Clinical profile and outcomes in cervical cancer: An audit from a tertiary cancer center

Background: Carcinoma cervix contributes to a major proportion of cancer treatment in tertiary oncology centers. The outcomes are dependent on multiple factors. We conducted an audit to establish the pattern of treatment practiced for carcinoma cervix at the institute and suggest changes thereof to improve the quality of care. Methodology: A retrospective observational study of 306 diagnosed cases of carcinoma cervix was carried out for the year 2010. Data was collected with regards to diagnosis, treatment, and follow-up. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20. Results: Out of 306 cases, 102 (33.33%) patients received only radiation therapy and 204 (66.66%) patients received concurrent chemotherapy. The most common chemotherapy used was weekly cisplatin 99 (48.52%), followed by weekly carboplatin 60 (29.41%) and three weekly cisplatin 45 (22.05%). Disease-free survival (DFS) at 5 years was 36.6% with patients of overall treatment time (OTT) of <8 weeks and >8 weeks showing DFS of 41.8% and 34% (P = 0.149), respectively. Overall survival (OS) was 34%. Concurrent chemoradiation improved overall survival by a median of 8 months (P = 0.035). There was a trend towards improved survival with three weekly cisplatin regimen, however, insignificant. Stage correlated with improved overall survival significantly with stage I and II showing 40% and stage III and IV showing 32% (P < 0.05) OS. Acute toxicity (grade I-III) was higher in the concurrent chemoradiation group (P < 0.05). Conclusion: This audit was a first of its kind in the institute and threw light on the treatment and survival trends. It also revealed the number of patients lost to follow-up and prompted us to review the reasons for it. It has laid the foundation for future audits and recognized the importance of electronic medical records in the maintenance of data

Content validation of an instrument for medical record audits / Validación de contenido de un instrumento para auditoría clínica de registros médicos / Validação de conteúdo de um instrumento para auditoria clínica de prontuários

ABSTRACT Objective: To build and validate the content of an instrument to conduct medical record audits; to conduct a pre-test. Methods: Methodological study conducted from May/2020 to May/2021 in three stages: 1) development of the instrument by bibliographic survey and benchmarking; 2) content validation using the Delphi technique; 3) application of the instrument and descriptive analysis in a sample of 200 medical records. Results: An instrument was constructed with 11 domains containing sub-items that characterize the quality of care. Two stages of the Delphi technique were necessary to reach a content validity index higher than 0.90. For each domain, a graduated scale with a numerical value from 1 to 4 points was attributed, reflecting the quality of its completion. The average time of application was 35 minutes per record. Conclusions: The tool proved to be viable to support clinical audits to identify the level of excellence and reveal opportunities for improvement in care processes.

RESUMEN Objetivo: Construir y validar contenido de un instrumento para realización de auditoría clínica de prontuarios; realizar pre-test. Métodos: Estudio metodológico, realizado de mayo/2020 a mayo/2021 en tres etapas: 1) construcción del instrumento por análisis bibliográfico y benchmarking; 2) validación de contenido por la técnica Delphi; 3) aplicación del instrumento y análisis descriptivo en una muestra de 200 prontuarios. Resultados: Construido un instrumento con 11 dominios conteniendo subitems que caracterizan la calidad de la asistencia. Para llegar al índice de validez de contenido superior a 0,90, fueron necesarias dos etapas de la técnica Delphi. Para cada dominio, atribuido una escala graduada con valor numérico de 1 a 4 puntos, reflejando la calidad del relleno. El tiempo mediano de aplicación fue de 35 minutos por prontuario. Conclusiones: El instrumento construido se demostró viable para basar la auditoría clínica en la identificación del nivel de excelencia o oportunidades de mejoría en procesos asistenciales.

RESUMO Objetivo: Construir e validar conteúdo de um instrumento para realização de auditoria clínica de prontuários; realizar pré-teste. Métodos: Estudo metodológico, realizado de maio/2020 a maio/2021 em três etapas: 1) construção do instrumento por levantamento bibliográfico e benchmarking; 2) validação de conteúdo pela técnica Delphi; 3) aplicação do instrumento e análise descritiva em uma amostra de 200 prontuários. Resultados: Construiu-se um instrumento com 11 domínios contendo subitens que caracterizam a qualidade da assistência. Para chegar ao índice de validade de conteúdo superior a 0,90, foram necessárias duas etapas da técnica Delphi. Para cada domínio, atribuiu-se uma escala graduada com valor numérico de 1 a 4 pontos, refletindo a qualidade do preenchimento. O tempo médio de aplicação foi de 35 minutos por prontuário. Conclusões: O instrumento construído demonstrou-se viável para embasar a auditoria clínica na identificação do nível de excelência ou oportunidades de melhoria em processos assistenciais.

Avaliação do rastreio de retinopatia diabética por meio de uma auditoria clínica em uma Unidade de Atenção Primária à Saúde rural no interior de Minas Gerais / Assessment of screening for diabetic retinopathy through a clinical audit in a rural primary health care unit in the interior of Minas Gerais / Evaluación de cribado de retinopatía diabética mediante auditoría clínica en una Unidad de Atención Primaria de Salud en la zona rural de Minas Gerais

Introdução: A retinopatia diabética é uma complicação do diabetes mellitus com grande impacto na saúde, mas seu diagnóstico por oftalmoscopia e a instituição do tratamento precoce comprovadamente reduzem a progressão para a perda visual. No território adscrito pela Unidade de Atenção Primária à Saúde (UAPS) onde realizou-se o presente estudo a equipe médica percebeu uma quantidade significativa de pessoas que não realizam fundo de olho periodicamente. Objetivo: Avaliar a taxa de pessoas adequadamente rastreadas quanto à retinopatia entre os diabéticos tipo 2 dessa localidade rural. Métodos: Este estudo consiste em um relato de experiência da realização de uma auditoria clínica para avaliar a taxa de rastreio de retinopatia entre diabéticos tipo 2 de uma UAPS. Para isso foi gerada uma planilha com os pacientes diabéticos de forma eletrônica pelo prontuário e-SUS, com posterior leitura de prontuário dos últimos dois anos em busca de menção à realização de oftalmoscopia. Resultados: O relatório gerou 3.736 cadastros ativos, dos quais 181 eram diabéticos. Destes, 156 foram selecionados para análise por serem comprovadamente diabéticos tipo 2. A taxa de rastreio nos últimos dois anos foi de 13,4%. Em 61,9% dos casos, a realização de fundoscopia foi realizada na própria UAPS. Conclusão: A auditoria clínica foi uma ferramenta útil para confirmar e delimitar a suspeita de baixa taxa de rastreio de retinopatia diabética. A realização de fundoscopia pelo médico de família e comunidade com treinamento foi uma estratégia que permitiu elevar essa porcentagem.

Introduction: Diabetic retinopathy is a complication of diabetes mellitus with a major impact on health, but its diagnosis through ophthalmoscopy and early treatment have been shown to reduce progression to visual loss. In the area assigned by the primary health care center where the present study was carried out, the medical team noticed a significant number of people who did not have a fundus examination periodically. Objective: To assess the rate of people adequately screened for retinopathy among those with type 2 diabetes in this rural location. Method: This study was an experience report of conducting a clinical audit to assess the rate of retinopathy screening among type 2 diabetics in a primary health care center. For this purpose, a spreadsheet with diabetic patients was generated electronically by the e-SUS record with subsequent reading of the record of the last two years in search of mentioning the performance of ophthalmoscopy. Results: The report generated 3736 active registrations, of which 181 were diabetic, of which, 156 were selected for analysis because they were proven to be type 2 diabetics. The screening rate in the last two years was 13.4%. In 61.9% of the cases, fundoscopy was performed at the primary health care center itself. Conclusion: The clinical audit was a useful tool in confirming and delimiting the suspicion of a low rate of screening for diabetic retinopathy. The accomplishment of fundoscopy by the trained family and community doctor was a strategy that allowed an increase in this percentage.

Introducción: La retinopatía diabética es una complicación de la diabetes mellitus con gran impacto en la salud, pero cuyo diagnóstico mediante oftalmoscopia y tratamiento precoz ha demostrado reducir la progresión a la pérdida visual. En el territorio asignado por la Unidad de Atención Primaria de Salud (UAPS) donde se realizó el presente estudio, el equipo médico detectó un número importante de personas que no realizan periódicamente un fondo de ojo. Objetivo: evaluar la tasa de personas adecuadamente cribadas para retinopatía entre los 87 diabéticos tipo 2 en esta zona rural. Método: Este estudio es un informe de experiencia de la realización de una auditoría clínica para evaluar la tasa de detección de retinopatía entre diabéticos tipo 2 en un Unidad de Atención Primaria de Salud. Para ello, se generó electrónicamente una hoja de cálculo con pacientes diabéticos mediante el registro e-SUS con posterior lectura del registro de los últimos dos años en busca de mencionar la realización de oftalmoscopia. Resultados: El informe generó 3736 registros activos, de los cuales 181 eran diabéticos, de estos, 156 fueron seleccionados para análisis porque se demostró que eran diabéticos tipo 2. La tasa de cribado en los últimos dos años fue del 13,4%. En el 61,9% de los casos la fondoscopia se realizó en la Unidad de Atención Primaria de Salud. Conclusión: La auditoría clínica fue una herramienta útil para confirmar y delimitar la sospecha de una baja tasa de cribado de retinopatía diabética. La realización de fondoscopia por parte del médico de familia y de la comunidad capacitado fue una estrategia que permitió incrementar este porcentaje.

Evaluation of perioperative mechanical prophylaxis of venous thrombosis in patients undergoing total knee and hip replacement and analysis of its obstacle factors / 中国实用护理杂志

Objective:To understand the current status of perioperative physical prevention of venous thrombosis in patients undergoing total knee and hip replacement and to analyze the barriers to clinical transformation of evidence and improve measures.Methods:Based on the evidence-based continued quality improvement model, then building a team, systematically searching, evaluating and summarizing evidences, establishing review indicators and review methods according to FAME principles (feasibility, appropriately, meanfulness, effectiveness), selecting patients undergoing total knee and hip replacement, nurses, and doctors who underwent total knee and hip replacement surgery from April 30 to August 31, 2020 in Shanxi Provincial People's Hospital as the review objects, and conducting a baseline review according to the review indicators one by one, and analyzing the obstacle factors and improvement measures based on the review results.Results:This study included 29 best evidences, and 17 review indicators were formulated based on the best evidences. Among them, the clinical compliance rate of 5 review indicators were greater than 80%, and the clinical compliance rate of 12 review indicators were less than 80%. The main obstacles were due to the imperfect venous thromboembolism (VTE) risk assessment and management process at the system level, and the low level of knowledge of VTE prevention and management among medical staff at the individual level.Conclusions:This study was based on the best evidences, scientifically and systematically developed clinical review indicators, rigorously and comprehensively analyzed obstacles, and constructed targeted improvement measures, not only for the future physical prevention of perioperative venous thrombosis in patients with total knee and hip replacement surgery transformation provides the basis but also can further promote clinical practice changes and continuous quality improvement.

Quest to Improve Management of Prostate Cancer in West Africa Development of a Clinical Audit Tool

In 2010 and during the following decade, two guidelines werepublished for the management of prostate cancer in West Africa.A key recommendation of the guidelines was the need for thedevelopment of a Clinical Audit Tool which should helpsurgeons and institutions to identify the gaps between therecommended standards and current practice. In this paper, aClinical Audit Tool, WAPCAT, was developed to facilitate andimplement the audit process for the management of Prostatecancer in a West African healthcare institution

A Clinical Audit and Impact of Interventions on Antibiotic Prescribing Practices at a Public Dental Primary Care Clinic

ABSTRACT@#Inappropriate antibiotic prescribing in dentistry has been widely reported but local studies are scarce. We aimed to evaluate antibiotic prescribing practices among dental officers in a public dental primary care clinic against current guidelines: specifically assessing the number, appropriateness, accuracy of prescriptions, type of antibiotics prescribed and repeated prescribing of the same type of antibiotics within a specific duration. A retrospective audit consisting of two cycles (1st cycle: July to September 2018, 2nd cycle: July to September 2019) was carried out by manually collecting relevant data of patients (aged 18 and above) who were prescribed antibiotics from carbon copies of prescription books. Between each cycle, various interventions such as education through a continuous professional development (CPD) session, presentation of preliminary findings and making guidelines more accessible to dental officers were implemented. When the 1st and 2nd cycles were compared, the number of antibiotic prescriptions issued reduced from 194 to 136 (–30.0%) whereas the percentage of appropriate prescriptions increased slightly by 4.1%. Inaccurate prescriptions in terms of dosage and duration decreased (–0.5% and –13.7%, respectively) whilst drug form and frequency of intake increased (+15.7% and +0.7%, respectively). Repeated prescribing of the same antibiotics by the same officer within a period of ≤6 weeks no longer occurred. Amoxicillin and metronidazole were most commonly prescribed in both cycles. Overall, the antibiotic prescribing practices did not closely adhere to current guidelines. However, clinical audit in conjunction with targeted interventions resulted in improvement in the antibiotic prescribing patterns. Thus, further intervention and re-audit is necessary.

Clinical audit on examination tools used by physical therapists in Metro Manila in examining conditions with neck pain

BACKGROUND@#Neck pain is considered the fourth leading cause of disability, with an annual prevalence rate of 15 to 30%. Using evidence-based practice in neck pain examination is a vital part of the rehabilitation process as it serves as a basis for determining the best treatment. The objective of the study is to determine the usage of recommended examination tool for neck pain among the physical therapists in selected hospitals and clinics in Metro Manila.@*METHODS@#The study has three distinct phases wherein phase 1 was the development and validation of a data extraction sheet, phase 2 was the assessment of interrater reliability among the investigators who will perform the chart review, and phase 3 was the chart review process. Descriptive statistics were used for data analysis.@*RESULTS@#In phase 1, the contents of the data extraction sheet were found to be valid. In phase 2, the inter-rater reliability was 96.7% percent. In phase 3, the visual analogue scale was the most commonly used examination tool, yielding a 54% usage. This was followed by cervical range of motion & cervical manual muscle testing (22%), palpation (15%), sensory testing (7%), postural assessment (6%), special test (4%), ocular inspection (2%), functional assessment (1%), Functional Index Measure (1%) and functional muscle testing (1%). Neck Disability Index, which was one of the literature-recommended examination tools, was not used@*CONCLUSION@#Visual analogue scale was the most commonly used examination tool in conditions with neck pain in selected hospitals and clinics in Metro Manila. Further investigation can be done in order to know the reasons for the use or nonuse of examination tools.

A importância dos registros de enfermagem no contexto avaliativo da auditoria / The importance of nursing records within the audit assessment context

Objetivo: Analisar a importância dos registros de enfermagem no contexto avaliativo da auditoria. Método: Trata-se de uma revisão integrativa da literatura realizada nas bases de dados LILACS, MEDLINE e BDENF, por meio dos descritores Auditoria de Enfermagem; Auditoria Clínica; Registros de Enfermagem; Anotações de Enfermagem e Enfermagem. A busca foi realizada de 12 de janeiro a 26 de fevereiro de 2018 e selecionados 17 artigos que compõem o estudo. Resultados: a importância dos registros de enfermagem no contexto avaliativo da auditoria se dá pela investigação da qualidade do cuidado prestado por meio das evidências proporcionadas nos registro/anotações de enfermagem no portuário do paciente, evitar prejuízos na continuação do cuidado, intensificar sugestões de implantações de valores educacionais por meio da educação continuada e permanente, resgatar os valores econômicos perdidos por glosas em contas hospitalares e promover a melhoria da qualidade da assistência. Conclusão: foi possível verificar que, mesmo sendo uma prática que deva ser realizada com qualidade, o processo de auditora ainda encontra muita fragilidade nas informações encontradas nos diversos registros do profissional de enfermagem, o que acarreta grandes prejuízos.

Objective: To analyze the importance of nursing records in the evaluative context of the audit. Method: This is an integrative literature review performed in the LILACS, MEDLINE and BDENF databases using the descriptors Nursing Audit; Clinical audit; Nursing records; Nursing and Nursing Notes. The search was performed from January 12 to February 26, 2018, selecting a total of 17 articles. Results: the importance of nursing records in the evaluative context of the audit is due to the investigation of the quality of care provided through the evidence provided in the nursing records/annotations in the patient's chart, avoiding losses in the continuation of care, intensifying suggestions for implantation of nursing care, educational values through continuing and continuing education, recovering the economic values lost by disallowances in hospital bills and promoting the improvement of the quality of care. Conclusion: it was possible to verify that, even though it is a practice that should be performed with quality, the audit process still finds a lot of fragility in the information found in the various records of the nursing professional, which causes great losses.

A Clinical Audit – Magnetic Resonance Imaging Knee Image Acquisition Adequacy

Objective: The objective of the study was to evaluate the adequacy of magnetic resonance imaging (MRI) scans of knee, performed at the Radiology Department of Dr. D Y Patil Medical College, Hospital and Research Centre, Pimpri, Pune, according to the American College of Radiologist guidelines. Type of Study: This study was a clinical audit. Place and Duration of Study: This study was conducted at Dr. D Y Patil Medical College, Hospital and Research Centre, Pimpri, Pune, from January 2018 to July 2018. Materials and Methods: Retrospective study of approximate 40 patients who underwent MRI of knee in January 2018 for assessment of the quality of images obtained in the initial audit. Depending on the results of this first audit, a suggestion was made and reaudit was done 6 months later in July 2018 to look for improvement quality in local practice. Results: In the initial audit, images were acquired in all the three necessary planes and the sagittal and coronal images had appropriate slice thickness as well as adequate anatomical coverage in all the patients. However, field of view (FOV) was inappropriately set in 34% of cases in axial plane, 90% in sagittal plane, and 95% in coronal plane. Furthermore, the anatomical coverage was not up to the mark in axial plane with 13 studies (66%) having adequate superior coverage, and 16 cases (80%) having recommended inferior anatomical coverage. The reaudit performed 6 months later showed improvement with 100% compliance to standards. Conclusion: Initially, the first audit showed few lackings in acquiring of MRI knee images specifically with FOV to reduce the decrease in all planes and slight increase in anatomical coverage in the axial plane. These shortcomings and recommendations were made in departmental meetings and reaudit was done after 6 months. This reaudit showed 100% compliance.

A prospective closed loop audit on the quality of the operative notes in a general surgical unit in a quaternary care centre

Background: Proper documentation of the surgery done in the form of operative notes is a very important aspect of surgical practice. The aim of this clinical audit was to identify the existing standard of the operative notes written in a general surgical unit in a quaternary care hospital; and to compare it with the recommendations given by Royal College of Surgeons, England (in Good Surgical Practice, 2014) and if needed, to improve the standard of practice.Methods: In the first loop of this prospective audit, 75 consecutive operative notes which were written were compared with the RCS guidelines and the areas which had missing data were identified. These areas were informed to the residents, who are primarily involved in the documentation of the operative notes. The second loop of the audit was conducted after a gap of 4 months involving 75 consecutive operative notes again.Results: The areas which were initially deficient were better documented when analysed in the second loop.Conclusions: Documentation of operative notes does not always comply with the set guidelines as highlighted in the first loop of our audit. But by employing a clinical audit it is possible to identify the existing deficiencies and thereby improving the standards of practice. Also, operative note writing should be taught as part of surgical training. Definitions should be clearly provided, and specific guidelines should be established to improve the quality of the operative notes and their use to improve patient safety.

Survey on the rationality and standardization of clinical oxygen therapy in a general hospital in Shanghai / 中华全科医师杂志

Objective@#To survey the current status of oxygen therapy in a comprehensive hospital in Shanghai and to assess its rationality and standardization.@*Methods@#Cluster sampling method was adopted in selecting in-patients who received oxygen therapy from various departments in Changhai Hospital from March 2018 to June 2018. General information such as gender, age, and department were recorded. The self-developed Oxygen Therapy Form for Inpatients was used to collect clinical data such as admission diagnosis, oxygen therapy indications, oxygen therapy orders, and related parameters. BTS guideline for Oxygen use in adults in Health care and Emergency Settings was used to assess the rationality and standardization of oxygen therapy.@*Results@#In this survey, 464 patients were assessed for their oxygen treatment orders. According to the guidelines, the overall reasonable rate of oxygen therapy was 92.2% (428/464); the standardization rate of oxygen therapy was 22.4% (104/464). Among them, the reasonable rate of oxygen therapy in internal medicine ward (64.7%, 46/71) was lower than that in surgery ward (98.3%, 304/309) and in wards of other specialties (92.8%, 78/84) (χ2=91.09, P<0.01); while the reasonable rate of general ward (90.9%, 362/398) was lower than that of ICU (100.0%, 66/66) (χ2=6.47, P<0.05). In the standardization assessment, the wards of other specialties (54.8%, 46/84) were better than the internal medicine ward (26.8%, 19/71) and the surgery ward (12.6%, 39/309) (χ2=68.35, P<0.01); while the ICU (65.2%, 43/66) was superior to the general ward (15.3%, 61/398) (χ2=80.81, P<0.01).@*Conclusions@#The rationality of oxygen therapy in the general hospital is acceptable, but the standardization needs to be improved. There are some differences in the rationality and standardization of oxygen therapy orders among different departments and different levels of wards.

Clinical audit on outcome measures used in examination of knee osteoarthritis in selected hospitals and clinics in the Philippines

BACKGROUND@#Knee osteoarthritis is a degenerative joint disease affecting the aging Filipino population. Outcome measure tools are used to assess a patient’s health status for the quality of care improvement. With the increasing prevalence of knee osteoarthritis, it warrants the need to conduct a clinical audit to identify the most common outcome measure tools used by Filipino Physical Therapists.@*OBJECTIVES@#To determine the outcome measure tools used by Filipino Physical Therapists in assessing knee osteoarthritis in hospitals and clinics and compare it to the current global standard of assessment.@*METHODS@#A retrospective record audit study design was used to determine the current assessment tool compared with standards of assessment.@*RESULTS@#Of the 45 of 285 charts reviewed, 80% were females and 73.33%, aged older than 60 years. The following were examination tools used by Physical Therapists: In Subjective; a. pain score (97.77%), b Functional status (80%), and c. stiffness ( 4.44%). In Objective; a. ocular inspection and palpation(97.77% ), b. range of motion and manual muscle testing (93.33%), c. posture ( 48.89%), d. special testsB (33.33%), e. gait analysis ( 71.11%), and f. Functional assessment ( 91.11%). Physical Therapists did not use Western Ontario and McMaster Universities Osteoarthritis (WOMAC), Visual Analog Scale (VAS), Short Form-36 (SF-36), and Knee Injury and Osteoarthritis Outcome Score ( KOOS) outcome measures for assessing knee osteoarthritis.@*CONCLUSION@#Physical Therapists did not use standardized outcome measure tools in the assessment for knee osteoarthritis. Thus, the study shows the gap in the assessment for knee osteoarthritis in the Philippines and global standards.

The accuracy of the Manchester Triage System in an emergency service / Precisión del Sistema de Triaje Manchester en un servicio de emergencia / Acurácia do Sistema de Triagem de Manchester em um serviço de emergência

ABSTRACT Objective: To verify the accuracy of the Manchester Triage System (MTS) and the outcomes of adult patients in an emergency hospital service. Method: Cross-sectional study, conducted through an inspection of records of risk classification of adult patients treated in the emergency service of a hospital. Results: The patients (n = 400) were classified according to priority levels, in red (0.8%), orange (58.2%), and yellow (41.0%). The accuracy levels between auditors and nurses were substantial for the flowchart (K = 0.75), and moderate for discriminating factors (k = 0.46) and priority levels (k = 0.42). The accuracy of the MTS was 68.8% with regard to priority levels. Regarding outcomes, 60% of patients were discharged, 37% were transferred to other units, and 3% died. Conclusion: The MTS proved to be a good predictor of the assessed outcomes, showing that 65.9% of Low Urgency patients progress to discharges, and 3.8% of High Urgency patients progress to death. The accuracy of the MTS was moderate, which suggests the need to implement inspections in emergency services.

RESUMEN Objetivo: Verificar la precisión del Sistema de Triaje Manchester (STM) y los resultados de pacientes adultos en un servicio de emergencia en un hospital. Método: estudio transversal, realizado a través de un proceso de auditoría de registros de detección con clasificación de riesgo de pacientes adultos tratados en un servicio hospitalario de emergencia. Resultados: Los pacientes (n = 400) se clasificaron según el nivel de prioridad en rojo (0.8%), naranja (58.2%) y amarillo (41.0%). Niveles de flujo de trabajo entre auditores y enfermeras (K = 0.75), moderados para discriminadores (k = 0.46) y nivel de prioridad (k = 0.42). La precisión del STM fue del 68.8% en el nivel de prioridad. En cuanto a los resultados, el 60% de los pacientes fueron dados de alta, el 37% fueron transferidos a otras unidades, el 3% falleció. Conclusión: El STM demostró ser un buen predictor de los resultados evaluados, mostrando que el 65.9% de los pacientes de baja urgencia progresa al alta y el 3.8% de los pacientes de alta urgencia progresa a la muerte. La precisión del STM fue moderada, lo que sugiere la necesidad de implementar auditorías en los servicios de emergencia.

RESUMO Objetivo: Verificar a acurácia do Sistema de Triagem de Manchester (STM) e os desfechos dos pacientes adultos em um serviço de emergência hospitalar. Método: Estudo transversal, realizado por meio de um processo de auditoria dos registros de triagem com classificação de risco de pacientes adultos atendidos em um serviço de emergência hospitalar. Resultados: Os pacientes (n=400) foram classificados de acordo com o nível de prioridade em Vermelho (0,8%), Laranja (58,2%) e Amarelo (41,0%). A confiabilidade entre os auditores e enfermeiros foi substancial para fluxograma (K=0,75), moderada para discriminador (k=0,46) e nível de prioridade (k=0,42). A acurácia do STM foi de 68,8% no nível de prioridade. Em relação aos desfechos avaliados, 65,9% dos pacientes de Baixa Urgência evoluíram para alta, e 3,8% dos pacientes de Alta Urgência evoluíram para óbito. Conclusão: A acurácia do STM foi moderada. O STM se mostrou um bom preditor dos desfechos avaliados, evidenciando que a maioria dos pacientes de Baixa Urgência evoluem para alta, e 3,8% dos pacientes de Alta Urgência evoluem para óbito.

A study of cesarean section rate by using modified Robson's ten group classification system

Background: High caesarean section rate worldwide including India is matter of concern. The Robson’s Ten-group classification system allows critical analysis of caesarean deliveries according to characteristics of pregnancy. The objective was to analyze caesarean section rates in a tertiary care centre according to Modified Robson’s ten groups classification.Methods: This retrospective study was conducted at GMERS Gotri Medical College, Vadodara, Gujarat, India. All patients who delivered between August 2018 and March 2019, were included in the study. Women were classified in 10 groups according to modified Robson’s classification using their maternal characteristics and obstetric history. For each group, authors calculated the caesarean section rate within the group and its absolute and relative contribution to the overall caesarean rate.Results: Total number of delivery in my study institute in 8 months was 1531 out of them 456 was cesarean section, so the overall caesarean section rate was 29.78%. The main contributions to overall caesarean rate was 40.78% by group 5 (previous CS, singleton, cephalic, >37weeks) followed by 14.25% by group 1 (nullipara, singleton, cephalic, >37 weeks, spontaneous labour), 11.40% by group 2 (nullipara, singleton, cephalic,>37 weeks, induced or CS before labour). CS rates among various group ranges from 100% among women with abnormal lie (group 9) to 98.4% in previous CS (group 5), 84% in nulliparous breech (group 6), 58% in multiparous breech (group 7) and least 8.2% in multipara spontaneous labour (group 3).Conclusions: The Robson’s classification is easy to use. It is time to implement obstetric audit to lower the overall CS rates.

Audit of caesarian deliveries in a tertiary care center, in rural Bangalore, India

Background: The Robson’s Ten-Group Classification System allows critical analysis of caesarean deliveries according to characteristics of pregnancy. The objective was to analyze caesarean section rates in a rural tertiary care teaching hospital in Bangalore, using Robson’s ten groups classification.Methods: This study was done in MVJ Medical College and Research Hospital, a rural tertiary care teaching hospital. All patients who underwent caesarean delivery, between November 2017 and October 2018, were included in the study. Women were classified in 10 groups according to Robson’s classification. For each group, authors calculated its relative contribution to the overall caesarean rate.Results: The overall caesarean section rate was 46.7%. The main contributors to this high caesarean rate were primiparous women in spontaneous labour (group 1) and women with previous caesarean section (group 5).  52.1% of CS were conducted on women who were unbooked or booked at a peripheral health facility and referred to present institution due to complications in labor. Strategies to lower CS rates would include encouraging women with previous CS, to undergo trial of labor to reduce CS rates for group 5C. Sensitization of staff in peripheral medical facilities for early referral of high-risk pregnancies to a tertiary care center for better control of medical complications like hypertensive disorders of diabetes mellitus. Other strategies include offering external cephalic version to eligible women with breech presentation and consider offering vaginal breech delivery to suitable women in groups 6 and 7.Conclusions: The Robson’s classification is easy to use. It is time to implement obstetric audit to lower the overall CS rates.

Multi-Faceted Intervention to Improve the Antibiotic Prescriptions among Doctors for Acute URI and Acute Diarrhoea Cases: The Green Zone Antibiotic Project

@#Background: Antimicrobial resistance is a global problem that is perpetuated by the inappropriate use of antibiotics among doctors. This study aims to assess the antibiotic prescription rate for patients with acute upper respiratory infection (URI) and acute diarrhoea. Methods: A completed clinical audit cycle was conducted in 2018 in the busy emergency department of a public hospital in Malaysia. Pre- and post-intervention antibiotic prescription data were collected, and changes were implemented through a multifaceted intervention similar to Thailand’s Antibiotics Smart Use programme. Results: Data from a total of 1,334 pre-intervention and 1,196 post-intervention patients were collected from the hospital’s electronic medical records. The mean (SD) age of participants was 19.88 (17.994) years. The pre-intervention antibiotic prescription rate was 11.2% for acute diarrhoea and 29.1% for acute URI, both of which are above the average national rates. These antibiotic prescription rates significantly reduced post-intervention to 6.2% and 13.7%, respectively, falling below national averages. Antibiotic prescription rate was highest for young children. There were no significant changes in rates of re-attendance or hospital admission following the intervention. Conclusion: The multifaceted intervention, which included continuing medical education, physician reminders and patient awareness, was effective in improving the antibiotic prescription rates for these two conditions.

Clinical Audit of Sexual Abuse Referral Forms to the Sexual Assault Follow-up and Evaluation Clinic, Nassau, The Bahamas, among Females Aged 13 to 19 Years / Auditoría clínica de los formularios de remisión de abuso sexual a la Clínica de Evaluación y Seguimiento de Agresiones Sexuales, Nassau, Bahamas, entre mujeres de 13 a 19 años

ABSTRACT Objective: To evaluate the adequacy of the documentation of referral forms for sexually abused females aged 13-19 years directed to the Sexual Assault Follow-up and Evaluation (SAFE) Clinic at the Agape Family Medicine Clinic, Nassau, The Bahamas, for interim management. Methods: An approved review was performed on 123 referral forms regarding sexually abused females aged 13-19 years who attended the SAFE Clinic from 2011 to 2015. The exercise focussed on documentation adequacy based on a scoring system developed by the researchers (> 50% was assessed to be adequate; records of the referee's disposition of the patient, the date of the incident and evidence of sexually transmitted infection (STI) screening were considered vital for adequacy). Descriptive and inferential statistics were calculated. Results: The median age of the participants was 14 years (interquartile range: 13-15). Of the 63.4% (78) with documented nationality, 88.5% (69) were Bahamian and 11.5% (9) Haitian. Documentation status did not differ statistically significantly by nationality. Regarding documentation, 74% (91) recorded the name of the patient's school, 59.3% (73) recorded that the patient knew the assailant and 17.9% (22) indicated that the patient did not know the assailant, while 22.8% (28) did not document this latter information. Type of sexual penetration was indicated by 65.9% (81). Of the vital variables, 18.7% (23) recorded the referee's disposition of the patient, 29.8% (36) the date of the incident and 60.2% (74) evidence of STI screening; 7.3% (9) documented all three and 22.8% (28) two. The mean percentage of documentation for vital variables was 49.3% (± 3.6) for the Accident and Emergency (A&E) Department, Princess Margaret Hospital, Nassau, versus 30.5% (± 4.0) for public health clinics (PHCs) (p = 0.001). Overall, 69.9% (86 of 123) of the referral forms were deemed inadequate: 64.7% (33 of 51) from the A&E Department versus 73.4% (47 of 64) from PHCs among the 115 patients who provided referral information. Conclusion: Documentation deficiencies of the sexual abuse referral forms demand reform. Complete and consistent documentation is required.

RESUMEN Objetivo: Evaluar la idoneidad de la documentación de los formularios de remisión para mujeres de 13 a 19 años sexualmente abusadas, dirigidas a la Clínica de Evaluación y Seguimiento de Agresiones Sexuales (ESAS) en la Clínica Ágape de Medicina Familiar, Nassau, Bahamas, para la administración interina. Métodos: Se aprobó una revisión para examinar 123 formularios de remisión con respecto a las mujeres de 13 a 19 años sexualmente abusadas, que asistieron a la clínica de ESAS de 2011 a 2015. El ejercicio se centró en la idoneidad de la documentación basada en un sistema de puntuación desarrollado por los investigadores (50% fue adecuado según la valoración; los registros de la disposición de la paciente en el arbitraje, la fecha del incidente y la evidencia del tamizaje de la infección de transmisión sexual (ITS), fueron todos vitales a la hora de determinar la idoneidad). Se calcularon las estadísticas descriptivas e inferenciales. Resultados: La edad promedio de las participantes fue 14 años (rango intercuartil: 13-15). De 63.4% (78) con nacionalidad documentada, el 88.5% (69) fueron bahameñas y el 11.5% (9) haitianas. El estado de la documentación en término de las estadísticas no difirió significativamente por nacionalidad. Con respecto a la documentación, el 74% (91) registró el nombre de la escuela de la paciente, 59.3% (73) registró que la paciente conocía al agresor, y el 17.9% (22) indicó que la paciente no conocía al agresor, mientras que el 22.8% (28) no documentó esta última información. El tipo de penetración sexual fue indicado por 65.9% (81). De las variables vitales, 18.7% (23) registró la disposición de la paciente en el arbitraje, 29.8% (36) la fecha del incidente, y el 60.2% (74) evidencia del tamizaje de las ITS; 7.3% (9) documentó tres de ellas y 2.8% (28) dos. El porcentaje medio de documentación de las variables vitales fue 49.3% (± 3.6) para el Departamento de Accidentes y Emergencias (A&E), Hospital Princess Margaret, Nassau, frente al 30.5% (± 4.0) de las clínicas de salud pública (CSP) (p = 0.001). En general, el 69.9% (86 de 123) de los formularios de referencia se consideró inadecuado: 64.7% (33 de 51) del Departamento de A&E frente al 73.4% (47 de 64) de las CSP entre las 115 pacientes que proporcionaron la información de la remisión. Conclusión: Las deficiencias de la documentación de los formularios de remisión de abuso sexual exigen reformas. Se requiere una documentación completa y consistente.

Auditoría de historias clínicas: una herramienta de evaluación de la calidad asistencial. Hospital Pediátrico - Centro Hospitalario Pereira Rossell / Auditing medical records: a tool to evaluate the quality of medical care. Pediatric Hospital - Pereira Rossell Hospital / Auditoria do prontuário médico do paciente: uma ferramenta de avaliação da qualidade assistêncial. Hospital Pediátrico Pereira Rossell

Resumen: Introducción: la auditoría médica es el análisis crítico y sistemático del proceso de atención que incluye los procedimientos diagnósticos y terapéuticos, el uso de los recursos y los resultados de los mismos. Disponer de un sistema de auditoría constituye un instrumento de mejora continua de la calidad asistencial. Objetivo: evaluar la calidad de las historias clínicas (HC) de los niños hospitalizados. Material y método: estudio de corte transversal mediante revisión de HC de niños egresados de áreas de cuidados moderados de un centro de referencia entre el 1º de enero y el 31 de diciembre de 2015. Variables analizadas: datos patronímicos, cuadrícula, curvas de crecimiento, antecedentes socioeconómicos, ingresos, evolución, prescripción, transcripción, diagnóstico al egreso, resumen de egreso. Se establecieron tres categorías: suficiente puntaje mayor o igual a 80%, aceptable 60%-79%, insuficiente <60%. Se analizó la calidad de las HC en función de la edad, estadía hospitalaria, diagnóstico al egreso y estación del año. Se realizó un muestreo aleatorio (prevalencia esperada de error 50%, precisión 5%, poder 80%) (N=385 HC). Se consideró significativa p <0,05. Resultados: de las 385 HC analizadas, 52% (202) correspondieron a varones, mediana de edad: 3 meses. Fueron suficientes 17%, aceptables 49,6% e insuficientes 33,4%. Las HC suficientes predominaron en menores de 1 año (21,5% vs 14%) y con estadía menor o igual de 3 días (21% vs 11%) p <0,05. Las HC insuficientes predominaron en invierno (43% vs 29%, p <0,05). Conclusión: es necesario profundizar en el estudio de estos resultados mediante un análisis cualitativo. Resulta necesario implementar un sistema de auditoría de HC continuo y avanzar en el desarrollo de los registros electrónicos para mejorar la gestión clínica.

Summary: Introduction: medical audits involve critical and systematic analysis of the medical care process, diagnostic and therapeutic procedures, the use of resources and the results obtained. Auditing systems provide tools for quality continuous improvement. Objective: to assess the quality of medical records (HMR) of hospitalized children. Material and methods: HMR cross-sectional study of of children discharged from moderate care units at a reference hospital center between January 1 and December 31, 2015. Analyzed Variables: patients' personal data, grids, growth curves, socio-economic background, admissions, evolution, prescription, transcription, diagnosis at discharge, discharge Report 3 categories were devised: Sufficient score greater or equal 80%, Acceptable 60-79%, Insufficient < 60%. HMR's quality was analyzed by age, hospitalization time, diagnosis at discharge and season of the year. Random sampling was carried out (expected error prevalence 50%, accuracy 5%, power 80%) (N=385). P < 0,05 was considered significant. Results: Out of 385 HMRs analyzed, 52% (202) were boys, median age 3 months-old. 17% were sufficient, 49.6% were acceptable and 33.4% were insufficient. Sufficient HMRs were predominant in children of less than 1 year-old (21,5% vs 14%) which had a hospitalization time of less or equal 3 days (21% vs 11%) p<0.05. Insufficient HMRs were predominant in Winter (43% vs 29%. p<0.05). Conclusion: A qualitative analysis is needed in order to reinforce the analysis of these results. It is important to implement a continuous HMR auditing system in order to make progress regarding the development of electronic records as a tool to improve the clinical management systems.

Resumo: Introdução: a auditoria médica é a análise crítica e sistemática do processo de cuidado da saúde, e inclui procedimentos diagnósticos e terapêuticos, o uso de recursos e seus resultados. Ter um sistema de auditoria é um instrumento para melhoria contínua da qualidade do cuidado da saúde. Objetivo: avaliar a qualidade dos prontuários eletrônicos das crianças hospitalizadas. Métodos: estudo transversal do Prontuário Eletrônico do Paciente (PEP) de pacientes descarregados das áreas de cuidado moderado dum centro de referência entre 1 de janeiro e 31 de dezembro de 2015. As variáveis analisadas foram: dados pessoais dos pacientes, curvas de crescimento, antecedentes socioeconômicos, renda, evolução, prescrição, transcrição, diagnóstico e resumo no momento da alta hospitalar. Três categorias foram estabelecidas: Escore Suficiente maior ou igual 80%, Aceitável 60-79%, Insuficiente <60%. A qualidade do PEP foi analisada em quanto à idade, permanência hospitalar, diagnóstico na alta e estação do ano. Foi realizada uma amostragem aleatória (prevalência esperada de erro de 50%, precisão de 5%, poder de 80%) (N = 385 PEP). Considerou-se significativo p <0,05. Resultados: dos 385 PEP analisados, 52% (202) foram do sexo masculino, e a mediana da idade 3 meses. Suficientes 17%, Aceitáveis 49,6% e Insuficientes 33,4%. Os PEP foram suficientes maiormente nas crianças menores de 1 ano (21,5% vs. 14%) e que tinham permanecido menor ou igual 3 dias no hospital (21% vs. 11%) p <0,05. Os PEP foram Insuficientes maiormente no inverno (43% vs. 29%, p <0,05). Conclusão: é necessário aprofundar o estudo desses resultados através de uma análise qualitativa. Se deve implementar um sistema contínuo de auditoria de PEP e avançar no desenvolvimento dos Prontuários Eletrônicos para melhorar o gerenciamento clínico dos hospitais.

Clinical audit of intensive care unit admission relating to hypertensive disorders of pregnancy / 中华围产医学杂志

Objective To assess the current practice in managing hypertensive disorders of pregnancy (HDP) and provide possible interventions to improve the quality of care.MethodsA checklist was developed based on Chinese Medical Association's guideline on HDP. A criteria-based audit was conducted on 66 HDP patients who were admitted to the Intensive Care Unit (ICU) of Nanjing Drum Tower Hospital,The Affiliated Hospital of Nanjing University Medical School between January 1, 2014 and December 31, 2016. The quality of care during antepartum and hospitalized period were evaluated, and patient factors were also considered. We also collected data on patients' demographics, complications of HDP, acute physiology and chronic health evaluation (APACHE)Ⅱ score and duration of hospital stay.T or Mann-WhitneyU test orChi-square test was performed. Results(1) From 2014 to 2016, the number of deliveries in Nanjing Drum Tower Hospital was 18573, with 1561 cases (8.4％) of HDP. Among the 66 cases being audited, 44 (66.7％) were preeclampsia; 16 (24.2％) were preeclampsia complicated by chronic hypertension; six (9.1％) were eclampsia; no maternal death was reported. (2) Complications of HDP in this study included heart failure (17 cases, 25.8％), hemolysis, elevated liver enzyme levels, low platelet count (HELLP) syndrome (15 cases, 22.7％), anemia and/or thrombopenia requiring transfusion (12 cases, 18.2％), renal dysfunction (seven cases, 10.6％), eclampsia (six cases, 9.1％), pulmonary edema/acute respiratory distress syndrome (five cases, 7.6％), placenta abruption (four cases, 6.1％), cerebral venous and sinus thrombosis (two cases, 3.0％), cerebral hemorrhage (one case, 1.5％) and hepatic rupture (one case, 1.5％). Their APACHEⅡ score was 9.0±3.9. The duration of ICU and hospital stay was 2 (1-30) d and 8 (4-32) d, respectively. (3) Compared with the gravidas who registered during antenatal care, those without registrations were older [(33.0±6.0) vs (29.1±5.4) years old,t=-2.616], having less antenatal visits [2 (0-4) vs 5 (2-10) times, Z=110.000] and higher blood pressure on admission [(177.0±24.1) vs (155.5±24.6) mmHg of systolic blood pressure (t=-3.322), and (116.4±14.6) vs (108.0±18.7) mmHg of diastolic blood pressure (t=-3.013, 1 mmHg=0.133 kPa)], and only a few of them were nulliparas [23.8％(5/21) vs 71.1％(32/45),χ2=13.006] (all P<0.05). (4) Among the 66 cases, seven (10.6％) had preeclampsia history, but none of them received aspirin for HDP prevention; 21 (31.8％) did not have regular testing of blood pressure during antenatal check; 24 (36.4％) did not receive proper antenatal evaluation when hypertension was identified. (5) After excluding 20 cases directly admitted upon the first diagnosis of HDP, the rest 46 were managed in the outpatient department. Eighteen of them (39.1％) did not have blood pressure monitoring and 26 of them (56.5％) did not have a regular test of hemoglobin, platelet, urine protein, liver or renal function. (6) Twenty-nine gravidas (43.9％) suffered a delay in referral or admission. (7) All gravidas received magnesium sulphate administration. Thirty-three cases with severe hypertension (systolic blood pressure≥160 mmHg or diastolic blood pressure≥110 mmHg) were given antihypertensive drugs with satisfactory blood pressure control. Thirty-six cases with living fetus (26-34+6 gestational weeks) received antenatal dexamethasone. Termination of pregnancy was delayed in three cases after admission.ConclusionsThe management of HDP is not good enough in patients' education, screening for high-risk population, early diagnosis and antenatal care. Quality improvement efforts should be focused on strengthening patient education, training of doctors in primary and secondary hospitals, implementing protocols on antepartum care of preeclampsia and establishing a referral system for patients with severe obstetric complications.

Promoting clinical audit for severe maternal morbidity cases through early prevention / 中华围产医学杂志

The implementation of multidisciplinary clinical audit for cases with severe maternal morbidity is an important way to reduce preventable maternal death. We encourage using screening indicators and additional clinical criteria, especially professional review, to identify real critical case which is potentially improved and then trigger clinical audit. Whatever methods and processes we will take, it is time to start. Further investigations are needed to develop standardized process for facility-based clinical audit, and to provide evidence for updates of guidelines and public health policies.