A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist.

We implemented the World Health Organization surgical safety checklist at Auckland City Hospital from November 2007. We hypothesised that the checklist would reduce postoperative mortality and increase days alive and out of hospital, both measured to 90 postoperative days. We compared outcomes for cohorts who had surgery during 18-month periods before vs. after checklist implementation. We also analysed outcomes during 9 years that included these periods (July 2004-December 2013). We analysed 9475 patients in the 18-month period before the checklist and 10,589 afterwards. We analysed 57,577 patients who had surgery from 2004 to 2013. Mean number of days alive and out of hospital (95%CI) in the cohort after checklist implementation was 1.0 (0.4-1.6) days longer than in the cohort preceding implementation, p < 0.001. Ninety-day mortality was 395/9475 (4%) and 362/10,589 (3%) in the cohorts before and after checklist implementation, multivariable odds ratio (95%CI) 0.93 (0.80-1.09), p = 0.4. The cohort changes in these outcomes were indistinguishable from longer-term trends in mortality and days alive and out of hospital observed during 9 years, as determined by Bayesian changepoint analysis. Postoperative mortality to 90 days was 228/5686 (4.0%) for Maori and 2047/51,921 (3.9%) for non-Maori, multivariable odds ratio (95%CI) 0.85 (0.73-0.99), p = 0.04. Maori spent on average (95%CI) 1.1 (0.5-1.7) fewer days alive and out of hospital than non-Maori, p < 0.001. In conclusion, our patients experienced improving postoperative outcomes from 2004 to 2013, including the periods before and after implementation of the surgical checklist. Maori patients had worse outcomes than non-Maori.

A clinical audit of oral anticoagulant therapy in aged care residents with atrial fibrillation.

Background Atrial fibrillation (AF) is a risk factor for stroke in older people. Oral anticoagulants can reduce stroke risk but they are commonly under prescribed in the elderly, often due to concerns regarding the risk of bleeding. Prescribing in aged care residents may also be further complicated by associated geriatric conditions such as dementia and risk of falls. Systematic assessment of stroke and bleed risk can help identify people with AF expected to benefit from anticoagulant therapy and optimise prescribing. Objective The aim of this study was to assess the prescribing of anticoagulants in elderly aged care residents in accordance with Australian guideline recommendations. Setting Nineteen aged care facilities across southeast Queensland. Method A clinical audit of anticoagulant therapy in aged care residents was conducted. Main outcome measure Information was collected from the records of residents with non-valvular AF to assess the risk of stroke and bleeding and compare this prescribing to current evidence-based guidelines for anticoagulation in AF. Results A total of 1754 residents were screened with 359 (20.4%) identified to have a diagnosis of non-valvular AF. There were 356 (99.2%) residents with non-valvular AF and a sufficiently high risk of stroke to warrant the use of an anticoagulant. Of these, 172 (48.3%) were prescribed an oral anticoagulant and 40 (11.2%) residents had a documented decision not to prescribe oral anticoagulants in their records. The majority of residents prescribed anticoagulation were receiving non-vitamin K antagonists (76.8%). The prescribed dose was consistent with recommendations for 44.8% of residents prescribed oral anticoagulant therapy. Conclusion Many residents with non-valvular AF and significant risk of stroke were not receiving oral anticoagulation despite a lack of documented reason for non-prescribing. Non-vitamin K antagonists were widely prescribed but dosing of these agents could still be improved. There remains a need to improve anticoagulant prescribing for aged care residents and optimise stroke prevention in this population.

Adecuación de la práctica clínica en Pediatría de Atención Primaria / Adequacy of clinical practice in Pediatric Primary Care

Ofrecer a los pacientes una asistencia de calidad, en condiciones de trabajo no siempre óptimas, constituye un reto para todo pediatra. Todos asumimos que nuestras decisiones clínicas deben sustentarse en la mejor evidencia científica. Sin embargo, si realizamos un análisis crítico de nuestra práctica clínica, observamos que existe una injustificada variabilidad en los procedimientos diagnósticos y terapéuticos que usamos, que con frecuencia son inapropiados. Resulta fundamental reconocer los escenarios clínicos susceptibles de mejora en Pediatría de Atención Primaria y aprender las distintas estrategias que pueden ayudarnos a optimizar nuestro ejercicio profesional

Providing patients with quality care, under not always optimal working conditions, is a challenge for every pediatrician. We all assume that our clinical decisions must be based on the best scientific evidence. However, if we perform a critical analysis of our clinical practice, we observe that there is an unjustified variability in the diagnostic and therapeutic procedures that we use, which are often inappropriate. It is essential to recognize the clinical scenarios susceptible to improvement in pediatric primary care and learn the different strategies that can help us to optimize our professional practice

Audit-based measures of overuse of medical care in Australian hospital practice.

Overuse of care that does not confer benefit to patients and wastes limited resources is being increasingly recognised as a major healthcare problem. The preferred measure of overuse of a specific intervention is applying an evidence- or consensus-based measure of inappropriateness directly to the medical records of individual patients who have received the intervention. This study aimed to assess the extent of overuse of care in hospital practice in Australia based on peer-reviewed literature that reported clinical audits using explicit measures of overuse applied to patient-level clinical data. Thirty-five studies met selection criteria, 14 relating to investigations, 21 to management strategies. Overuse rates above 30% were reported for coagulation tests, blood cultures, troponin assays, abdominal imaging studies, use of telemetry, blood product infusions, polypharmacy in older patients, prescriptions for various medications (gastric acid suppressants, direct oral anticoagulants, inhaled corticosteroids), admissions for low-risk chest pain and futile interventions in end of life care. Hospital physicians may need to audit their current high-volume practices and ensure they align with current criteria of appropriateness.

Comparative outcomes in patients with ulcer- vs non-ulcer-related acute upper gastrointestinal bleeding in the United Kingdom: a nationwide cohort of 4474 patients.

BACKGROUND: Outcomes after Nonvariceal upper gastrointestinal bleeding (NVUGIB) have historically focused on ulcer-related causes. Little is known regarding non-ulcer bleeding, the most common cause of NVUGIB. AIM: To compare outcomes between ulcer- and non-ulcer-related NVUGIB and explore whether these could be explained by differences in baseline characteristics, bleeding severity or processes of care. METHODS: Analysis of 4474 patients with NVUGIB from 212 United Kingdom hospitals as part of a nationwide audit. Logistic regression models were used to adjust for baseline characteristics, bleeding severity and processes of care. RESULTS: 1682 patients had ulcer-related and 2792 patients had non-ulcer-related bleeding. Those with ulcer-related bleeding were older (median age 73 vs 69, P < 0.001), less likely to have been taking a PPI (18% vs 32%, P < 0.001), more likely to have been taking aspirin (40% vs 27%, P < 0.001) and present with shock (43% vs 32%, P < 0.001). Furthermore, those with ulcer-related bleeding were more likely to receive blood transfusion (66% vs 39%, P < 0.001), PPI infusion (27% vs 5%, P < 0.001) and endoscopic therapy (37% vs 8%, P < 0.001). Overall, ulcer-related bleeding had higher odds of in-hospital mortality (OR: 1.54; 95% CI: 1.21-1.96, P < 0.0001), rebleeding (OR: 2.08; 95% CI: 1.73-2.51, P < 0.0001) and need for surgical/radiologic intervention (OR: 2.64; 95% CI: 1.85-3.77, P < 0.0001). The associations disappeared after adjustment for bleeding severity, whereas adjustment for patient characteristics or process of care factors had no impact. CONCLUSION: Patients with ulcer-related NVUGIB bleeding have worse outcomes than those with non-ulcer-related NVUGIB bleeding, which is due to more severe bleeding.

Crohn's & Colitis Australia inflammatory bowel disease audit: measuring the quality of care in Australia.

BACKGROUND: Australia has among the highest prevalence of Crohn disease and ulcerative colitis in the world. Management of the chronic gastrointestinal disorders results in significant societal costs and the standard of care is inconsistent across Australia. AIM: To audit the quality of care received by patients admitted for inflammatory bowel disease (IBD) across Australia against national IBD standards. METHODS: A retrospective cross-sectional survey and clinical audit was undertaken assessing organisational resources, clinical processes and outcome measures. This study was conducted in Australian hospitals that care for inpatients with Crohn disease or ulcerative colitis. The main outcome measures were adherence to national IBD standards and comparison of quality of care between hospitals with and without multidisciplinary IBD services. RESULTS: A total of 71 hospitals completed the organisational survey. Only one hospital had a complete multidisciplinary IBD service and 17 had a partial IBD service (IBD nurse, helpline and clinical lead). A total of 1440 inpatient records was reviewed from 52 hospitals (mean age 37 years; 51% female, 53% Crohn disease), approximately 26% of IBD inpatient episodes over a 12-month period in Australia. These patients were chronically unwell with high rates of anaemia (30%) and frequent readmissions (40% within 2 years). In general, care was inconsistent, and documentation was poor. Hospitals with a partial IBD service performed better in many processes and outcome measures: for example, 22% reduction in admissions through emergency departments and greater adherence to standards for safety monitoring of biological (89% vs 59%) and immunosuppressive drugs (79% vs 55%) in those hospitals than those without. CONCLUSION: Patients admitted to hospital suffering from IBD are young, chronically unwell and are subject to substantial variations in clinical documentation and quality of care. Only one hospital met accepted standards for multidisciplinary care; hospitals with even a minimal IBD service provided improved care.

Posterior urethral valves: 10 years audit of epidemiologic, diagnostic and therapeutic aspects in Yaoundé gynaeco-obstetric and paediatric hospital.

BACKGROUND: The incidence of posterior urethral valve (PUV) is estimated at 1:5000-1:8000 males. It is the most common paediatric urologic urgency and the most common cause of male obstructive uropathy and chronic renal failure in children. The study aimed to describe the experience of Yaoundé gynaeco-obstetrics and paediatric hospital in the management of PUV. METHODS: Retrospectively, medical records were retrieved over a ten year period and all data recorded and analyzed for study objectives. Patients were called and evaluated for outcomes regarding morbidity and mortality. RESULTS: A total of 18 patients all males were managed over the ten year period, given prevalence of 13 cases/100,000 admissions and an admission rate of 2 per annum. The median age at presentation was 22 months and 13 (72.2%) participants presented late. Voiding urethrocystogram was done in all the participants where it showed dilated and elongated posterior urethral valves in 16 (88.9%) of the cases. Endoscopic valve ablation resulted in the relief of obstruction in all but 3 (16.7%) participants that had residual valves and 2 (11.2%) participants that had urethral stenosis. Type I valves were most common in 14 (78.0%) participants. The mean duration of follow up was 34.56 ± 21.47 months. Complications at final follow up were: 10 (55.6%) chronic renal failure, 2 (11.2%) end-stage renal failure. The case fatality rate was 5.6%. CONCLUSION: Many patients present late in our setting with already established complications. There is the need to counsel parents/guardians on the importance of long-term follow up after relief of obstruction.

Variation in hospital mortality after pancreatoduodenectomy is related to failure to rescue rather than major complications: a nationwide audit.

BACKGROUND: In the mandatory nationwide Dutch Pancreatic Cancer Audit, rates of major complications and Failure to Rescue (FTR) after pancreatoduodenectomy between low- and high-mortality hospitals are compared, and independent predictors for FTR investigated. METHODS: Patients undergoing pancreatoduodenectomy in 2014 and 2015 in The Netherlands were included. Hospitals were divided into quartiles based on mortality rates. The rate of major complications (Clavien-Dindo ≥3) and death after a major complication (FTR) were compared between these quartiles. Independent predictors for FTR were identified by multivariable logistic regression analysis. RESULTS: Out of 1.342 patients, 391 (29%) developed a major complication and in-hospital mortality was 4.2%. FTR occurred in 56 (14.3%) patients. Mortality was 0.9% in the first hospital quartile (4 hospitals, 327 patients) and 8.1% in the fourth quartile (5 hospitals, 310 patients). The rate of major complications increased by 40% (25.7% vs 35.2%) between the first and fourth hospital quartile, whereas the FTR rate increased by 560% (3.6% vs 22.9%). Independent predictors of FTR were male sex (OR = 2.1, 95%CI 1.2-3.9), age >75 years (OR = 4.3, 1.8-10.2), BMI ≥30 (OR = 2.9, 1.3-6.6), histopathological diagnosis of periampullary cancer (OR = 2.0, 1.1-3.7), and hospital volume <30 (OR = 3.9, 1.6-9.6). CONCLUSIONS: Variations in mortality between hospitals after pancreatoduodenectomy were explained mainly by differences in FTR, rather than the incidence of major complications.

Diabetic ketoacidosis in adult patients: an audit of factors influencing time to normalisation of metabolic parameters.

BACKGROUND: Diabetic ketoacidosis (DKA) is an acute life-threatening metabolic complication of diabetes that imposes substantial burden on our healthcare system. There is a paucity of published data in Australia assessing factors influencing time to resolution of DKA and length of stay (LOS). AIMS: To identify factors that predict a slower time to resolution of DKA in adults with diabetes. METHODS: Retrospective audit of patients admitted to St Vincent's Hospital Melbourne between 2010 to 2014 coded with a diagnosis of 'Diabetic Ketoacidosis'. The primary outcome was time to resolution of DKA based on normalisation of biochemical markers. Episodes of DKA within the wider Victorian hospital network were also explored. RESULTS: Seventy-one patients met biochemical criteria for DKA; median age 31 years (26-45 years), 59% were male and 23% had newly diagnosed diabetes. Insulin omission was the most common precipitant (42%). Median time to resolution of DKA was 11 h (6.5-16.5 h). Individual factors associated with slower resolution of DKA were lower admission pH (P < 0.001) and higher admission serum potassium level (P = 0.03). Median LOS was 3 days (2-5 days), compared to a Victorian state-wide LOS of 2 days. Higher comorbidity scores were associated with longer LOS (P < 0.001). CONCLUSIONS: Lower admission pH levels and higher admission serum potassium levels are independent predictors of slower time to resolution of DKA. This may assist to stratify patients with DKA using markers of severity to determine who may benefit from closer monitoring and to predict LOS.

Off-label use of rituximab in autoimmune disease in the Top End of the Northern Territory, 2008-2016.

BACKGROUND: Rituximab, an anti-CD20 B-cell depleting monoclonal antibody, is increasingly prescribed off-label for a range of autoimmune diseases. There has not previously been an audit of off-label rituximab use in the Northern Territory, where the majority of patients are Aboriginal. AIMS: To evaluate retrospectively off-label rituximab use in autoimmune diseases in the Top End of the Northern Territory. METHODS: We performed a retrospective audit of 8 years of off-label rituximab use at the Royal Darwin Hospital, the sole tertiary referral centre for the Darwin, Katherine and East Arnhem regions. Electronic and paper records were reviewed for demographic information, diagnosis/indication for rituximab, doses, previous/concomitant immunosuppression, clinical outcomes and specific adverse events. RESULTS: Rituximab was prescribed off-label to 66 patients for 24 autoimmune diseases. The majority of patients (62.1%) were Aboriginal and 60.6% female. The most common indications were refractory/relapsing disease despite standard therapies (68.7%) or severe disease with rituximab incorporated into an induction immunosuppressive regimen (19.4%). Systemic lupus erythematosus was the underlying diagnosis in 28.8% of cases. A clinically significant response was demonstrated in 74.2% of cases overall. There were 18 clinically significant infections; however, 13 were in patients receiving concurrent immunosuppressive therapy. There was a total of nine deaths from any cause. CONCLUSION: Rituximab has been used off-label for a range of autoimmune diseases in this population with a high proportion of Aboriginal patients successfully and safely in the majority of cases.

Two-year audit of outcomes of pituitary surgery at an Australian teaching hospital.

BACKGROUND: There is evidence that cure rates and complications are influenced by the caseload in neurosurgical centres performing transsphenoidal pituitary surgery. Although Australian centres may perform relatively small numbers of these procedures, there have been few published audits of their performance. AIMS: To conduct an audit of surgery for pituitary tumours between 2012 and 2014 in the only public hospital neurosurgical unit in the state of Western Australia. METHODS: A retrospective chart review was conducted, with standardised extraction of data relating to indications for surgery, tumour type, procedure and postoperative endocrinological and other outcomes. RESULTS: Of 53 patients identified, most (91%) underwent transsphenoidal surgery. Most tumours were non-functioning (71.7%), and most of these extended outside the sella turcica (86.8 vs 73.3% of functioning tumours). There was complete removal in 43.4% of patients and evidence of biochemical cure in 33.3% of functioning tumours, but readmission for further surgery was infrequent (5.7%). Persistent cerebrospinal fluid leakage, photophobia and deep venous thrombosis occurred in <4% of patients. There were no deaths. There was a relatively high rate of permanent diabetes insipidus (DI) (13.2 vs <5% in published series), while the frequency of new postoperative anterior pituitary dysfunction (9.4%) was within the range reported in the literature (3-14%). CONCLUSION: The outcomes of pituitary surgery in this audit were largely comparable to those reported from other neurosurgical units in Australia and other countries. The increased risk of permanent postoperative DI may reflect the high proportion of non-functioning tumours with extension outside the sella turcica.

A combined hands-on teaching programme and clinical pathway focused on pleural ultrasound and procedure supervision transforms pleural procedure outcomes.

BACKGROUND: Management of pleural effusions is a common diagnostic and management problem. AIMS: We reviewed the outcomes from pleural procedures after the instigation of pleural effusion management guidelines, focusing on pleural ultrasound and a hands-on teaching programme followed by procedure supervision that enabled many operators to perform such procedures. METHODS: This is a retrospective analysis of all procedures performed for pleural effusions on medical patients. Outcomes were assessed prior to the instigation of pleural effusion management guidelines (pleural pathway) and hands-on teaching (January 2010 to June 2011) and following these interventions (January 2012 to June 2013). RESULTS: A total of 171 procedures involving 129 patients (pre-pathway group) and 146 procedures involving 115 patients (post-pathway group) was analysed. The rate of complications prior to the pleural pathway was 22.2% (38 of 171 procedures). Following the pathway, the rate of complications declined to 7.5% (11 of 146 procedures, P < 0.003). The use of pleural ultrasound increased dramatically (72.5 vs 90.2%). The number of patients who underwent repeated procedures (defined as ≥3) reduced dramatically (21 vs 7, P < 0.01). This improvement occurred using many supervised operators who completed the hands-on teaching programme (n = 32) and followed the pleural pathway (127 of 146 procedures). CONCLUSION: The instigation of a clinical pathway focused on the use of bedside pleural ultrasound, and teaching of drainage techniques with procedure supervision vastly improved patient outcomes. This not only allowed better quality of care for patients, it also provided the acquisition of new skills to medical staff, not limiting these skills to specialised staff.

Chemotherapy-related cardiotoxicity: are Australian practitioners missing the point?

BACKGROUND: It has long been established that cardiotoxicity occurs as a result of exposure to certain chemotherapeutics, particularly anthracyclines. Historically, clinicians equate cardiotoxicity with a poor prognosis, in a small percentage of patients and deem long-term surveillance as optional. Emerging evidence suggests that anthracycline cardiotoxicity (ACT) is a life-long risk with an incidence approaching 20%. AIMS: To elucidate the incidence of anthracycline cardiotoxicity within a current paediatric oncology survivor cohort. METHODS: Participants were identified through the Haematology-Oncology database at the Royal Children's Hospital, Melbourne. Patients were identified from a retrospective audit of outpatient attendances between January 2008 and December 2015. Patients with a cancer diagnosis exposed to anthracyclines were eligible for the study. Patient demographics and echocardiogram findings were recorded with patients subcategorised according to degree of ACT. More significant ACT defined as fractional shortening (FS) <24% and less significant if FS 24-28% or a decline in baseline ejection fraction of >10%. RESULTS: Two hundred and eighty-six of a total 481 identified patients were eligible for study inclusion. Twenty patients displayed significant ACT with FS <24%. Ten patients had a FS 24-28% and 25 patients with a decline in ejection fraction from baseline of >10%. Overall, 6.6% demonstrated significant cardiac complications, whilst 19.6 % demonstrated some degree of ACT and decline in myocardial function. When stratified for cumulative anthracycline dose, the incidence of severe cardiac dysfunction was 5.1% (<250 mg/m2 ) and 25% (>250 mg/m2 ) CONCLUSION: This study demonstrates, in keeping with modern literature, the higher incidence of anthracycline associated cardiac toxicity and a need for better surveillance and follow up.

Variation in quality report viewing by providers and correlation with NICU quality metrics.

BACKGROUND: To examine variation in quality report viewing and assess correlation between provider report viewing and neonatal intensive care unit (NICU) quality. METHODS: Variation in report viewing sessions for 129 California Perinatal Quality Care Collaborative NICUs was examined. NICUs were stratified into tertiles based on their antenatal steroid (ANS) use and hospital-acquired infection (HAI) rates to compare report viewing session counts. RESULTS: The number of report viewing sessions initiated by providers varied widely over a 2-year period (median=11; mean=25.5; s.d.=45.19 sessions). Report viewing was not associated with differences in ANS use. Facilities with low HAI rates had less frequent report viewing. Facilities with high report views had significant improvements in HAI rates over time. CONCLUSIONS: Available audit and feedback reports are utilized inconsistently across California NICUs despite evidence that report viewing is associated with improvements in quality of care delivery. Further studies are needed for reports to reach their theoretical potential.

Provision of stroke thrombolysis services in New Zealand: changes between 2011 and 2016.

AIMS: To obtain an overall picture of the organisation of stroke thrombolysis provision in New Zealand hospitals and compare changes between 2011 and 2016. METHODS: Surveys were distributed to all New Zealand district health boards (DHBs) in 2011 and 2016, and included questions about the infrastructure, staffing, training, guidelines and audit provided for stroke thrombolysis. RESULTS: Responses were received from all DHBs, with 86% offering stroke thrombolysis in 2011 and 100% in 2016. In 2016, thrombolysis rosters of large DHBs (those with a population >250,000 people) had a mean (range) of 14 (5-34) clinicians, approximately double that of medium-sized DHBs (population 125-250,000) who had eight (3-15) and small DHBs (population <125,000) with seven, (2-13) clinicians. While a similar distribution of senior medical officer clinical specialty was seen across medium and small DHBs in both years, large DHBs in 2016 had a higher number of neurologists (5, 1-12) and an increasing number of general physicians (8, 0-30) rostered to provide thrombolysis compared to 2011. Thrombolysis services at medium and small DHBs are chiefly managed by general physicians and geriatricians, while telestroke support was only available in three medium-sized DHBs. In 2016, all hospitals had developed thrombolysis guidelines and audited thrombolysed patients in the National Stroke Thrombolysis Register, which is an improvement compared with 2011 when only seven (39%) DHBs reported regular audit. Challenges in staffing and training remain greatest in smaller and geographically isolated DHBs. CONCLUSION: While there have been improvements in the provision of stroke thrombolysis throughout New Zealand, regional variations in service quality remains. The needs for better solutions to geographical barriers and formal training must be addressed as priorities.

A tertiary hospital audit of the use of medical imaging in the 24 h preceding death.

This study aims to investigate the number, modality and indication for imaging studies performed on acute hospital inpatients in the 24 h prior to death. Data were obtained from retrospective analysis of deceased patients from a university affiliated tertiary hospital over a 2-year period and it was found that around one in five inpatients received medical imaging in the last 24 h of their life (364 of 1855, 19.6%).

A tertiary hospital audit of opioids and sedatives administered in the last 24 h of life.

BACKGROUND/AIM: To audit the doses of opioids and sedatives administered to patients in the last 24 h of life in an Australian tertiary hospital and compare results with doses published in New Zealand (NZ) benchmarking studies and to examine the effect of caring for dying patients using a modified version of the Liverpool Care Pathway (mLCP) in respect to doses of opioids and sedatives. METHODS: A retrospective chart audit of 102 patients who died in a tertiary hospital was carried out over a 3-month period in 2011. Diagnosis, demographic patient characteristics, use of the mLCP, use of subcutaneous infusions and key symptoms were identified. Chi-squared and the non-parametric Mann-Whitney tests were applied to compare the group differences for categorical and continuous variables as appropriate. Parenteral morphine-equivalent daily dose (pMEDD) was calculated. A t-test assessed the variable mean doses of medication and patient characteristics. RESULTS: Of the audited patients, 76.5% died of non-malignant disease. The overall mean dose of midazolam was significantly lower compared with that of the NZ study pMEDD (6.0 vs 20.7 mg). The overall mean dose of morphine benchmarked closely with the NZ study (56.5 mg Australian study vs 47.8 mg NZ study). A total of 83% of patients with a malignant diagnosis was supported with the mLCP compared with 51% of patients with a non-malignant diagnosis. CONCLUSION: The significance of the lower midazolam doses was postulated, including the possibility of inadequate symptom control for patients with a non-malignant diagnosis. The use of the mLCP did not lead to the provision of higher doses of medications.

When and how to audit a diabetic foot service.

Quality improvement depends on data collection and audit of clinical services to inform clinical improvements. Various steps in the care of the diabetic foot can be used to audit a service but need defined audit standards. A diabetes foot service should have risk stratification system in place that should compare to the population-based figures of 76% having low-risk feet, 17% moderate risk and 7% being at high risk of ulceration. Resources can then be directed towards those with high-risk feet. Prevalence of foot ulceration needs to be audited. Community-based studies give an audit standard of around 2%, with 2 to 9% having had an ulcer at some stage in the past. Amputation rates should be easier to measure, and the best results are reported to be around 1.5-3 per 1000 people with diabetes. This is a useful benchmark figure, and the rate has been shown to decrease by approximately a third over the last 15 years in some centres. Ulceration rates and ulcer healing rates are the ultimate outcome audit measure as they are always undesirable, whilst occasionally for defined individuals, an amputation can be a good outcome. In addition to clinical outcomes, processes of care can be audited such as provision of clinical services, time from new ulcer to be seen by health care professional, inpatient foot care or use of antibiotics. Measurement of clinical services can be a challenge in the diabetic foot, but it is essential if clinical services and patient outcomes are to be improved.