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1.
N Z Med J ; 133(1523): 76-86, 2020 10 09.
Artigo em Inglês | MEDLINE | ID: mdl-33032305

RESUMO

AIMS: Sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists are classes of medications shown to reduce cardiovascular events and slow decline in renal function in people with type 2 diabetes (T2DM). They are recommended for many people as second-line agents after metformin by the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD). PHARMAC have proposed criteria for funding in New Zealand. This clinical audit compares which patients would be eligible for treatment under each criterion. METHODS: This retrospective audit was conducted in December 2019 of all registered patients with T2DM at three general practices within the Wellington/Porirua region. Relevant data were extracted from the electronic health records to enable assessment of eligibility under PHARMAC and ADA/EASD criteria. RESULTS: Of the 23,517 patients enrolled, 1,160 had T2DM. Under PHARMAC criteria 399 (34.4%) patients would be eligible for funded access compared with 339 (27.2%) by the 2018 ADA/EASD criteria and 559 (48.2%) by the revised 2020 ADA/EASD criteria. Differences in eligibility relate to threshold of HbA1c and inclusion of microalbuminuria for treatment. CONCLUSION: The proposed PHARMAC criteria will give access to these important drugs to those people with T2DM who will likely benefit the most.


Assuntos
Doenças Cardiovasculares , Diabetes Mellitus Tipo 2 , Hipoglicemiantes/uso terapêutico , Nefropatias , Adulto , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Auditoria Clínica , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/epidemiologia , Progressão da Doença , Feminino , Humanos , Nefropatias/complicações , Nefropatias/epidemiologia , Nefropatias/fisiopatologia , Nefropatias/prevenção & controle , Masculino , Nova Zelândia , Estudos Retrospectivos , Adulto Jovem
2.
S Afr Med J ; 110(8): 783-790, 2020 Jul 29.
Artigo em Inglês | MEDLINE | ID: mdl-32880307

RESUMO

BACKGROUND: Rates of healthcare-associated infections (HAIs) among babies born in developing countries are higher than among those born in resource-rich countries, as a result of suboptimal infection prevention and control (IPC) practices. Following two reported deaths of neonates with carbapenem-resistant Klebsiella pneumoniae bloodstream infections (BSIs), we conducted an outbreak investigation in a neonatal unit of a regional hospital in Gauteng Province, South Africa. OBJECTIVES: To confirm an outbreak of K. pneumoniae BSIs and assess the IPC programme in the neonatal unit. METHODS: We calculated total and organism-specific BSI incidence risks for culture-confirmed cases in the neonatal unit for baseline and outbreak periods. We conducted a clinical record review for a subset of cases with K. pneumoniae BSI that had been reported to the investigating team by the neonatal unit. An IPC audit was performed in different areas of the neonatal unit. We confirmed species identification and antimicrobial susceptibility, and used polymerase chain reaction for confirmation of carbapenemase genes and pulsed-field gel electrophoresis (PFGE) for typing of submitted clinical isolates. RESULTS: From January 2017 to August 2018, 5 262 blood cultures were submitted, of which 11% (560/5 262) were positive. Of 560 positive blood cultures, 52% (n=292) were positive for pathogenic organisms associated with healthcare-associated BSIs. K. pneumoniae comprised the largest proportion of these cases (32%; 93/292). The total incidence risk of healthcare-associated BSI for the baseline period (January 2017 - March 2018) was 6.8 cases per 100 admissions, and that for the outbreak period (April - September 2018) was 10.1 cases per 100 admissions. The incidence risk of K. pneumoniae BSI for the baseline period was 1.6 cases per 100 admissions, compared with 5.0 cases per 100 admissions during the outbreak period. Average bed occupancy for the entire period was 118% (range 101 - 133%), that for the baseline period was 117%, and that for the outbreak period was 121%. In a subset of 12 neonates with K. pneumoniae bacteraemia, the median (interquartile range (IQR)) gestational age at birth was 27 (26 - 29) weeks, and the median (IQR) birth weight was 1 100 (880 - 1 425) g. Twelve bloodstream and 31 colonising K. pneumoniae isolates were OXA-48-positive. All isolates were genetically related by PFGE analysis (89% similarity). Inadequate IPC practices were noted, including suboptimal adherence to aseptic technique and hand hygiene (57% overall score in the neonatal intensive care unit), with poor monitoring and reporting of antimicrobial use (pharmacy score 55%). CONCLUSIONS: Overcrowding and inadequate IPC and antimicrobial stewardship contributed to a large outbreak of BSIs caused by genetically related carbapenemase-producing K. pneumoniae isolates in the neonatal unit.


Assuntos
Bacteriemia/microbiologia , Infecção Hospitalar/microbiologia , Surtos de Doenças , Unidades Hospitalares , Infecções por Klebsiella/epidemiologia , Gestão de Antimicrobianos , Bacteriemia/epidemiologia , Proteínas de Bactérias/metabolismo , Auditoria Clínica , Infecção Hospitalar/epidemiologia , Aglomeração , Humanos , Incidência , Recém-Nascido , Controle de Infecções , Klebsiella pneumoniae/enzimologia , Klebsiella pneumoniae/isolamento & purificação , Programas Médicos Regionais , África do Sul/epidemiologia , beta-Lactamases/metabolismo
3.
S Afr Med J ; 110(8): 791-795, 2020 Jul 29.
Artigo em Inglês | MEDLINE | ID: mdl-32880308

RESUMO

BACKGROUND: Intensive care unit (ICU)-related healthcare-associated infections (HCAIs) are two to three times higher in lower-income countries than in higher-income ones. Hand cleansing and other hygiene measures have been documented as one of the most effective measures in combating the transmission of HCAIs. There is a paucity of data pertaining to hygiene practices in the ICU in developing countries. OBJECTIVES: To determine compliance with hygiene practices among healthcare workers in a tertiary hospital ICU. METHODS: Hygiene practices of healthcare workers in a tertiary academic hospital ICU in Johannesburg, South Africa, were discreetly observed over an 8-week period. Compliance with hand cleansing and other hygiene practices was documented and analysed. Retrospective consent was obtained, and subject confidentiality was maintained. RESULTS: A total of 745 hygiene opportunities were observed. Of the 156 opportunities where handwashing with soap and water was indicated (20.9%), compliance was noted in 89 cases (57.1%), while an alcohol-based hand rub was inappropriately used in 34 cases (21.8%) and no hand hygiene was performed in the remaining 33 cases (21.1%). Of the 589 opportunities where an alcohol-based hand-rub was indicated, it was used in 312 cases (53.0%). Compliance with the donning of disposable surgical gloves, disposable plastic aprons and being 'bare below the elbows' was noted in 114 (90.6%), 108 (71.1%) and 355 (47.7%) opportunities, respectively, where these were indicated. CONCLUSIONS: Overall compliance with hygiene measures among healthcare workers in the ICU was suboptimal in this study, but in keeping with general international trends. Regular retraining of staff, frequent reminders, peer oversight and regular audits may improve compliance.


Assuntos
Desinfecção das Mãos , Higienizadores de Mão/administração & dosagem , Controle de Infecções/estatística & dados numéricos , Unidades de Terapia Intensiva , Recursos Humanos em Hospital , Roupa de Proteção/estatística & dados numéricos , Centros Médicos Acadêmicos , Auditoria Clínica , Estudos Transversais , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Controle de Infecções/normas , África do Sul , Centros de Atenção Terciária
4.
S Afr Med J ; 110(7): 691-694, 2020 Jul 07.
Artigo em Inglês | MEDLINE | ID: mdl-32880349

RESUMO

BACKGROUND: The most common clinical indication for renal biopsy in the early post-transplant period is early graft dysfunction (EGD), which may present either as delayed graft function (DGF) or acute graft dysfunction. Even though it is a valuable diagnostic tool, renal allograft biopsy is not without risk of major complications. Recent studies have suggested that, with modern immunosuppressive induction regimens and more accurate ways to determine high immunological risk transplants, early acute rejection (AR) is uncommon and routine biopsy for EGD does not result in a change in management. OBJECTIVES: To describe the histological findings and complications of renal allograft biopsies for EGD in our setting, and to determine whether our current threshold for biopsy is appropriate. METHODS: This study was a retrospective audit that included all patients who underwent renal allograft biopsy within the first 30 days of transplantation at Groote Schuur Hospital, Cape Town, South Africa, from 1 June 2010 to 30 June 2018. The indication for biopsy was any patient who showed significant EGD, characterised by acute graft dysfunction or DGF with dialysis dependence. RESULTS: During the study period, 330 patients underwent renal transplantation, of whom 105 (32%) had an early biopsy and were included in the study. The median age of recipients was 39 (range 17 - 62) years, with 65% males and 35% females. The majority of donors were deceased donations after brain death (70%), with an overall median cold ischaemic time of 9 hours (interquartile range (IQR) 4 - 16). The average number of human leukocyte antigen mismatches was 5 (IQR 4 - 7). A donor-specific antibody was recorded for 18% of recipients and a panel-reactive antibody score of >30% was recorded for 21%. The median duration after transplant for biopsy was 8 (IQR 6 - 10) days. During the first month of EGD, AR was diagnosed in 42% of patients who underwent biopsies. In 21% of these patients, there was acute cellular rejection, in 16% antibody-mediated rejection, and in 5% both of these. Acute tubular necrosis was the primary finding in 32%, with acute interstitial nephritis in 8%, and acute calcineurin toxicity in 4% of cases. A significant biopsy-related complication was recorded in 3 patients: 1 small-bowel perforation repaired via laparotomy, and 2 vascular injuries successfully embolised by interventional radiology. CONCLUSIONS: Considering the relative safety and high rate of detection of AR, a liberal approach to renal biopsy for EGD remains justifiable in our setting.


Assuntos
Aloenxertos , Biópsia , Transplante de Rim , Rim/patologia , Adolescente , Adulto , Calcineurina/efeitos adversos , Auditoria Clínica , Feminino , Rejeição de Enxerto/diagnóstico , Humanos , Necrose Tubular Aguda/patologia , Masculino , Pessoa de Meia-Idade , Nefrite Intersticial/patologia , Disfunção Primária do Enxerto/diagnóstico , Estudos Retrospectivos , África do Sul , Adulto Jovem
5.
Am J Gastroenterol ; 115(9): 1532-1533, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32694291

RESUMO

INTRODUCTION: To characterize the clinical pharmacists' impact on caring for patients with inflammatory bowel disease during COVID-19. METHODS: A clinical pharmacist's encounters between March 17 and April 14, 2020, were audited to determine encounter frequency and indication. RESULTS: The clinical pharmacist addressed COVID-19 and inflammatory bowel disease treatment concerns with 140 patients, conducted 34 medication education and monitoring visits, reviewed 141 patients' charts and helped rescheduled 18 patients who missed their biologic infusion, transitioned 12 patients to home infusions, and assisted 5 patients with medication access. DISCUSSION: Clinical pharmacists embedded in gastroenterology practices permit for continued optimal patient care during a pandemic.


Assuntos
Betacoronavirus , Auditoria Clínica , Infecções por Coronavirus/complicações , Doenças Inflamatórias Intestinais/tratamento farmacológico , Equipe de Assistência ao Paciente/normas , Assistência ao Paciente/métodos , Farmacêuticos/normas , Pneumonia Viral/complicações , Infecções por Coronavirus/epidemiologia , Humanos , Doenças Inflamatórias Intestinais/complicações , Pandemias , Pneumonia Viral/epidemiologia , Papel Profissional , Estudos Retrospectivos
6.
J Contemp Dent Pract ; 21(4): 431-437, 2020 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-32584282

RESUMO

AIMS: Periodontitis is one of the most widespread diseases worldwide. Many efforts have been made to increase the efficacy of periodontitis therapy as much as possible. Recently, minimally invasive nonsurgical techniques (MINST) were introduced in the periodontal field as an alternative to minimally invasive surgical techniques (MIST). This clinical audit aims to evaluate the results of MINST in the initial phase of treatment for periodontitis. MATERIALS AND METHODS: One hundred seven patients with periodontitis who were treated with MINST between 2013 and 2017 and reevaluated after 2 months were included in this clinical audit. The primary outcome analyzed was the proportion of pocket closure. The secondary outcomes were tooth extraction before active periodontal therapy, full-mouth plaque score (FMPS) change, full-mouth bleeding score (FMBS) change, average probing pocket depth (PPD) reduction, and average clinical attachment level (CAL) gain between the baseline and reevaluation values. RESULTS: A total of 2,407 teeth were included in the analysis. At the patient level, the treatment resulted in a mean pocket closure rate of 71.6 ± 15.7% for sites with an initial PPD ≥5 mm. The treatment was statistically significantly (p < 0.001) more effective with respect to the primary outcome compared with expected values reported in a recent meta-analysis (57%). The subgroup analysis revealed statistically significant differences between single and multirooted teeth and between shallow (5-6 mm) and deep pockets (≥7 mm) at the baseline. CONCLUSION: Nonsurgical periodontal therapy with MINST achieved satisfactory results that were better than expected based on the scientific literature. Single-rooted and shallow pockets showed the best proportion of pocket closure at the reevaluation after treatment. CLINICAL SIGNIFICANCE: Minimally invasive nonsurgical techniques can be the treatment of choice when approaching periodontally diseased patients with nonsurgical periodontal therapy.


Assuntos
Periodontite , Auditoria Clínica , Raspagem Dentária , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Perda da Inserção Periodontal , Índice Periodontal , Resultado do Tratamento
7.
Postgrad Med J ; 96(1137): 379-383, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32522845

RESUMO

INTRODUCTION: Managing healthcare service during pandemics and outbreaks is a challenging process. The aim is to keep patient safety as the priority, besides, continuing to provide essential healthcare services. METHODS: Situational audit was performed for the services rendered before and during COVID-19 pandemic and the elevation of the disease alert status, and a retrospective analysis of the attendance and procedures performed in the service. RESULTS: We present a methodology for performing a situational audit and generating service modification for hand and reconstructive microsurgery unit in a pandemic. There was no significant difference between the number of patients seen at outpatient clinics. However, there was a reduction in the numbers of total surgeries performed, with a 40% drop in the number of elective surgeries performed. There was also a reduction of cases seen in the emergency department hand clinic. DISCUSSION: COVID-19 pandemic is currently affecting not only the health service but also, other vital services all over the world. The pandemic puts significant challenges to acute surgical services in a hospital system involved in the management of the pandemic. Surgeons need to take proactive and a systematic approach in managing the available resources while maintaining essential surgical services. This paper provides the tools and methodology for doctors to plan their services in a pandemic situation. CONCLUSIONS: It is possible to maintain essential surgical services in a pandemic situation through rapid situational audits and generating localised strategies while considering the constraints imposed during the pandemics while maintaining patient and staff safety.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Procedimentos Cirúrgicos Eletivos/métodos , Traumatismos da Mão/cirurgia , Controle de Infecções/organização & administração , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Procedimentos Cirúrgicos Reconstrutivos/métodos , Auditoria Clínica , Humanos , Microcirurgia , Segurança do Paciente , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Singapura/epidemiologia
8.
Spec Care Dentist ; 40(4): 374-381, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32506575

RESUMO

INTRODUCTION: Dental extractions can be safely carried out on patients under vitamin K antagonists (VKAs) therapy, without stopping or changing the dosage, but the international normalized ratio (INR) needs to be monitored on the day of the intervention, showing adequate rates before proceeding. OBJECTIVES: This study aims at evaluating INR values, measured before oral surgery procedures, to assess the rate of patients, under VKAs therapy, outside the therapeutic range. MATERIALS AND METHODS: A clinical audit was carried out involving patients under VKAs, who needed minor oral surgery procedures, over a period of 18 months. The patient was instructed to not modify or suspend VKAs prior to the intervention. Before surgery, each patient fulfilled a questionnaire on dietary and oral hygiene habits, and a blood sample was collected for INR assessment (cut-off value for surgical procedure ≤3.5). RESULTS: One hundred twenty-two patients were enrolled: 69 (56.6%) had an INR value within the established therapeutic range, 53 (43.4%) were out of range. No intra- or postsurgical major bleeding was recorded. CONCLUSIONS: INR, measured on the same day of oral surgery, has the potential to prevent bleeding complications by the identification of those patients out of range, who may require adjusting the drug therapeutic dosage.


Assuntos
Procedimentos Cirúrgicos Bucais , Vitamina K , Administração Oral , Anticoagulantes/uso terapêutico , Auditoria Clínica , Humanos , Coeficiente Internacional Normatizado
10.
Can J Surg ; 63(3): E241-E249, 2020 05 08.
Artigo em Inglês | MEDLINE | ID: mdl-32386475

RESUMO

Background: The Tokyo Guidelines were published in 2007 and updated in 2013 and 2018, with recommendations for the diagnosis and management of acute cholecystitis. We assessed guideline adherence at our academic centre and its impact on patient outcomes. Methods: This is a retrospective chart review of patients with acute calculous cholecystitis who underwent cholecystectomy at our institution between November 2013 and March 2015. Severity of cholecystitis was graded retrospectively if it had not been documented preoperatively. Compliance with the Tokyo Guidelines' recommendations on antibiotic use and time to operation was recorded. Cholecystitis severity groups were compared statistically, and logistic regression was used to determine predictors of complications. Results: One hundred and fifty patients were included in the study. Of these, 104 patients were graded as having mild cholecystitis, 45 as having moderate cholecystitis, and 1 as having severe cholecystitis. Severity was not documented preoperatively for any patient. Compliance with antibiotic recommendations was poor (18.0%) and did not differ by cholecystitis severity (p = 0.90). Compliance with the recommendation on time to operation was 86.0%, with no between-group differences (p = 0.63); it improved when an acute care surgery team was involved (91.0% v. 76.0%, p = 0.025). On multivariable analysis, comorbidities (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.19-1.85, p < 0.001) and conversion to laparotomy (OR 13.45, 95% CI 2.16-125.49, p = 0.01) predicted postoperative complications, while severity of cholecystitis, antibiotic compliance and time to operation had no effect. Conclusion: In this study, compliance with the Tokyo Guidelines was acceptable only for time to operation. Although the poor compliance with recommendations relating to documentation of severity grading and antibiotic use did not have a negative affect on patient outcomes, these recommendations are important because they facilitate appropriate antibiotic use and patient risk stratification.


Assuntos
Antibacterianos/uso terapêutico , Colecistectomia/normas , Colecistite Aguda/cirurgia , Auditoria Clínica/normas , Fidelidade a Diretrizes , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Colúmbia Britânica/epidemiologia , Colecistite Aguda/diagnóstico , Colecistite Aguda/tratamento farmacológico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento , Adulto Jovem
11.
J Cardiothorac Surg ; 15(1): 95, 2020 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-32410658

RESUMO

BACKGROUND: Evidence that Enhanced Recovery After Thoracic Surgery (ERAS) improves clinical outcomes is growing. Following the recent publications of the international ERAS guidelines in Thoracic surgery, the aim of this audit was to capture variation and perceived difficulties to ERAS implementation, thus helping its development at a national level. METHODS: We designed an anonymous online survey and distributed it via email to all 36 centres that perform lung lobectomy surgery in the UK and Ireland. It included 38 closed, open and multiple-choice questions on the core elements of ERAS and took an average of 10 min to complete. RESULTS: Eighty-two healthcare professionals from 34 out of 36 centres completed the survey; majority were completed by consultant thoracic surgeons (57%). Smoking cessation support varied and only 37% of individuals implemented the recommended period for fluid fasting; 59% screen patients for malnutrition and 60% do not give preoperative carbohydrate loading. The compliance with nerve sparing techniques when a thoracotomy is performed was poor (22%). 66% of respondents apply suction on intercostal drains and although 91% refer all lobectomies for physiotherapeutic assessment, the physiotherapy adjuncts varied across centres. Perceived barriers to implementation were staffing levels, lack of teamwork/consistency, limited resources over weekend and the reduced access to smoking cessation services. CONCLUSION: Centres across the UK are working to develop the ERAS pathway. This survey aids this process by providing insight into "real life" ERAS, increasing exposure of staff to the ESTS- ERAS recommendations and identifying barriers to implementation.


Assuntos
Recuperação Pós-Cirúrgica Melhorada , Neoplasias Pulmonares/cirurgia , Pneumonectomia , Padrões de Prática Médica/estatística & dados numéricos , Auditoria Clínica , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Irlanda , Estudos Retrospectivos , Reino Unido
12.
Orv Hetil ; 161(21): 873-880, 2020 05.
Artigo em Húngaro | MEDLINE | ID: mdl-32427572

RESUMO

Introduction, aim: Quality control of patient documentation for cerebral palsy (CP) at Semmelweis University. METHOD: In our retrospective audit, we revised patient records for all children born between 2005 and 2015, with suspected CP, registering 673 cases with confirmed CP. Based on the available patient data, we assessed clinical and etiological classification of CP and data availability. RESULTS: Patient records of 86% of children were suitable for clinical classification. Among them, 90.5% were spastic, 7.8% hypotonic, 1.2% dyskinetic and 0.5% ataxic. Among the classifiable spastic cases (98% of all spastic cases), 51% presented with tetraparetic/tetraplegic, 26% diparetic/diplegic and 23% hemiparetic/hemiplegic localization; in the remaining 2%, sufficient data for topological classification was unavailable. Severity assessed on Gross Motor Function Classification System was definable in 82% of cases, 43% showing grade I-II, 28% grade III and 29% grade IV-V impairment. Patient history was specified in 91% of cases. Prematurity was documented in 55%, perinatal asphyxia/hypoxic-ischemic encephalopathy in 31%, intraventricular/intracranial haemorrhage in 27%, multiple births in 19%, intrauterine growth restriction in 18%, intrauterine/perinatal/infancy infection in 15%, congenital malformation in 12%, in vitro fertilisation in 5%, stroke in 3% and CP-associated genetic mutation in 3% of cases. Negative patient history was determined in 16% of children. CONCLUSIONS: Our audit established that clinical documentation of CP is performed based on uniform criteria, detecting missing data primarily in clinical classification and patient history. We propose a patient documentation standard in the clinical care of affected children, which is a prerequisite for unified data recording and a future national CP registry. Orv Hetil. 2020; 161(21): 873-880.


Assuntos
Paralisia Cerebral/epidemiologia , Auditoria Clínica , Confiabilidade dos Dados , Documentação/normas , Criança , Feminino , Humanos , Recém-Nascido , Gravidez , Prevalência , Estudos Retrospectivos , Universidades
13.
N Z Med J ; 133(1512): 15-21, 2020 04 03.
Artigo em Inglês | MEDLINE | ID: mdl-32242174

RESUMO

BACKGROUND: This is a baseline clinical audit looking at indwelling urinary catheter (IDC) use and trial removal of catheter (TROC) in stroke patients. We collected data on stroke patients admitted to North Shore Hospital between 26 November 2018-24 May 2019, who underwent insertion of an IDC as an inpatient. A minority of patients had TROC within the recommended guideline period. A high incidence of urinary tract infection (UTI) was found in this patient population. Insufficient documentation and inappropriate indications for IDC insertion were features noted during this audit. Daily electronic reminders and prompting by all members of the rehabilitation team concerning TROC are important to reduce catheter days and reduce UTI rates. AIMS: To identify if the trial removal of indwelling urinary catheters (TROC) in stroke patients complies with the 2016 American Heart Association/American Stroke Association (AHA/ASA) AHSA guidelines, and to identify any precipitating factors that prevent compliance with the guidelines. METHODS: We performed a clinical baseline audit that identified patients who were admitted to the acute stroke ward at North Shore Hospital with a diagnosis of stroke from 26 November 2018-24 May 2019 and had an indwelling urinary catheter (IDC) inserted during their admission. The audit consisted of both retrospective and prospective components. Data was collected on patient demographics, the documented indication for IDC insertion, total number of catheter days, the incidence of UTIs and the outcomes after catheter removal. RESULTS: A total of 49 patients were included. 4.1% of patients had catheters removed within 24 hours (95% confidence interval: 0.011-0.137). The average number of catheter days before removal of IDC was approximately five days. 24.5% of our patient sample went on to develop a urinary tract infection. CONCLUSIONS: Insufficient documentation and inappropriate indications for IDC insertion were features noted during this audit. Daily electronic reminders and prompting concerning TROC are important to reduce catheter days and reduce infection rates. Indwelling catheters and associated infections impact the length of hospitalisation, mortality and morbidity of stroke patients.


Assuntos
Cateteres de Demora , Remoção de Dispositivo , Acidente Vascular Cerebral , Cateterismo Urinário , Auditoria Clínica , Feminino , Fidelidade a Diretrizes , Hospitais , Humanos , Masculino , Nova Zelândia/epidemiologia , Estudos Prospectivos , Estudos Retrospectivos , Infecções Urinárias/epidemiologia
14.
Cochrane Database Syst Rev ; 3: CD012982, 2020 03 25.
Artigo em Inglês | MEDLINE | ID: mdl-32212268

RESUMO

BACKGROUND: The United Nations' Sustainable Development Goals (SDGs) include reducing the global maternal mortality rate to less than 70 per 100,000 live births and ending preventable deaths of newborns and children under five years of age, in every country, by 2030. Maternal and perinatal death audit and review is widely recommended as an intervention to reduce maternal and perinatal mortality, and to improve quality of care, and could be key to attaining the SDGs. However, there is uncertainty over the most cost-effective way of auditing and reviewing deaths: community-based audit (verbal and social autopsy), facility-based audits (significant event analysis (SEA)) or a combination of both (confidential enquiry). OBJECTIVES: To assess the impact and cost-effectiveness of different types of death audits and reviews in reducing maternal, perinatal and child mortality. SEARCH METHODS: We searched the following from inception to 16 January 2019: CENTRAL, Ovid MEDLINE, Embase OvidSP, and five other databases. We identified ongoing studies using ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and searched reference lists of included articles. SELECTION CRITERIA: Cluster-randomised trials, cluster non-randomised trials, controlled before-and-after studies and interrupted time series studies of any form of death audit or review that involved reviewing individual cases of maternal, perinatal or child deaths, identifying avoidable factors, and making recommendations. To be included in the review, a study needed to report at least one of the following outcomes: perinatal mortality rate; stillbirth rate; neonatal mortality rate; mortality rate in children under five years of age or maternal mortality rate. DATA COLLECTION AND ANALYSIS: We used standard Cochrane Effective Practice and Organisation of Care (EPOC) group methodological procedures. Two review authors independently extracted data, assessed risk of bias and assessed the certainty of the evidence using GRADE. We planned to perform a meta-analysis using a random-effects model but included studies were not homogeneous enough to make pooling their results meaningful. MAIN RESULTS: We included two cluster-randomised trials. Both introduced death review and audit as part of a multicomponent intervention, and compared this to current care. The QUARITE study (QUAlity of care, RIsk management, and TEchnology) concerned maternal death reviews in hospitals in West Africa, which had very high maternal and perinatal mortality rates. In contrast, the OPERA trial studied perinatal morbidity/mortality conferences (MMCs) in maternity units in France, which already had very low perinatal mortality rates at baseline. The OPERA intervention in France started with an outreach visit to brief obstetricians, midwives and anaesthetists on the national guidelines on morbidity/mortality case management, and was followed by a series of perinatal MMCs. Half of the intervention units were randomised to receive additional support from a clinical psychologist during these meetings. The OPERA intervention may make little or no difference to overall perinatal mortality (low certainty evidence), however we are uncertain about the effect of the intervention on perinatal mortality related to suboptimal care (very low certainty evidence).The intervention probably reduces perinatal morbidity related to suboptimal care (unadjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.40 to 0.95; 165,353 births; moderate-certainty evidence). The effect of the intervention on stillbirth rate, neonatal mortality, mortality rate in children under five years of age, maternal mortality or adverse effects was not reported. The QUARITE intervention in West Africa focused on training leaders of hospital obstetric teams using the ALARM (Advances in Labour And Risk Management) course, which included one day of training about conducting maternal death reviews. The leaders returned to their hospitals, established a multidisciplinary committee and started auditing maternal deaths, with the support of external facilitators. The intervention probably reduces inpatient maternal deaths (adjusted OR 0.85, 95% CI 0.73 to 0.98; 191,167 deliveries; moderate certainty evidence) and probably also reduces inpatient neonatal mortality within 24 hours following birth (adjusted OR 0.74, 95% CI 0.61 to 0.90; moderate certainty evidence). However, QUARITE probably makes little or no difference to the inpatient stillbirth rate (moderate certainty evidence) and may make little or no difference to the inpatient neonatal mortality rate after 24 hours, although the 95% confidence interval includes both benefit and harm (low certainty evidence). The QUARITE intervention probably increases the percent of women receiving high quality of care (OR 1.87, 95% CI 1.35 - 2.57, moderate-certainty evidence). The effect of the intervention on perinatal mortality, mortality rate in children under five years of age, or adverse effects was not reported. We did not find any studies that evaluated child death audit and review or community-based death reviews or costs. AUTHORS' CONCLUSIONS: A complex intervention including maternal death audit and review, as well as development of local leadership and training, probably reduces inpatient maternal mortality in low-income country district hospitals, and probably slightly improves quality of care. Perinatal death audit and review, as part of a complex intervention with training, probably improves quality of care, as measured by perinatal morbidity related to suboptimal care, in a high-income setting where mortality was already very low. The WHO recommends that maternal and perinatal death reviews should be conducted in all hospitals globally. However, conducting death reviews in isolation may not be sufficient to achieve the reductions in mortality observed in the QUARITE trial. This review suggests that maternal death audit and review may need to be implemented as part of an intervention package which also includes elements such as training of a leading doctor and midwife in each hospital, annual recertification, and quarterly outreach visits by external facilitators to provide supervision and mentorship. The same may also apply to perinatal and child death reviews. More operational research is needed on the most cost-effective ways of implementing maternal, perinatal and paediatric death reviews in low- and middle-income countries.


Assuntos
Mortalidade da Criança , Auditoria Clínica , Mortalidade Infantil , Mortalidade Perinatal , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Gravidez , Complicações na Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Natimorto
15.
Can J Surg ; 63(2): E150-E154, 2020 03 27.
Artigo em Inglês | MEDLINE | ID: mdl-32216251

RESUMO

Background: Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown. Methods: In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed. Results: A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively. Conclusion: Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada.


Assuntos
Emergências , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Canadá/epidemiologia , Auditoria Clínica , Feminino , Humanos , Laparoscopia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Estudos Prospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos
16.
Br J Radiol ; 93(1110): 20190897, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32142373

RESUMO

OBJECTIVE: Assessment of the extent of variation in delineations and dose optimisation performed at multiple UK centres as a result of interobserver variation and protocol differences. METHODS: CT/MR images of 2 cervical cancer patients previously treated with external beam radiotherapy (EBRT) and Brachytherapy were distributed to 11 UK centres. Centres delineated structures and produced treatment plans following their local protocol. Organ at risk delineations were assessed dosimetrically through application of the original treatment plan and target volume delineations were assessed in terms of variation in absolute volume and length, width and height. Treatment plan variation was assessed across all centres and across centres that followed EMBRACE II. Treatment plans were assessed using total EQD2 delivered and were compared to EMBRACE II dose aims. Variation in combined intracavitary/interstitial brachytherapy treatments was also assessed. RESULTS: Brachytherapy target volume delineations contained variation due to differences in protocol used, window/level technique and differences in interpretations of grey zones. Planning target volume delineations were varied due to protocol differences and extended parametrial tissue inclusion. All centres met EMBRACE II plan aims for PTV V95 and high-riskclinical target volume D90 EQD2, despite variation in prescription dose, fractionation and treatment technique. CONCLUSION: Brachytherapy target volume delineations are varied due to differences in contouring guidelines and protocols used. Planning target volume delineations are varied due to the uncertainties surrounding the extent of parametrial involvement. Dosimetric optimisation is sufficient across all centres to satisfy EMBRACE II planning aims despite significant variation in protocols used. ADVANCES IN KNOWLEDGE: Previous multi-institutional audits of cervical cancer radiotherapy practices have been performed in Europe and the USA. This study is the first of its kind to be performed in the UK.


Assuntos
Braquiterapia/métodos , Protocolos Clínicos , Órgãos em Risco/diagnóstico por imagem , Planejamento da Radioterapia Assistida por Computador/métodos , Neoplasias do Colo do Útero/diagnóstico por imagem , Neoplasias do Colo do Útero/radioterapia , Idoso , Auditoria Clínica , Feminino , Humanos , Pessoa de Meia-Idade , Variações Dependentes do Observador , Dosagem Radioterapêutica , Incerteza , Reino Unido
17.
Gastroenterol. hepatol. (Ed. impr.) ; 43(2): 79-86, feb. 2020. graf, tab
Artigo em Inglês | IBECS | ID: ibc-188298

RESUMO

Introduction: Cure of Helicobacter pylori infection in patients with gastric lymphoma of mucosa-associated lymphoid tissue (MALT) leads to long-term clinical remission in the initial stages. As it is a rare disease, its management in clinical practice remains largely unknown and heterogeneity of care remains a concern. The aim was to audit the management and evolution of a large series of low-grade gastric MALT lymphomas from thirteen Spanish hospitals. Materials and methods: Multicentre retrospective study including data on the diagnosis and follow-up of patients with gastric low-grade MALT lymphoma from January 1998 to December 2013. Clinical, biological and pathological data were analyzed and survival curves were drawn. Results: One-hundred and ninety-eight patients were included. Helicobacter pylori was present in 132 (69%) patients and 103 (82%) in tumors confined to the stomach (stage EI) and was eradicated in 92% of patients. Chemotherapy was given in 90 (45%) patients and 43 (33%) with stage EI. Marked heterogeneity in the use of diagnostic methods and chemotherapy was observed. Five-year overall survival was 86% (89% in EI). Survival was similar in EI patients receiving aggressive treatment and in those receiving only antibiotics (p=0.577). Discussion: Gastric MALT lymphoma has an excellent prognosis. We observed, however, a marked heterogeneity in the use of diagnostic methods or chemotherapy in early-stage patients


Introducción: La cura de la infección por Helicobacter pylori (H. pylori) en pacientes con linfoma gástrico de tejido linfoide asociado mucosas (mucosa-associated lymphoid tissue [MALT]) conduce a la remisión clínica a largo plazo en los estadios iniciales. Al tratarse de una enfermedad rara, su tratamiento en la práctica clínica en muchas ocasiones se desconoce y la heterogeneidad de la atención sigue siendo motivo de preocupación. El objetivo es auditar el tratamiento y la evolución de una gran serie de linfomas gástricos MALT de bajo grado procedentes de 13 hospitales españoles. Materiales y métodos: Estudio retrospectivo y multicéntrico que incluye datos sobre el diagnóstico y el seguimiento de pacientes con linfoma MALT gástrico de bajo grado desde enero de 1998 hasta diciembre del 2013. Se analizaron los datos clínicos, biológicos y patológicos, y se trazaron las curvas de supervivencia. Resultados: Se incluyó a 198 pacientes. El H. pylori estaba presente en 132 (69%) de los pacientes y en 103 (82%) tumores confinados al estómago (estadio EI) y se erradicó en el 92% de los pacientes. Se administró quimioterapia a 90 (45%) de los pacientes y a 43 (33%) en estadio EI. Se observó una marcada heterogeneidad en el uso de los métodos de diagnóstico y de la quimioterapia. La supervivencia global a los 5 años fue del 86% (89% en estadio EI). La supervivencia fue similar en los pacientes en estadio EI que recibieron tratamiento agresivo y en los que recibieron solo antibióticos (p=0,577). Discusión: El linfoma MALT gástrico presenta un pronóstico excelente. Sin embargo, se observó una marcada heterogeneidad en el uso de los métodos de diagnóstico o la quimioterapia en pacientes en estadio inicial


Assuntos
Humanos , Linfoma/patologia , Tecido Linfoide/patologia , Auditoria Clínica/métodos , Neoplasias Gástricas/tratamento farmacológico , Espanha , Estudos Retrospectivos , Intervalo Livre de Progressão , Infecções por Helicobacter/tratamento farmacológico , Mucosa Gástrica/efeitos dos fármacos , Mucosa Gástrica/patologia
18.
Int J Med Inform ; 136: 104086, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32058263

RESUMO

BACKGROUND: In activity based funding systems, the misclassification of inpatient episode Diagnostic Related Groups (DRGs) can have significant impacts on the revenue of health care providers. Weakly informative Bayesian models can be used to estimate an episode's probability of DRG misclassification. METHODS: This study proposes a new, Hybrid prior approach which utilises guesses that are elicited from a clinical coding auditor, switching to non-informative priors where this information is inadequate. This model's ability to detect DRG revision is compared to benchmark weakly informative Bayesian models and maximum likelihood estimates. RESULTS: Based on repeated 5-fold cross-validation, classification performance was greatest for the Hybrid prior model, which achieved best classification accuracy in 14 out of 20 trials, significantly outperforming benchmark models. CONCLUSIONS: The incorporation of elicited expert guesses via a Hybrid prior produced a significant improvement in DRG error detection; hence, it has the ability to enhance the efficiency of clinical coding audits when put into practice at a health care provider.


Assuntos
Teorema de Bayes , Auditoria Clínica/normas , Codificação Clínica/normas , Interpretação Estatística de Dados , Grupos Diagnósticos Relacionados/classificação , Grupos Diagnósticos Relacionados/normas , Erros de Diagnóstico/prevenção & controle , Prova Pericial/estatística & dados numéricos , Humanos , Funções Verossimilhança
19.
J Pediatr Surg ; 55(5): 889-892, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32067806

RESUMO

BACKGROUND/PURPOSE: Improvement opportunities exist in the accuracy and timeliness of the diagnosis of childhood appendicitis. The purpose of our study was to conduct a post-implementation audit of a diagnostic pathway for children with suspected appendicitis presenting to our pediatric emergency department. METHODS: We adopted a diagnostic pathway that utilized a validated risk of appendicitis stratification tool (Alvarado Score) with protocolized use of abdominal ultrasound for moderate risk patients. We conducted a 10% convenience sample audit of pathway patients treated over the subsequent 18-month period. Outcome measures included false negative and positive rates, sensitivity, specificity, and overall pathway accuracy. RESULTS: One hundred thirty-four pathway patients, of which 22 (16.4%) had appendicitis confirmed pathologically, were evaluated. The risk group distribution of patients was: low risk (29%), moderate risk (60%), and high risk (11%). The negative appendectomy rate was 4.4% (reduced from 14% pre-pathway), and the false negative (missed appendicitis) rate was 3.0%. No patients received CT scans. Pathway sensitivity was 81.8%% (95% CI 59.7% to 94.8%), specificity-92.9%% (95% CI 86.4%-96.9%), and overall accuracy-91.0% (95% CI 84.9%-95.3%). CONCLUSION: Implementation of a diagnostic pathway achieved a high level of accuracy and reduced our institutional negative appendectomy rate by 67%. The audit identified additional pathway improvement opportunities. LEVELS OF EVIDENCE: Level IV.


Assuntos
Apendicite/diagnóstico , Adolescente , Apendicectomia , Apendicite/diagnóstico por imagem , Apendicite/cirurgia , Apêndice/diagnóstico por imagem , Criança , Pré-Escolar , Auditoria Clínica , Intervalos de Confiança , Técnicas e Procedimentos Diagnósticos/normas , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Fatores de Risco , Sensibilidade e Especificidade , Ultrassonografia
20.
N Z Med J ; 133(1510): 56-61, 2020 02 21.
Artigo em Inglês | MEDLINE | ID: mdl-32078601

RESUMO

AIM: Oesophagectomy is a complex operation, with high rates of morbidity and mortality. Traditional post-operative care often involves admission to an intensive care unit, however with advancing surgical and anaesthetic techniques this may not be routinely required. The objective of this study is to investigate the utilisation of intensive care-specific resources following oesophagectomy in a New Zealand tertiary hospital. METHODS: All patients undergoing oesophagectomy over a five-year period at Christchurch Hospital, New Zealand were identified and data collected. Utilisation of ICU-specific resources and the occurrence of complications in relation to ICU discharge were recorded. RESULTS: Fifty-two patients underwent oesophagectomy between 1 January 2015 and 31 May 2019. The majority (75%) were extubated prior to admission to ICU, and only 8% required non-invasive positive pressure ventilation after extubation. Haemodynamic support with inotropic or vasopressor agents was required in 48% of patients. Most complications were managed in a non-ICU setting. The ICU readmission rate was 16%-all but one of these readmissions was following reoperation. CONCLUSION: This study shows a large proportion of post-operative oesophagectomy patients do not require ICU level support, however in the absence of a reliable pre-operative predictive tool, post-operative ICU care is still required in our setting. An individualised post-operative approach could be explored to help divert stable patients, potentially up to half of the group, away from ICU.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Esofagectomia , Utilização de Instalações e Serviços/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/terapia , Idoso , Auditoria Clínica , Cuidados Críticos/métodos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Alta do Paciente/estatística & dados numéricos , Segurança do Paciente , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos
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