RESUMO
Patient positioning, using "anti-deformity positioning," is a standard practice in burn rehabilitation to assist with edema management, scar contracture prevention, and wound healing. Consistently providing proper positioning requires the combined effort of the multidisciplinary burn team. Our primary goal was to increase the frequency that patients were correctly positioned to over 90%. At a medium-sized, academic burn unit, random audits were conducted by burn lead therapists on the compliance of proper patient positioning over six months. Using this data as a trigger, a quality improvement project was designed using the PDSA (Plan-Do-Study-Act) cycle. Surveys were distributed to therapy and nursing staff to identify barriers to proper positioning. Effects on positioning compliance post-intervention were monitored. In the six months prior to intervention, average correct positioning was 76%. Surveys identified the following barriers to care: nursing needed more education and the approach was too heavily reliant on nursing efforts alone. To address this, therapists provided education to all nurses, communicated daily about positioning expectations, shifted the project to a multidisciplinary approach, and made changes in therapy workflow. The median compliance improved from 79% to 91% (p < 0.05). Coordinating efforts of the entire burn team improves consistency for positioning in burn patients. Utilizing the PDSA cycle allowed us to identify areas for improvement and develop appropriate interventions to increase education for nursing staff and workflow improvements for therapists. Following the completion of our interventions we were able to obtain an immediate improvement in our patient positioning compliance.
RESUMO
OBJECTIVES: To study non-tolerance to spectacle prescriptions in a busy community optometric practice, with several practitioners. METHODS: A spectacle non-tolerance was defined in a pragmatic way, as a patient who had collected spectacles from the practice and subsequently returned because they were either having problems with, or were unable to wear, their new spectacles. Patients over 16 years of age, who met the above definition of non-tolerance were sequentially recruited over a 6 month period. Patients experiencing adaptation problems were first seen by a dispensing optician and any dispensing issues resolved. If the spectacle dispensing was felt to be correct, or if the non-tolerance persisted, then the patient was re-examined by an optometrist and the results analysed. RESULTS: Non-tolerance examinations accounted for 62 of the 3091 eye examinations during the study period. The average rate of non-tolerance, averaged across the practitioners, was 1.8%, varying from 1.3-3.3% for individual practitioners. Gender was not a factor in non-tolerance, however age was, with presbyopes accounting for 88.1%. The most common reasons for non-tolerance were, in order of decreasing frequency: prescription related (61.0%), dispensing related (22.0%), pathology (8.5%), data entry error (6.8%) and binocular vision anomalies (1.7%). Of prescription related errors, gauging the spherical element accounted for the majority of inaccuracies, followed by problems with the near/intermediate addition. In every case, the final prescription was within 1.00 D of the not tolerated, prescription; 84.4% were within +/-0.50 D. CONCLUSIONS: Spectacle prescription non-tolerance forms a small, but important, form of adverse reaction in optometric clinics. Most non-tolerances can be resolved by small changes, within 0.50 D, to the prescription.