Results of the IROCA international clinical audit in prostate cancer radiotherapy at six comprehensive cancer centres.

To assess adherence to standard clinical practice for the diagnosis and treatment of patients undergoing prostate cancer (PCa) radiotherapy in four European countries using clinical audits as part of the international IROCA project. Multi-institutional, retrospective cohort study of 240 randomly-selected patients treated for PCa (n = 40/centre) in the year 2015 at six European hospitals. Clinical indicators applicable to general and PCa-specific radiotherapy processes were evaluated. All data were obtained directly from medical records. The audits were performed in the year 2017. Adherence to clinical protocols and practices was satisfactory, but with substantial inter-centre variability in numerous variables, as follows: staging MRI (range 27.5-87.5% of cases); presentation to multidisciplinary tumour board (2.5-100%); time elapsed between initial visit to the radiation oncology department and treatment initiation (42-102.5 days); number of treatment interruptions ≥ 1 day (7.5-97.5%). The most common deviation from standard clinical practice was inconsistent data registration, mainly failure to report data related to diagnosis, treatment, and/or adverse events. This clinical audit detected substantial inter-centre variability in adherence to standard clinical practice, most notably inconsistent record keeping. These findings confirm the value of performing clinical audits to detect deviations from standard clinical practices and procedures.

Inflammatory bowel disease integral care units: Evaluation of a nationwide quality certification programme. The GETECCU experience.

BACKGROUND: One of the most valued targets in inflammatory bowel disease (IBD) is for physicians to provide and patients to receive a high-level quality of care. This study aimed to evaluate the implementation of a nationwide quality certification programme for IBD units. METHODS: Identification of quality indicators (QI) for IBD Unit certification was based on Delphi methodology that selected 53 QI, which were subjected to a normalisation process. Selected QI were then used in the certification process. Coordinated by GETECCU, this process began with a consulting round and an audit drill followed by a formal audit carried out by an independent certifying agency. This audit involved the scrutiny of the selected QI in medical records. If 80%-90% compliance was achieved, the IBD unit audited received the qualification of "advanced", and if it exceeded 90% the rating was "excellence". Afterwards, an anonymous survey was conducted among certified units to assess satisfaction with the programme for IBD units. RESULTS: As of January 2021, 66 IBD units adhere to the nationwide certification programme. Among the 53 units already audited by January 2021, 31 achieved the certification of excellence, 20 the advanced certification, and two did not obtain the certification. The main survey results indicated high satisfaction with an average score of 8.5 out of 10. CONCLUSION: Certification of inflammatory bowel disease units by GETECCU is the largest nationwide certification programme for IBD units reported. More than 90% of IBD units adhered to the programme achieved the certification.

Current process and outcomes of the surgical management of LUTS due to benign prostatic enlargement: how consistent are we? - results from the multi-institutional audit of surgical management of BPE (AuSuM BPE) in the United Kingdom.

OBJECTIVE: In view of changing landscape of surgical treatment for LUTS secondary to BPE, this audit was undertaken to assess key aspects of the processes and outcomes of the current interventional treatments for BPE, across different units in the UK. MATERIALS AND METHOD: A multi-institutional snapshot audit was conducted for patients undergoing interventions for LUTS/BPE over 8-week period. Using Delphi process two-part proforma was designed to capture data. RESULTS: 529 patients were included across 20 NHS trusts in England and Wales. Median age was 73 years. Indications for surgery were acute retention (47%) and LUTS (45%). 80% of patients had prior medical therapy. TURP formed the commonest procedure. 27% patients had <23 hour hospital stay. Immediate (21%) and delayed (18%) complications were Clavien-Dindo <2 category. High proportion of patients reported residual symptoms. Type and indication of surgery were significant predictor of complications, length of stay and failure of TWOC outcomes, on multivariate analyses. There were variations in departmental processes, 50% centres used PROMs. CONCLUSION: Monopolar TURP still remains the commonest intervention for BPE. Most departments are adopting newer technologies. The audit identified opportunities for development of consistent, effective and patient centric practices as well as need for large-scale focused studies.

Reducing the knowledge to action gap in hospital nutrition care - Developing and implementing nutritionDay 2.0.

BACKGROUND & AIMS: In hospital nutrition care the difficulty of translating knowledge to action often leads to inadequate management of patients with malnutrition. nutritionDay, an annual cross-sectional survey has been assessing nutrition care in healthcare institutions in 66 countries since 2006. While initial efforts led to increased awareness of malnutrition, specific local remedial actions rarely followed. Thus, reducing the Knowledge-to-action (KTA) gap in nutrition care requires more robust and focused strategies. This study describes the strategy, methods, instruments and experience of developing and implementing nutritionDay 2.0, an audit and feedback intervention that uses quality and economic indicators, feedback, benchmarking and self-defined action strategies to reduce the KTA gap in hospital nutrition care. METHODS: We used an evidence based multi-professional mixed-methods approach to develop and implement nutritionDay 2.0 This audit and feedback intervention is driven by a Knowledge-to-Action framework complemented with robust stakeholder analysis. Further evidence was synthesized from the literature, online surveys, a pilot study, World Cafés and individual expert feedback involving international health care professionals, nutrition care scientists and patients. RESULTS: The process of developing and implementing nutritionDay 2.0 over three years resulted in a new audit questionnaire based on 36 nutrition care quality and economic indicators at hospital, unit and patient levels, a new action-oriented feedback and benchmarking report and a unit-level personalizable action plan template. The evaluation of nutritionDay 2.0 is ongoing and will include satisfaction and utility of nutritionDay 2.0 tools and short-, mid- and long-term effects on the KTA gap. CONCLUSION: In clinical practice, nutritionDay 2.0 has the potential to promote behavioural and practice changes and improve hospital nutrition care outcomes. In research, the data generated advances knowledge about institutional malnutrition and quality of hospital nutrition care. The ongoing evaluation of the initiative will reveal how far the KTA gap in hospital nutrition care was addressed and facilitate the understanding of the mechanisms needed for successful audit and feedback. TRIAL REGISTRATION: Registration in clinicaltrials.gov: Identifier: NCT02820246.

Calcium daily intake and the efficacy of a training intervention on optimizing calcium supplementation therapy: A clinical audit.

BACKGROUND AND AIMS: Calcium is an essential element for human health, with key roles in the prevention and therapy of multifactorial conditions. Calcium dietary intake is often insufficient in the general population. The aim of this study was to perform a clinical audit for general practitioners (GPs) to understand the efficacy of training intervention on doctors' awareness about dietary calcium and supplements. METHODS AND RESULTS: General practice outpatients were enrolled (Before Clinical Audit, BCA) from the same sanitary district, and calcium dietary intake was evaluated with a validated questionnaire, also collecting information about the consumption of calcium and vitamin D supplements. Then, a training intervention with a frontal lesson and discussion with GPs involved was performed. After one month of this intervention, a second outpatient enrolment was performed (Post Clinical Audit, PCA) in the same general practices to evaluate differences in nutritional suggestions and supplement prescription by GPs. In BCA, the calcium dietary intake was low, with nobody reaching 1000 mg as suggested by the guidelines. Only 6.6% and 24.5% took calcium and vitamin D supplements, respectively; in the PCA, these percentages increased to 28% and 78% for calcium and vitamin D supplements, respectively (p < 0.01 PCA vs BCA). There were no differences in calcium dietary intake between BCA and PCA. CONCLUSION: Training intervention on GPs was successful to sensitize them regarding calcium intake problems; GPs tended to increase the prescription of supplements but not to suggest changes in dietary habits.

Translating Evidence-Based Guidelines into Practice-Are We Getting It Right? A Multi-Centre Prospective International Audit of Nutrition Care in Patients with Foregut Tumors (INFORM).

Malnutrition is highly prevalent in patients with foregut tumors comprising head and neck (HNC) and esophageal (EC) cancers, negatively impacting outcomes. International evidence-based guidelines (EBGs) for nutrition care exist; however, translation of research evidence into practice commonly presents considerable challenges and consequently lags. This study aimed to describe and evaluate current international nutrition care practices compared with the best-available evidence for patients with foregut tumors who are at high risk of malnutrition. A multi-centre prospective cohort study enrolled 170 patients commencing treatment of curative intent for HNC (n = 119) or EC (n = 51) in 11 cancer care settings in North America, Europe and Australia between 2016 and 2018. Adherence criteria were derived from relevant EBG recommendations with pooled results for participating centres reported according to the Nutrition Care Model at either system or patient levels. Adherence to EBG recommendations was: good (≥80%) for performing baseline nutrition screening and assessment, perioperative nutrition assessment and nutrition prescription for energy and protein targets; moderate (≥60 to 80%) for utilizing validated screening and assessment tools and pre-radiotherapy dietitian consultation; and poor (60%) for initiating post-operative nutrition support within 24 h and also dietetic consultation weekly during radiotherapy and fortnightly for 6 weeks post-radiotherapy. In conclusion, gaps in evidence-based cancer nutrition care remain; however, this may be improved by filling known evidence gaps through high-quality research with a concurrent evolution of EBGs to also encompass practical implementation guidance. These should aim to support multidisciplinary cancer clinicians to close evidence-practice gaps throughout the patient care trajectory with clearly defined roles and responsibilities that also address patient-reported concerns.

Appropriateness of trimethoprim as empiric treatment for cystitis in 15-55 year-old women: an audit.

AIM: To assess whether trimethoprim remains an appropriate empiric treatment for uncomplicated cystitis in women 15-55 years old. METHODS: General practitioners in Auckland, Nelson-Marlborough, Otago and Southland were invited to participate in this audit of current practice. Participating general practitioners were asked to submit urine to the laboratory for microscopy and culture from any woman aged 15-55 years presenting with uncomplicated cystitis. Urine samples submitted as part of the audit were identified by a "copy to" code. Data on laboratory results were extracted from the laboratory information system. RESULTS: Data were collected from June 2016 to August 2018. Four hundred and eighty-one samples were submitted, of which 340 (70.7%) met the inclusion criteria of the audit. A urinary pathogen was identified in 181 (53.2%) specimens, of which 148 (81.8%) were E. coli, 13 (7.2%) other coliforms and 20 (11.0%) Staphylococcus saprophyticus. Of the E. coli isolates, 109 of 148 (73.6%, 95% CI 66.6-80.7) were susceptible to trimethoprim, 144 of 144 (100%, 95% CI 100-100) to nitrofurantoin and 143 of 148 (96.6%, 95% CI 93.7-99.5) to cefalexin. Of the urinary pathogens, 139 of 185 (75.1%, 95% CI 68.9-81.4) were susceptible to trimethoprim, 164 of 177 tested (92.7%, 95% CI 88.8-96.5) to nitrofurantoin and 166 of 178 tested (93.3%, 95% CI 89.6-96.9) to cefalexin. Overall, a uropathogen resistant to trimethoprim was detected in 13.5%, to nitrofurantoin in 3.8%, and to cefalexin in 3.5% of samples tested. CONCLUSION: Similar rates of resistance to trimethoprim were seen in women 15-55 years old presenting with cystitis compared with unselected samples submitted from the general community. Given the high rates of resistance, trimethoprim is no longer appropriate as an empiric treatment option for cystitis in this group. Nitrofurantoin or cefalexin are appropriate alternative empiric treatment options. Given the current recommendation that a urine sample should not be submitted to the laboratory from women with uncomplicated cystitis, ongoing audits will be required to ensure that empiric treatment recommendations remain appropriate.

The landscape of psoriasis provision in the UK.

Psoriasis remains one of the commonest conditions seen in dermatological practice, and its treatment is one of the greatest cost burdens for the UK National Health Service. Treatment of psoriasis is complex, with numerous overlapping lines and therapies used in combination. This complexity reflects the underlying pathophysiology of the disease as well as the heterogeneous population that it affects. National Institute for Health and Care Excellence (NICE) guidance for the treatment of psoriasis has been available since 2013, and has been the subject of three national audits conducted by the British Association of Dermatologists. This report synthesizes the results of the most recent of those exercises and places it in the context of the NICE guidance and previous audits. It clearly shows the significant burden of disease, issues with provision of services and long waiting times and the marked shift in therapies towards targeted biologic therapies.

Use of Direct Oral Anticoagulants Versus Traditional Therapies for Acute Venous Thromboembolism After Direct Discharge From the Emergency Department or After Hospitalization: An Audit of 16 Canadian Hospitals.

PURPOSE: This study compares and describes the use of direct oral anticoagulants (DOACs) versus traditional therapies (parenteral anticoagulant with or without warfarin) for acute venous thromboembolism (VTE) between individuals discharged directly from the emergency department (ED) versus those hospitalized. This study also reports patterns based on discharge from an academic, community, or rural-based site. METHODS: This retrospective medical records study included patients discharged with acute VTE (2015-2016) from 16 institutions across 4 provinces. Patients with atypical clots, other indications for anticoagulants, or an anticipated lifespan <3 months or those who were pregnant or breastfeeding were excluded. FINDINGS: Overall, 590 individuals (30.0%) discharged from the ED and 809 (53.8%) discharged after hospitalization were studied. Hospitalized patients were significantly older, had more comorbidities (cancer, pulmonary disease, and heart failure), and were more likely to have pulmonary embolism than deep vein thrombosis. DOAC use was significantly higher in the ED cohort versus the hospitalized cohort (51.4% vs 44.3%; P < 0.004) and more common for those having lower risk of pulmonary embolisms (simplified Pulmonary Embolism Severity Index score of 0 compared with ≥1) in the ED (58.0% and 26.5%; P < 0.0001) and hospitalized cohorts (57.1% and 35.7%; P < 0.0001). Use of DOACs was lowest in academic settings (46.2%) and highest in rural sites (56.7%). Follow-up patterns were different, with specialists and VTE clinics being most common in academic sites and family physicians being most common in rural practices. IMPLICATIONS: DOACs were used in less than half of all patients, with more use in EDs and rural sites. Follow-up patterns (VTE clinic or specialist vs family physician) varied and likely contributed to therapy selection. Over time, use of DOACs is likely to increase, and patient factors (eg, those younger with fewer comorbidities) and health care contact (eg, place of discharge or availability of an ambulatory VTE clinic) will likely continue to influence practice patterns.

Safety and Efficacy of an On-Site Intensive Treatment Protocol for Mild and Moderate Sympathomimetic Toxicity at Australian Music Festivals.

INTRODUCTION: Serotonin and sympathomimetic toxicity (SST) after ingestion of amphetamine-based drugs can lead to severe morbidity and death. There have been evaluations of the safety and efficacy of on-site treatment protocols for SST at music festivals. PROBLEM: The study aimed to examine the safety and efficacy of treating patients with SST on-site at a music festival using a protocol adapted from hospital-based treatment of SST. METHODS: The study is an audit of presentations with SST over a one-year period. The primary outcome was need for ambulance transport to hospital. The threshold for safety was prospectively defined as less than 10% of patients requiring ambulance transport to hospital.The protocol suggested patients be treated with a combination of benzodiazepines; cold intravenous (IV) fluid; specific therapies (cyproheptadine, chlorpromazine, and clonidine); rapid sequence intubation; and cooling with ice, misted water, and convection techniques. RESULTS: One patient of 13 (7.7%) patients with mild or moderate SST required ambulance transport to hospital. Two of seven further patients with severe SST required transport to hospital. CONCLUSIONS: On-site treatment may be a safe, efficacious, and efficient alternative to urgent transport to hospital for patients with mild and moderate SST. The keys to success of the protocol tested included inclusive and clear education of staff at all levels of the organization, robust referral pathways to senior clinical staff, and the rapid delivery of therapies aimed at rapidly lowering body temperature. Further collaborative research is required to define the optimal approach to patients with SST at music festivals.

A Collaborative Multicenter QI Initiative to Improve Antibiotic Stewardship in Newborns.

OBJECTIVES: To determine if NICU teams participating in a multicenter quality improvement (QI) collaborative achieve increased compliance with the Centers for Disease Control and Prevention (CDC) core elements for antibiotic stewardship and demonstrate reductions in antibiotic use (AU) among newborns. METHODS: From January 2016 to December 2017, multidisciplinary teams from 146 NICUs participated in Choosing Antibiotics Wisely, an Internet-based national QI collaborative conducted by the Vermont Oxford Network consisting of interactive Web sessions, a series of 4 point-prevalence audits, and expert coaching designed to help teams test and implement the CDC core elements of antibiotic stewardship. The audits assessed unit-level adherence to the CDC core elements and collected patient-level data about AU. The AU rate was defined as the percentage of infants in the NICU receiving 1 or more antibiotics on the day of the audit. RESULTS: The percentage of NICUs implementing the CDC core elements increased in each of the 7 domains (leadership: 15.4%-68.8%; accountability: 54.5%-95%; drug expertise: 61.5%-85.1%; actions: 21.7%-72.3%; tracking: 14.7%-78%; reporting: 6.3%-17.7%; education: 32.9%-87.2%; P < .005 for all measures). The median AU rate decreased from 16.7% to 12.1% (P for trend < .0013), a 34% relative risk reduction. CONCLUSIONS: NICU teams participating in this QI collaborative increased adherence to the CDC core elements of antibiotic stewardship and achieved significant reductions in AU.

Implementation of a model of care for hospitalised older persons with cognitive impairment (the Confused Hospitalised Older Persons program) in six New South Wales hospitals.

OBJECTIVE: To evaluate the implementation of a model of care known as the Confused Hospitalised Older Persons (CHOPs) program to improve recognition, assessment and management of older persons with cognitive impairment (delirium and/or dementia) admitted to acute hospitals. METHODS: The model of care was implemented in six selected hospitals across New South Wales. Pre- and postimplementation medical record audits, environmental audits, and staff knowledge and care confidence surveys were performed. Interviews with clinical leads postimplementation identified enablers and barriers. RESULTS: There were significant increases in cognitive screening within 24 hours (OR = 3.32 [2.50-4.91]), delirium risk identification (OR = 4.04 [2.89-5.64]), assessment of cognitive impairment (OR = 2.55 [1.90-3.43]) and interaction with families (OR = 2.81 [2.09-3.79]). Staff education and care confidence were improved, and positive environmental changes occurred in all hospitals. Barriers and enablers to implementation were identified. CONCLUSION: The CHOPs program improved identification, risk assessment and management of cognitive impairment in older hospitalised patients.

Analysis of English general practice level data linking medication levels, service activity and demography to levels of glycaemic control being achieved in type 2 diabetes to improve clinical practice and patient outcomes.

OBJECTIVE: Evaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices (GPP), to quantify the opportunities for diabetes care performance improvement. METHOD: From the National Diabetes Audit in 2015-2016 and 2016-2017, GPP target glycaemic control (TGC-%HbA1c ≤58 mmol/mol) and higher glycaemic risk (HGR -%HbA1c results >86 mmol/mol) outcomes were linked using multivariate linear regression to prescribing, demographics and practice service indicators. This was carried out both cross-sectionally (XS) (within year) and longitudinally (Lo) (across years) on 35 indicators. Standardised ß coefficients were used to show relative level of impact of each factor. Improvement opportunity was calculated as impact on TGC & HGR numbers. RESULTS: Values from 6525 GPP with 2.7 million T2DM individuals were included. The cross-sectional model accounted for up to 28% TGC variance and 35% HGR variance, and the longitudinal model accounted for up to 9% TGC and 17% HGR variance. Practice service indicators including % achieving routine checks/blood pressure/cholesterol control targets were positively correlated, while demographic indicators including % younger age/social deprivation/white ethnicity were negatively correlated. The ß values for selected molecules are shown as (increased TGC; decreased HGR), canagliflozin (XS 0.07;0.145/Lo 0.04;0.07), metformin (XS 0.12;0.04/Lo -;-), sitagliptin (XS 0.06;0.02/Lo 0.10;0.06), empagliflozin (XS-;0.07/Lo 0.09;0.07), dapagliflozin (XS -;0.04/Lo -;0.4), sulphonylurea (XS -0.18;-0.12/Lo-;-) and insulin (XS-0.14;0.02/ Lo-0.09;-). Moving all GPP prescribing and interventions to the equivalent of the top performing decile of GPP could result in total patients in TGC increasing from 1.90 million to 2.14 million, and total HGR falling from 191 000 to 123 000. CONCLUSIONS: GPP using more legacy therapies such as sulphonylurea/insulin demonstrate poorer outcomes, while those applying holistic patient management/use of newer molecules demonstrate improved glycaemic outcomes. If all GPP moved service levels/prescribing to those of the top decile, both TGC/HGR could be substantially improved.

Intervention fidelity monitoring of Urban Zen Integrative Therapy (UZIT) for persons with pulmonary hypertension.

BACKGROUND: Systematic and consistent dose delivery is critical in intervention research. Few studies testing complementary health approach (CHA) interventions describe intervention fidelity monitoring (IFM) and measurement. OBJECTIVE: To describe methodological processes in establishing and measuring consistent dose, delivery, and duration of a multi-component CHA intervention. METHODS: Adults with pulmonary hypertension received six weekly, 1-hour Urban Zen Integrative Therapy (UZIT) sessions. A total of 78 sessions were delivered and 33% of these sessions were audited. Intervention dose (time allocated to each component), intervention consistency (protocol adherence audits), and intervention delivery (performance and sequence of components) were captured using remote video observation and review of the recorded video. IFM audits were performed at the beginning (n = 16), middle (n = 5), and end (n = 5) of the study. RESULTS: UZIT interventionists adhered to the intervention protocol (99.3%) throughout the study period. Interventionists delivered UZIT components within the prescribed timeframe: 1) Beginning: gentle body movement (18.9 ± 5.8 min.), restorative pose with guided body awareness meditation (21.3 ± 2.7 min.), and Reiki (22.8 ± 3.1 min.); 2) Middle: gentle body movement (15.9 ± 1.5 min.), pose/body awareness meditation (30.1 ± 6.5 min.), and Reiki (30.1 ± 7.0 min.); 3) End: gentle body movement (18.1 ± 3.6 min.), pose/body awareness meditation (35.3 ± 6.4 min.), and Reiki (34.5 ± 7.0 min.). Essential oil inhalation was delivered during UZIT sessions 100% of the time. Interventionists adhered to treatment delivery behaviors throughout the study period: beginning (98.86%), middle (100%), and end (100%). DISCUSSION: In this pilot study, we demonstrated that the dose, consistency, and delivery of multi-component CHA therapy can be standardized and monitored to ensure intervention fidelity.

Stroke mortality audit using the Structured Judgement Review method.

Mortality data provided by the Sentinel Stroke National Audit Programme demonstrated the Royal Cornwall Hospitals Trust (RCHT) to have a higher than national average mortality ratio.1 In response to this, the RCHT stroke department undertook a mortality review of patients admitted with stroke making use of the Structured Judgement Review (SJR) process.2The review found all patients were deemed as receiving adequate, good or excellent care. There were no cases where death was deemed as definitely avoidable. The team found the SJR to be a useful, validated tool for mortality review though recognised specific limitations to its use and wider limitations within our review process. Focused areas for improvement derived from the review included improving compliance with local palliative care guides, improved documentation, links with primary care via Care Quality Commission atrial fibrillation group and consideration of improved scanning facilities. We also acknowledged wider unaccounted factors which may impact stroke mortality and thus influence perceived mortality ratios.

MedManage: The development of a tool to assist medication reconciliation in a rural primary care clinic.

BACKGROUND: Medication reconciliation is a critical step in the health care process to prevent hospital readmission, adverse drug events, and fall prevention. The purpose of the study was to pilot test a medication reconciliation process, MedManage, informed by the Medications at Transitions and Clinical Handoffs (MATCH) toolkit with nursing staff in a rural primary care clinic. METHODS: The research team conducted 38 chart audits of high-risk patients, and preintervention and postintervention were conducted to assess changes in medications reported by patients. The intervention included a chart audit tool and medication reconciliation tool created by the interdisciplinary team, MedManage, were pilot tested in the clinic. CONCLUSIONS: The Use of MedManage resulted in improvements in patient reporting of over-the-counter (82% of patients reported previously unrecorded OTCs), PRN medications (3% unreported), and herbal supplements/vitamins (28% reported previously unrecorded vitamins). IMPLICATIONS FOR PRACTICE: MedManage may be an effective tool to assist clinical nursing staff to attain a more complete and accurate medication list from patients and should be assessed more broadly across rural primary care clinics.