What did audit achieve? Lessons from preliminary evaluation of a year's medical audit.

OBJECTIVE--To evaluate the experience of a year''s audit of care of medical inpatients. DESIGN--Audit of physicians by monthly review of two randomly selected sets of patients'' notes by 12 reviewers using a detailed questionnaire dedicated to standards of medical records and to clinical management. Data were entered into a database and summary statistics presented quarterly at audit meetings. Assessment by improvement in questionnaire scores and by interviewing physicians. SETTING--1 District general hospital. PARTICIPANTS--About 40 consultant physicians, senior registrars, and junior staff dealing with 140 inpatient records. MAIN OUTCOME MEASURES--Median scores (range 1 to 9) for each item in the questionnaire; two sets of notes were discussed monthly at "general" audit meetings and clinical management of selected common conditions at separate monthly meetings. RESULTS--A significant overall increase in median scores for questions on record keeping occurred after the start of the audit (p less than 0.01), but interobserver variation was high. The parallel audit meetings on clinical management proved to be more successful than the general audits in auditing medical care and were also considered to be more useful by junior staff. CONCLUSIONS AND ACTION--Medical audit apparently resulted in appreciable improvements in aspects of care such as clerking and record keeping. Analysis of the scores of the general audits has led to the introduction of agreed standards that can be objectively measured and are being used in a further audit, and from the results of the audits of clinical management have been developed explicit guidelines, which are being further developed for criterion based audit.     

Cost of urology: financial audit in a clinical department.

OBJECTIVES--To cost a clinical unit over one month in 1991, to cost treatment of individual patients from audit data, and to compare this costing method with the hospital charging system. DESIGN--A financial breakdown was obtained for one month''s work. Ward stay, operating time, investigations, and outpatient visits were costed and a formula (episode = days on ward+hours of operating+investigations+outpatient visits) was used to cost patient episodes from audit data. SETTING--The adult urology unit in a teaching hospital. MAIN OUTCOME MEASURES--Costs for each part of patients'' treatment. RESULTS--Total cost was 147,796 pounds for 159 admissions, 738 inpatient days, 131 operations in 29 operating lists, and 615 outpatient visits. An uncomplicated transurethral prostatectomy cost 1140 pounds but complications increased this to 1500 pounds in another patient. The costs of diagnostic cystoscopy were 130 pounds in outpatients, 240 pounds in day surgery, and 430 pounds in inpatients. Hospital charges do not reflect the individual costs of treatment, charges being greater than costs for some patients and lower than costs for others. CONCLUSIONS--Clinicians can produce a financial analysis of their work and cost their patients'' treatment. Audit is strongly advocated as a resource planning tool.     

Community surveillance of complications after hernia surgery.

OBJECTIVE--To assess the effect of a programme of postoperative community surveillance on the rate of detection of wound complications after operation for inguinal hernia. DESIGN--Prospective audit of wound complications including complications recorded in case notes and those discovered by community surveillance. SETTING--Academic surgical unit of three consultant surgeons. PATIENTS--510 patients undergoing elective inguinal hernia repair between June 1985 and August 1989. RESULTS--The wound infection rate recorded in the hospital notes was 3% compared with 9% when additional information was obtained from community surveillance. Wound complications were detected in 143 (28%) patients by community surveillance compared with a complication rate of 7% in the case records for the same patients. CONCLUSIONS--Wound complications are common after clean surgery in patients discharged home early. Complication rates are a reflection not only of the standards of surgical practice but also the rigour with which they are sought. Before national comparative audit data are published the method of collection must be standardised. For short stay surgery this should include meaningful community surveillance.     

Audit of a surgical firm by microcomputer: five years' experience

From 1982 to 1986 inclusive work of one surgical firm was audited with a microcomputer. Data were recorded on 4336 patients having 3355 operations, who were under the care of one consultant in a general surgical unit; fifty items of information were recorded on each patient, allowing a wide range of analyses to be performed—for example, the number of admissions and operations, grades of operation, diagnostic grouping, complications, and complication rates associated with individual surgeons. Data collected for the audit provided a valuable baseline for the unit, defining aspects of practice that could be reviewed and improved. During the audit the overall rate of complications as a percentage of admissions fell significantly from 13% to 9% and the rate of postoperative complications decreased significantly from 16% in 1982 to 11% in 1986. The incidence of chest and wound infections also decreased significantly. The system was improved by using the data to produce discharge summaries as well as audit; the microcomputer thus became an integral part of the office work of the unit.     

PAIR FORMATION AND PAIR MAINTENANCE IN THE REDSHANK TRINGA TOTANUS

The percentage (45.6%) of colour-marked Redshanks which return to Banks Marsh NNR retain the pair from the previous year. whilst 6.9% of the previous year's pairs separate and take new mates. In 29.8%, of the previous year's pairs only the male returns and in 17.7%, only the female returns. Usually pairs are established by the male performing a display flight and pair maintenance is facilitated by means of an alighting ceremony. Two main peaks occur in the performance of these displays which are associated with two physiological groups within the population. early and late breeders.     

Audit of amniocentesis from a district general hospital: is it worth it?

OBJECTIVE--To audit all mid-trimester amniocenteses performed by obstetricians at a district general hospital to see whether experience improved the outcome. DESIGN--Retrospective review of medical records. SETTING--Royal Gwent Hospital, south Wales. SUBJECTS--All 469 amniocenteses carried out in 1985-7. OUTCOME MEASURES--Number of attempts at withdrawal of amniotic fluid; number with bloodstained liquor; and number of subsequent miscarriages, terminations, and congenital abnormalities. RESULTS--Of the 469 amniocenteses, 411 were performed by one obstetrician, and initial comparisons with those performed by the rest of the hospital team showed no significant differences in outcome of pregnancy. The main difference between the two groups was in the number of attempts at withdrawal of amniotic fluid and the number with bloodstained liquor. The single obstetrician failed to obtain amniotic fluid on 1% of occasions compared with 10% for the other operators by the end of the second attempt. The costs of carrying out the audit were considerable. The review of fewer than 500 case records cost the equivalent of 2000 pounds in staff time and took over 200 hours to complete, equivalent to 63 sessions of one person''s time. CONCLUSIONS--The audit was useful in that it provided information on complication rates, which could be compared with published data, and comparisons between obstetricians who perform large and small numbers of procedures. IMPLICATIONS--For an individual''s practice the monitoring of amniocentesis should not be continuously carried out and subsequent audits should tackle other common procedures. When an audit is attempted the health service should provide adequate support to clinicians for this purpose.     

A total audit of preventive procedures in 45 practices caring for 430,000 patients.

OBJECTIVE--To develop and report the results of a system of audit of computer records in general practice. DESIGN--A retrospective audit of records in practices using the same computer system. Information about recorded preventive procedures was collected by sending the same audit program to each practice on floppy disk. Other characteristics of the practices were determined by postal questionnaire. SETTING--Forty five general practices, widely distributed in England and Wales. SUBJECTS--All 430,901 patients registered with the practices. MAIN OUTCOME MEASURES--Within each practice the percentage of patients in specified age groups for whom certain preventive procedures were recorded as having been carried out. These measures were analysed in relation to practice characteristics. RESULTS--Practice characteristics and recording rates for preventive procedures varied over a wide range. Recording rates were higher in practices with computer terminals on every doctor''s desk. Only one practice achieved the new contract target of 90% coverage for recorded primary immunisations, and fewer than two thirds recorded 80% coverage for cervical cytology in the past five years. Practices holding clinics did no better than those without. Smaller partnerships and smaller doctors'' list sizes were associated with better performance. CONCLUSIONS--Centrally programmed audit of computerised records is a feasible method of providing data on a regular basis for epidemiological purposes and for performance review. The fact that practices with smaller list sizes had higher levels of recorded preventive care suggests that the trend towards larger lists promoted by the new contract might militate against the intended effect of better preventive care.     

Will operate for food.

After spending 15 years in university, Dr. Robert Patterson recently received the right to write FRCSC after his name, and then began to look for gainful employment as a general surgeon. It was a long and frustrating search. He recounts how he finally found work in northern Alberta, and wonders if next year''s residents will encounter the same shortage of opportunities that he discovered.     

Informal complaints procedure in general practice: first year's experience.

OBJECTIVE--To evaluate the first year''s experience of an informal patient complaints system that encourages extensive patient participation. DESIGN--Audit of an informal complaints procedure. SETTING--The Marylebone Health Centre, London. SUBJECTS--39 complaints received over the audit period. MAIN OUTCOME MEASURES--Types of complaints (administrative, about doctors or medical care or both, staff about patients, mixed, other) and resolution of complaints (how complaints were dealt with and their resolution). RESULTS--37 of the 39 complaints were resolved within two weeks. Two complaints sent direct to the family health services authority were resolved (with patients'' agreement) by the informal complaints procedure. CONCLUSIONS--The informal complaints procedure was more cost effective than the family health services authority system and was comparatively straightforward to implement within the practice without major organisational restructuring. The two way process of the procedure ensured patients received a quick response to complaints and helped morale of health centre staff.     

The role of brain scanning in the differential diagnosis of seizures

Of 200 patients with seizures who had brain scans, the studies were abnormal in 86% of patients with tumours and in 67% of those with strokes. The scan detected 84% of the 19 potentially curable lesions. There were no false positive studies. Seventy-nine per cent of patients with seizures of less than one year''s duration had an abnormal scan; however, the scan was also abnormal in 22% of patients with non-focal seizures of less than one year''s duration.     

Renal Failure in Acute Pancreatitis

In three patients with acute pancreatitis complicated by renal failure recovery followed dialysis and treatment of associated complications. The records of cases of pancreatitis treated at Addenbrooke''s Hospital, Cambridge, suggest that renal failure is a grave and not infrequent complication of acute pancreatitis.     

Trauma services requirements in a district general hospital serving a rural area.

OBJECTIVE--To assess the demands made on a regional trauma centre by a district trauma unit. DESIGN--Two part study. (1) Prospective analysis of one month''s workload. (2) Retrospective analysis of one year''s workload by using a computer based records system. Comparison of two sets of results. SETTING--Accident unit in Gwynedd Hospital, Bangor. PATIENTS--(1) All patients who attended the accident unit in August 1988. (2) All patients who attended the accident unit in the calendar year April 1988-April 1989. MAIN OUTCOME MEASURE--Workload of a district trauma unit. RESULTS--In August 1988 there were 2325 attendances; 2302 of these were analysed. In all, 1904 attendances were for trauma; 213 patients were admitted to the trauma ward and 103 required an operation that entailed incision. Patients who attended the unit had a mean (range) injury severity score of 2-13 (0-25). Only two patients had injuries that a district general hospital would not be expected to cope with (injury severity score greater than 20). In the year April 1988-April 1989, 21,007 patients attended the unit. In all, 17,958 attendances were for orthopaedic injuries or injuries caused by an accident; 1966 patients were admitted to the unit. CONCLUSIONS--Most trauma is musculoskeletal and relatively minor according to the injury severity score. All but a few injuries can be managed in district general hospitals. In their recent report the Royal College of Surgeons has overestimated the requirements that a British district general hospital would have of a regional trauma centre.     

Surgical audit: Comparison of the work load and results of two hospitals in the same district.

Surgical audit is being undertaken to monitor and compare (by computer) the type of patient, work load, and results of two similar surgical units. Both units are in the City and Hackney District of London, one at St Bartholomew''s Hospital and the other at Hackney Hospital. During 1978, 736 patients were admitted by the unit at St Bartholomew''s Hospital and 902 by the unit at Hackney. At St Bartholomew''s 70% of admissions were elective compared with 49% at Hackney, where 86% of patients lived within the district compared with only 36% at St Bartholomew''s. The wound was the commonest site for complications, infection affecting 9% of those at Hackney and 6% at St Bartholomew''s, despite identical antibiotic policies. There were six post-operative deaths at St Bartholomew''s and 32 at Hackney. In both hospitals the length of stay was similar, 50% of patients being discharged within one week and 80% within two weeks. As a result of the audit a vigorous venous thrombosis prophylactic regimen has been instituted, and at Hackney the anaesthetic department has been strengthened and a new intensive care unit opened.     

Auditing audits: use and development of the Oxfordshire Medical Audit Advisory Group rating system.

OBJECTIVES--To assess the value of the Oxfordshire Medical Audit Advisory Group rating system in monitoring and stimulating audit activity, and to implement a development of the system. DESIGN--Use of the rating system for assessment of practice audits on three annual visits in Oxfordshire; development and use of an "audit grid" as a refinement of the system; questionnaire to all medical audit advisory groups in England and Wales. SETTING--All 85 general practices in Oxfordshire; all 95 medical audit advisory groups in England and Wales. MAIN OUTCOME MEASURES--Level of practices'' audit activity as measured by rating scale and grid. Use of scale nationally together with perceptions of strengths and weaknesses as perceived by chairs of medical audit advisory groups. RESULTS--After one year Oxfordshire practices more than attained the target standards set in 1991, with 72% doing audit involving setting target standards or implementing change; by 1993 this had risen to 78%. Most audits were confined to chronic disease management, preventive care, and appointments. 38 of 92 medical audit advisory groups used the Oxfordshire group''s rating scale. Its main weaknesses were insensitivity in assessing the quality of audits and failure to measure team involvement. CONCLUSIONS--The rating system is effective educationally in helping practices improve and summatively for providing feedback to family health service authorities. The grid showed up weakness in the breadth of audit topics studied. IMPLICATIONS AND ACTION--Oxfordshire practices achieved targets set for 1991-2 but need to broaden the scope of their audits and the topics studied. The advisory group''s targets for 1994-5 are for 50% of practices to achieve an audit in each of the areas of clinical care, access, communication, and professional values and for 80% of audits to include setting targets or implementing change.     

Between Difference and Belonging: Configuring Self and Others in Inpatient Treatment for Eating Disorders

Dedicated inpatient care for eating disorders has profound impact on patients'' embodied practices and lived realities. Analyses of inpatients'' accounts have shown that participants endorse complex and conflicting attitudes toward their experiences in eating disorders wards, yet the apparent ambivalence that characterizes inpatient experiences has not been subject to critical examination. This paper examines the narrated experiences of 13 participants (12 women and one man; age 18–38 years at first interview) with past or present anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified, who had been hospitalized in an inpatient eating disorders ward for adults in central Israel. The interviews, which took place in 2005–2006, and again in 2011, were part of a larger longitudinal study exploring the subjective experiences of eating disorders and recovery among Israeli adults. Employing qualitative analysis, this study finds that the participants'' accounts were concerned with dynamics of difference and belonging, as they played out in various aspects of inpatient care, including diagnosis, treatment, relationships with fellow patients and staff, and everyday life in hospital. Notably, participants simultaneously defined themselves as connected to, but also distinct from, the eating disordered others who formed their reference group at the ward. Through negotiating a protectively ambivalent positioning, participants recognized their eating disordered identities and connected with others on the ward, while also asserting their non-disordered individuality and distancing themselves from the potential dangers posed by ‘excessive’ belonging. The paper suggests that this ambivalent positioning can usefully be understood through the anthropological concept of liminality: being both a part of and apart from one''s community.     

Survey of "do not resuscitate" orders in a district general hospital.

OBJECTIVE--To evaluate the local use of written "Do not resuscitate" orders to designate inpatients unsuitable for cardiopulmonary resuscitation in the event of cardiac arrest. DESIGN--Point prevalence questionnaire survey of inpatients'' medical and nursing records. SETTING--10 acute medical and six acute surgical wards of a district general hospital. PARTICIPANTS--Questionnaires were filled in anonymously by nurses and doctors working on the wards surveyed. MAIN OUTCOME MEASURES--Responses to questionnaire items concerning details about each patient, written orders not to resuscitate in the medical case notes and nursing records, whether prognosis had been discussed with patients'' relatives, whether a "crash call" was perceived as appropriate for each patient, and whether the "crash team" would be called in the event of arrest. RESULTS--Information was obtained on 297 (93.7%) of 317 eligible patients. Prognosis had been discussed with the relatives of 32 of 88 patients perceived by doctors as unsuitable for resuscitation. Of these 88 patients, 24 had orders not to resuscitate in their medical notes, and only eight of these had similar orders in their nursing notes. CONCLUSIONS--In the absence of guidelines on decisions about resuscitation, orders not to resuscitate are rarely included in the notes of patients for whom cardiopulmonary resuscitation is thought to be inappropriate. Elective decisions not to resuscitate are not effectively communicated to nurses. There should be more discussion of patients'' suitability for resuscitation between doctors, nurses, patients, and patients'' relatives. Suitability for resuscitation should be reviewed on every consultant ward round.     

Audit of major colorectal and biliary surgery to reduce rates of wound infection.

OBJECTIVE--To reduce the rates of wound infection for major colorectal and biliary surgery. DESIGN--Prospective audit of antibiotic prophylaxis by keeping copies of typed notes of operations and annotating them at discharge and at first follow up visit and annual review of prophylactic regimen according to yearly rate of wound infection and modification if necessary. SETTING--The work of one consultant surgeon working in a district general hospital. PATIENTS--All patients having major colorectal resection during 1976-89 (400) and cholecystectomy during 1981-9 (500). MAIN OUTCOME MEASURES--Wound infection, defined as any discharge from the wound as detected by observation during inpatient stay and by specific questioning at the first follow up visit six weeks later. RESULTS--Serial changes in prophylaxis for colorectal surgery resulted in a progressive reduction in the rate of wound infection from 43% in 1976, with no prophylaxis, to 1% during 1986-9 with single intravenous doses of metronidazole and cefuroxime intraoperatively and with lavage of the peritoneal cavity and wound with 0.1% tetracycline. During 1981-7, with no prophylaxis, the rate of infection in biliary surgery was 12% whereas in 1988-9, after the introduction of lavage with tetracycline alone, the rate was reduced to 2%. IMPLICATIONS AND ACTION--Simple prospective audit identified the need for changes in antibiotic prophylaxis; successive rounds of audit resulted in improved rates of wound infection, and lavage with 0.1% tetracycline seemed to be a major factor in achieving this.     

Ecoinformatics Reveals Effects of Crop Rotational Histories on Cotton Yield

Crop rotation has been practiced for centuries in an effort to improve agricultural yield. However, the directions, magnitudes, and mechanisms of the yield effects of various crop rotations remain poorly understood in many systems. In order to better understand how crop rotation influences cotton yield, we used hierarchical Bayesian models to analyze a large ecoinformatics database consisting of records of commercial cotton crops grown in California''s San Joaquin Valley. We identified several crops that, when grown in a field the year before a cotton crop, were associated with increased or decreased cotton yield. Furthermore, there was a negative association between the effect of the prior year''s crop on June densities of the pest Lygus hesperus and the effect of the prior year''s crop on cotton yield. This suggested that some crops may enhance L. hesperus densities in the surrounding agricultural landscape, because residual L. hesperus populations from the previous year cannot continuously inhabit a focal field and attack a subsequent cotton crop. In addition, we found that cotton yield declined approximately 2.4% for each additional year in which cotton was grown consecutively in a field prior to the focal cotton crop. Because L. hesperus is quite mobile, the effects of crop rotation on L. hesperus would likely not be revealed by small plot experimentation. These results provide an example of how ecoinformatics datasets, which capture the true spatial scale of commercial agriculture, can be used to enhance agricultural productivity.     

Long-term Anticoagulant Therapy after Myocardial Infarction in Women

A multicentre trial from five medical departments in Oslo has been carried out to determine the value in women patients of one year''s long-term anticoagulant therapy. Follow-up long-term laboratory control and anticoagulant dosage were performed at one centre (the Rikshospitalet). One hundred and fifty-nine patients were assigned randomly into two similar well-matched groups (control and treatment). Dosage was controlled by Thrombotest, aiming at 10–20% levels, and 50% of the tests were less than 14%. Compared with the control group, the treatment group showed a significant reduction in mortality and in reinfarction rate. No serious bleeding complications occurred. It is concluded that women benefit as much as men from long-term anticoagulant therapy.