aim Statement: The primary objective of this study is to describe ED visits for adult patients with no fixed address in London, Ontario to assess for potential areas to improve care. Measures & Design: This is a retrospective chart review, of patients with no fixed address visiting London, Ontario Emergency Departments in 2018. ED visits were identified and pulled using either a diagnosis of “homeless”, a lack of postal code, or a postal code for a known shelter. Cases included based on postal code were manually reviewed to determine whether the patient had a resident address with the same postal code. Evaluation/Results: From this search, 4,294 visits were identified for 1237 unique patients. The median visits per person was 1 (IQR 1-2), with 388 patients having 3 or more visits, and the max being 138 visits. The median age was 38 (IQR 28-52), with 73% male. Ground ambulance was used for 46% of visits. 28% of visits were CTAS 1&2 and 5% were CTAS 5. Police facilitated visits in 401 cases. Top 3 discharge diagnosis categories were mental health (19%), infection (18%), drug misuse (17%). Discussion/Impact: Several errors were identified with our search strategy suggesting the current system of capturing homelessness in the EPR is not accurate, leading to an underestimation of the problem and limiting our ability to describe this population. The Ministry of Health mandates homelessness be applied as a tertiary discharge diagnosis during coding of the patient visit if possible. However, use of this code is inconsistent leading to large-scale omission of visits and an underrepresentation of pediatric cases. Systemic steps should be taken to improve identification of these patients moving forward.

Fluid balance charts are an important monitoring document for patient safety and clinical care. The National Confidential Enquiry into Patient Outcome and Death report shows that inaccurate fluid balance monitoring impacts patient deaths in the perioperative period.1 Our audit aimed to assess accuracy, completeness and attitudes towards fluid balance charts including evidence of appropriate escalation when required. This work is part of an ongoing audit conducted over an acute surgical and medical ward in a …

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.

ObjectiveTo determine if an educational intervention can decrease the inappropriate antibiotic treatment of long-term care (LTC) residents with asymptomatic bacteriuria (ASB).DesignProspective chart audit between May and July 2017.SettingSeven LTC facilities in Regina, Saskatchewan, Canada.ParticipantsChart audits were performed on all LTC residents over 18 years of age with a positive urine culture. Educational sessions and tools were available to all clinical staff at participating LTC facilities.InterventionFifteen-minute educational sessions were provided to LTC facility staff outlining the harms of unnecessary antibiotic use, antibiotic resistance and the diagnostic criteria of a urinary tract infection (UTI). Educational sessions were complimented with posters and pocket cards that summarised UTI diagnostic criteria.Main outcome measureThe primary outcome measure was the number of residents who received inappropriate antibiotic treatment for ASB. Secondary outcome measures included the appropriateness of urine culture tests, number of tests and cost associated with inappropriate treatments.ResultsIn the preintervention period, 172 urine culture and sensitivity (UC&S) tests were performed, 62 (36.0%) were positive and 50/62 (80.6%) residents had ASB based on chart review. In the postintervention period, 151 UC&S tests were performed, 50 (33.1%) were positive and 35/50 (70.0%) residents had ASB. There was a statistically significant decrease in the number of residents treated with antibiotics for ASB, from 45/50 (90%) preintervention to 22/35 (62.9%) postintervention (χ2=9.087, p=0.003).ConclusionsAn educational intervention was associated with a statistically significant decrease in inappropriate antibiotic treatment of LTC residents with ASB.

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.

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.

Introduction In recent years researchers have reported deficits in the quality of care provided to patients with rheumatoid arthritis (RA), including low rates of performance on quality measures. We sought to determine the influence of a quality improvement (QI) continuing education program on rheumatologists’ performance on national quality measures for RA, along with other measures aligned with National Quality Strategy priorities. Performance was assessed through baseline and post-education chart audits. Methods Twenty community-based rheumatologists across the United States were recruited to participate in the QI education program and chart audits. Charts were retrospectively audited before (n = 160 charts) and after (n = 160 charts) the rheumatologists participated in a series of accredited QI-focused educational activities that included private audit feedback, small-group webinars, and online- and mobile-accessible print and video activities. The charts were audited for patient demographics and the rheumatologists’ documented performance on the 6 quality measures for RA included in the Physician Quality Reporting System (PQRS). In addition, charts were abstracted for documentation of patient counseling about medication benefits/risks and adherence, lifestyle modifications, and quality of life; assessment of RA medication side effects; and assessment of RA medication adherence. Results Mean rates of documented performance on 4 of the 6 PQRS measures for RA were significantly higher in the post-education versus baseline charts (absolute increases ranged from 9 to 24% of patient charts). In addition, after the intervention, significantly higher mean rates were observed for patient counseling about medications and quality of life, and for assessments of medication side effects and adherence (absolute increases ranged from 9 to 40% of patient charts). Conclusion This pragmatic study provides preliminary evidence for the positive influence of QI-focused education in helping rheumatologists improve performance on national quality measures for RA. Electronic supplementary material The online version of this article (doi:10.1007/s40744-015-0018-7) contains supplementary material, which is available to authorized users.

Background: Patients with end-stage kidney disease often have difficulty in adhering to aspects of their haemodialysis regimens. Objectives: This study aimed to quantify the number of patients who attended 100% of their scheduled haemodialysis sessions, and the number of patients who gained no more than one kilogram per day between dialysis sessions, over a three-month period. Design: Retrospective chart audit Participants Patients undergoing haemodialysis at an in-hospital centre in tropical Australia. Methods: A renal nurse audited the 72 charts pertaining to a 12-week period in 2013. Results: Patients attended 90.1% of all scheduled dialysis sessions. Forty-one patients attended all sessions, with the remaining 31 missing at least one scheduled session. One patient missed 16 scheduled sessions. The following were statistically less likely to attend all their scheduled sessions: Aboriginal and Torres Strait Islander patients; patients on a three times per week dialysis schedule; patients who had relocated from rural or regional towns and younger patients. The average daily weight gain ranged from 0.414 kg to 1.017 kg (mean = 0.885 kg). Younger patients were statistically less likely to adhere to fluid restrictions; patients without diabetes were more likely to adhere to the fluid allowances. Conclusions and applications to practice: Renal services need to assist patients to adhere to their regimens. Initially, this service will examine strategies to maximise the likelihood of patients attending all of their dialysis sessions. Such an outcome will help to delay deterioration in the patients' health status, while minimising additional strain on the health service.

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.

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.

Background: As cross-border migration increases internationally, speech pathologists will see growing numbers of people with aphasia from culturally and linguistically diverse (CALD) backgrounds. A...

Background: In Australia, 36% of women who experienced violence by a partner reported that this occurred when they were pregnant.1 Around seventeen percent of women experience domestic violence (DV) for the first time during pregnancy. Routine enquiry about domestic violence during pregnancy is now accepted best practice. Training is essential to improve knowledge and practice. Yet very few studies have undertaken a comprehensive evaluation of training impact over time. Aim: This presentation will provide an overview of an evaluation of the longitudinal impact of a domestic violence training and support program to promote midwives’ routine antenatal enquiry for domestic violence using a mixed methods design. Method: Data sources included (1) surveys of midwives at 6 months post-training, (2) interviews with key stakeholders at 12 months, (3) chart audit data of screening, risk, and disclosure rates (for 16 months). Measures included midwives’ knowledge and preparation for routine antenatal enquiry, and perceptions of organisational barriers to routine enquiry. Findings: Forty (out of 83) participant surveys could be matched and responses compared to baseline and post-training scores. Wilcoxon signed-rank test identified that all 6-month follow-up scores were significantly higher than those at baseline. Level of preparedness increased from 42.3 to 51.05 (Z = 4.88, p 90%) reported improved confidence to undertake routine inquiry. A chart audit of screening rates for 16 months post-training revealed of the 6671 women presenting for antenatal care, nearly 90% were screened. Disclosure of domestic violence was low (

Background: Heart failure (HF) is the primary cause of hospitalizations and readmissions to a hospital within 30 days of initial discharge. In 2010 HF cost an estimated $39.2 billion in health care services, lost productivity and medications. Optimizing outpatient care is vital to effectively manage this patient population. Objective: The purpose of this paper is to describe and evaluate the effectiveness of an optimized outpatient HF clinic. Patient outcomes from a Midwestern community hospital were based on quality of life (QOL) and readmission rates. Methods: A retrospective chart audit was conducted on a random sample of patients enrolled in the Heart Failure Recovery Center (HFRC). The QOL outcomes were measured using the Minnesota Living with Heart Failure® Questionnaire. Results: Enrolled patients demonstrated improvement in their QOL in the emotional, physical, and overall scores across the first 6 months of care. In addition, there were significantly fewer 30-day all-cause readmissions when compared to non-Clinic patients. Conclusion: Utilization of an APN-managed multidisciplinary HF clinic improved patient's QOL and contributed to one hospital's decreased all-cause readmission rates for the HF population.

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.

Background. Colorectal cancer (CRC) is a growing public health concern with increasing rates in countries with previously known low incidence. This study determined pattern and distribution of CRC in Tanzania and identified hot spots in case distribution. Methods. A retrospective chart audit reviewed hospital registers and patient files from two national institutions. Descriptive statistics, Chi square (χ2) tests, and regression analyses were employed and augmented by data visualization to display risk variable differences. Results. CRC cases increased sixfold in the last decade in Tanzania. There was a 1.5% decrease in incidences levels of rectal cancer and 2% increase for colon cancer every year from 2005 to 2015. Nearly half of patients listed Dar es Salaam as their primary residence. CRC was equally distributed between males (50.06%) and females (49.94%), although gender likelihood of diagnosis type (i.e., rectal or colon) was significantly different (P=0.027). More than 60% of patients were between 40 and 69 years. Conclusions. Age (P=0.0183) and time (P=0.004) but not gender (P=0.0864) were significantly associated with rectal cancer in a retrospective study in Tanzania. Gender (P=0.0405), age (P=0.0015), and time (P=0.0075) were all significantly associated with colon cancer in this study. This retrospective study found that colon cancer is more prevalent among males at a relatively younger age than rectal cancer. Further, our study showed that although more patients were diagnosed with rectal cancer, the trend has shown that colon cancer is increasing at a faster rate.

Background: Practice Management Report is a tool used to describe the practice activity and productivity for each resident. The aim of this study is to monitor resident adherence to ACGME-I performance standards. Methods: Data was extracted and analyzed from practice management reports of all family medicine residents for the period from July 2014 to June 2015. Total number of residents was 31 residents. Results: Residents reached the target of total number of patient visits by 43% while reached the target of male/ female ratio by 62%. Residents reached the target of hospital admission visits by 27%. Residents reached the target of seeing patients less than 19 years by 87% while reached the target of seeing patients more than 60 years by 22%. Residents reached the target of patients visit distribution by 21%. Residents completed their chart audit by 97% and achieved patient satisfaction by 99%. The most deficient cases seen by residents were high risk pregnancy by 43%, well baby cases by 20%, eye problems by 16% and Asthma by 11%. Conclusion: Practice management report is of considerable importance to monitor and assess resident performance according to ACGME-I standards. Despite some difficulties in its application and analysis process, it will guide improving deficiencies in areas as antenatal and well-baby care and physician alert system.

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.

In this clinical performance review, the chart audit is introduced in a county jail as a tool to educate about and enforce standard of care management of detainees with chronic diseases including d...

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.

Background The Royal College Of Physicians (RCP) has shown that the multiplicity of locally developed Early Warning Scores (EWS) used throughout the UK is causing a ‘lack of consistency in detecting the deterioration of patients [1]. The RCP therefore produced a report in July 2012 proposing a National Early Warning Score (NEWS), a point based system, with the aim of standardisation across the UK. However, there is concern that if locally developed systems are working well why “fix what isn’t broken”. The current system used at Sandwell & West Birmingham Hospitals (SWBH) NHS Trust, UK is a simple colour coded observation chart. As observations become more abnormal they are documented in amber or red zones on the chart. Instructions on the chart explain that single “amber”, double “amber” or “red” observation should trigger a specified action, to be documented in the clinical notes, and increased frequency of observations. Previous audits of patients admitted to the Intensive Care Units of SWBH indicated that even this simple colour coded system was not accurately followed and could indicate that the NEWS, a more complicated point based system, may worsen compliance. The aims of this audit were to evaluate adherence to the current colour-coded EWS adult observation chart across a variety of wards.

INTRODUCTION Gestational diabetes mellitus (GDM) is a major health concern in Aboriginal communities, with significant short- and long-term adverse effects for both mother and child. Optimal care can improve outcomes. Evidence-based standards have been developed to provide clinical practice guidelines for healthcare providers. This study examines the use of these standards in screening for GDM in Norway House, Manitoba, Canada, and evaluates the impact of educational reinforcement on changing practices. METHOD A chart audit was performed before and after an educational session that focused on GDM was offered to physicians and nurses involved in prenatal care. In addition, flow charts designed to facilitate use of the recommended standard of care were provided. RESULTS The initial chart audit showed that, in general, screening for GDM was inconsistent with the recommended standard of care. Screening improved following the educational session, although in many cases screening and follow-up were still suboptimal. Several systemic weaknesses in care were exposed. CONCLUSION This study provided valuable insight into the importance of addressing systemic infrastructures in addition to providing education when introducing changes in standards of practice.

Aim The study aims to assess the health burden of children admitted with ‘scabies’ to Mt Isa Hospital, the referral centre for North West Queensland, from 2006 to 2010. Methods This is a retrospective chart audit of admissions of children with ‘scabies’ including age, sex, date, residence, Indigenous status, result of skin swabs and length of stay, and the number of admissions with acute rheumatic fever (ARF) and acute post-streptococcal glomerulo-nephritis (APSGN) in that period. Financial burden was estimated from daily bed costs and transportation. Results There were 113 admissions with mean age of 23/12: 11% were

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

218 Background: Since 2007, Cancer Care Ontario has provincially mandated symptom screening of cancer patients using the Edmonton Symptom Assessment Scale (ESAS). Screening rates are the primary performance metric used across 14 Regional Cancer Centres (RCCs), however this indicator does not detail how symptoms are managed during the clinic visit. The objective is to share our accomplishments using a chart audit process and share upcoming changes aimed to improve the measurement of clinician response to symptom screening. Methods: The initial chart audit tool was created by regional stakeholders who oversee cancer symptom management. The tool measures the concordance between clinician response to the patient symptom screen and best practices outlined in the Cancer Care Ontario Symptom Management Guides. RCCs conduct an annual chart audit for seven of the ESAS symptoms, and sample at least 20 patients with high symptom scores (>=4). Chart documentation is analyzed to determine whether the patient received appropriate assessment and interventions. Results: 7,952 chart audits have been completed since 2012. Patients reporting symptom burden in FY 2015/16 often received an assessment (72-93%) and intervention (48-79%) during the clinic visit, depending on the symptom. Annual provincial aggregate results are intended to support quality improvement, inform clinician symptom management education, and provide a snapshot of resource utilization. Shortcomings of the audit have been identified over time. These highlight the need for more actionable items and a standardized process to ensure representative sampling, as aggregate results can be biased when RCCs co-opt the audit to measure local projects. This prompted an overhaul of the audit process: new audit tool created; results linkable to administrative data; and objectives clearly defined to balance local and provincial needs. Conclusions: Measuring the frequency of symptom screening is important, but the most clinically relevant question is whether the patient’s symptoms are being managed. Changing the chart audit process will ease the burden on auditors, improve data quality, and ensure data utility at all levels.

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.

The Emergency Triage Education Kit (ETEK) was published in 2007. To date, the impact of ETEK has not been measured. The purpose of this study was to measure the effectiveness of ETEK on paediatric triage.A retrospective chart audit was undertaken in a tertiary paediatric hospital. Its' aim was to review the completeness of documentation recorded at the point of triage after a standardised documentation framework was introduced and to measure inter-rater agreement. Primary assessment and physiological discriminators documented at the point of triage were compared with those from the paediatric physiological discriminator table (PPDT) within ETEK. Using an audit tool developed by the researchers, a parallel decision-making pathway was used to ascertain whether the original ATS score could be substantiated by the PPDT. Improvement in documentation of the primary assessment and inter-rater agreement was measured over time.600 triage records were selected; 200 each from 2007, 2008 and 2010. Triage documentation that did not support parallel decision-making decreased significantly according to the year of presentation (2007; 112 (56%), 2008; 106 (53%), 2010; 13 (7%), P0.001). When parallel decision-making was facilitated by an improvement in triage documentation, there was improvement in matched triage scores (2007; 54%, 2008; 69%, 2010; 72%, P=0.01).The introduction of ETEK has had a significant impact in this ED, particularly when combined with education sessions. The use of the PPDT as a framework to guide documentation and triage language facilitated parallel decision-making and auditing, and led to an improvement in inter-rater agreement when applied to children.

OBJECTIVE To determine the effectiveness of an online module for reducing insulin administration errors by nurses caring for hospitalized pediatric patients. RESEARCH DESIGN AND METHODS Pediatric nursing staff completed a mandatory online educational module teaching insulin pharmacokinetics and the insulin order form, using diluted insulin and finishing with 15 interactive cases. A chart audit to determine all possible insulin errors of patients receiving insulin was done before and 2–6 months after the educational module. RESULTS All of the medical center's 283 pediatric nurses successfully completed the educational module. A total of 24 charts were audited in the preintervention phase and 22 in the postintervention phase. The preintervention insulin error rate was 14.8%, reduced to 1.7% (P < 0.001) postintervention. Improvement occurred in correct insulin dosing and type, timing of administration, and timely blood glucose monitoring and documentation. CONCLUSIONS An interactive online educational module can be an effective strategy for reducing pediatric nurses' insulin administration errors.

280 Background: The members of a network of community cancer centers affiliated with an academic medical center report following National Comprehensive Cancer Network (NCCN) guidelines. To determine guideline compliance, cisplatin regimens were audited. Cisplatin was selected because of its wide use, high emetic potential, and the impact on QOL for patients with unmanaged nausea and vomiting.The community cancer centers affiliated with an academic medical center report following National Comprehensive Cancer Network (NCCN) guidelines for treatment plans. To determine guideline compliance rates, cisplatin regimens were audited. Cisplatin was selected because of its wide use, high emetic potential, and the impact on QOL for patients with unmanaged nausea and vomiting. Methods: Prior to a chart audit, medical oncologists were surveyed on their knowledge of NCCN antiemesis guidelines, frequency of prescribing based on guidelines, and reasons for not using guidelines. Auditors identified patient charts through billing records and reviewed cycle 1 day 1 orders of cisplatin regimens. Secondary data was collected on hydration orders and home medications for antiemesis. Results: Guideline adherence varied from 0% to 76% with overall adherence at 28%. Dexamethasone doses ranged from 2-20 mg (guideline 12 mg) as did serotonin antagonists (5HT3) ordered at higher IV doses of 24-32 mg (guideline 8-16 mg). Conclusions: Although cancer centers report following the guidelines, this study did not find consistent adherence. The cancer center with the highest adherence rate works closely with a pharmacist and has built order sets with the guidelines. One cancer center had wide variances among practitioners. The variances increase the potential for error. The cancer center with lowest adherence rate used 10 mg doses of dexamethasone because the drug is delivered in 10 mg vials. This study identified multiple systems issues impacting guideline compliance. Managing nausea and vomiting is important for patient QOL and to manage costs by decreasing hospitalizations, treatment delays, and nutritional deficits. Understanding prescribing habits relative to guidelines provides an opportunity to change practice and reduce variability.

Background: Magnesium sulphate is a high-risk medication that is used extensively for prophylaxis and treatment of eclampsia. To accommodate recommendations related to fluid restrictions and patient safety, a proto col was developed for the administration of 20% magnesium sulphate. Objectives: To determine whether administration of 20% magnesium sulphate increased the risk of phlebitis relative to 2% to 8% magnesium sulphate solutions, to determine if the institution’s protocol for adminis tration of 20% magnesium sulphate reduced errors during administration, and to identify strategies to further reduce potential errors. Methods: A retrospective chart audit was undertaken for patients who had received magnesium sulphate for prophylaxis of eclampsia from December 2004 to December 2007. A failure mode and effect analysis was used to identify additional safety strategies. Results: A total of 47 patients received magnesium sulphate according to the old administration protocol (2% to 8% solution) and 29 according to the new protocol (20% solution). No evidence of phlebitis was documented for any of these 76 patients. A few errors occurred with changes in rates or concentrations and because of failure to reset the pump after the loading dose, but there was no documented harm to any of the patients. Strategies to further reduce errors in the administration of magnesium sulphate included development of preprinted orders, use of 20% magnesium sulphate for all infusion rates, changes to pump settings to enable use of fractional infusion rates, preparation of magnesium sulphate in mini-bags in the pharmacy, double-check of pump settings by nurses, anesthesiology consult, and distribution of protocols to all areas in the hospital (to limit errors associated with patient transfers). Conclusions: There was no documented phlebitis, and fewer errors occurred when 20% magnesium sulphate was used. Several additional strategies were identified to reduce errors in the administration of this high-risk medication.