Australian clinical review最新文献

This paper documents serial audits on technical aspects of the performance of fibre-optic examination of the large intestine by a number of proceduralists, in one institution, over 7 years. The completeness of the procedure and the associated morbidity are recorded and compared with results reported in the world literature. The study provides a clear demonstration of continuous quality improvement in practice.

In an effort to improve patient safety, some hospitals require that two nurses rather than one administer all medications. Such a policy has not been subjected to an economic evaluation. The authors conducted a cross-over study comparing error rates when medication was administered by two nurses as against a single nurse. During a 46 week study period, 319 errors were detected among 129,234 medications administered in a geriatric assessment and rehabilitation unit, giving an overall error rate of 2.5 per 1000 medications. The vast majority of errors detected were relatively minor and had no serious adverse consequences. The error rate per 1000 medications administered by a single nurse was 2.98 (95% CI: 2.45-3.51) and was statistically significantly higher than 2.12 (95% CI: 1.69-2.55) per 1000 for two nurses. A time and motion study indicated that when two nurses rather than one administered medication an additional 17.1 h of nursing time was required per 1000 medications administered. The authors conclude that the use of two nurses to administer medication does statistically significantly reduce the medication error rate, but the clinical advantages are dubious and in our view such a policy cannot be recommended.

In 1991 the third of a series of trials of concurrent case note screening was conducted over a 4 month period in one surgical and one medical unit of a busy metropolitan public teaching hospital in South Australia. The conclusion reached was that there is insufficient evidence of consistent improvement to justify the continuation of this expensive method of quality assurance. Traditional monitoring of performance by consultants, perhaps with the aid of computer-assisted management information, should achieve similar results.

A retrospective review of 279 hospital admissions at two Melbourne hospitals was conducted to develop a method for identifying diagnostic error using the Injury Severity Score (ISS) as a model for clinical audit. Two scores were calculated for each patient, the first according to injuries diagnosed on initial assessment in the Emergency Department and the second according to final, confirmed diagnoses upon discharge from hospital. Diagnostic errors were identified as discrepancies between the initial and final scores. ISS discrepancies were found in 48 cases (17.2%). Some were clinically significant errors of diagnosis while others reflected inaccurate injury description or record keeping. Abdominal injuries were the most frequently missed, followed in decreasing order by spinal, thoracic, extremities (limbs), head/face and external injuries (skin and subcutaneous tissues). The frequency and pattern of injury misdiagnosis concurs with the findings of other studies. The diagnostic error rate was found to increase with injury severity and with the number of anatomic body regions involved. The authors suggest that comparing initial and final ISS provides a convenient mechanism for the audit of early diagnosis in trauma cases.

A computer search in the New South Wales (NSW) Department of Health statistical data base was made to obtain the medical record numbers of patients who had had hysterectomies in the public or private hospitals of the Hunter Area of the State during the years 1987-89. The medical records of patients so identified were then extracted and reviewed by a medical team. The age at and the principal indication for hysterectomy were noted in each case and these data were then compared with those for the rest of NSW. The hysterectomy rate in the Hunter Area was 66.5 per 10,000 women aged 15 years or more, compared with a rate of 33.8 per 10,000 in the rest of NSW. When the 9.04% of hysterectomies performed on patients whose domicile was outside the Hunter Area were excluded, the corrected hysterectomy rate for the area was 57.46 per 10,000 women. The commonest indications for hysterectomy were menorrhagia (25.4%) and fibroids (15.32%). The limitations of this kind of retrospective study are discussed and suggestions are made for an improved methodology to be used in a future study.

Laparoscopic cholecystectomy is rapidly diffusing throughout Australia. Its advantages are low morbidity, fast recovery and lower overall costs compared with open cholecystectomy. However several issues need to be addressed in relation to this procedure such as adequate training, use of disposable instruments, suitability as an outpatient treatment, and cost and payment questions.

Objective: To assess patient satisfaction with day surgery facilities in New South Wales public hospitals.

Method: One hundred and fifty patients from each of 8 day surgery units were asked to complete a self-administered questionnaire to assess satisfaction with their day surgery experience, including details on their admission, care and postoperative course. The questionnaire responses were anonymous and there was no follow-up of non-respondents.

Results: The overall response rate to the questionnaire was 37.3%. There was considerable variation in response rates across hospitals, ranging from a low of 14.7% to a high of 52.7%. Three procedures accounted for 55% of responses: endoscopies of the gastrointestinal tract (21.7%), gynaecological procedures (18.3%) and eye procedures (16.3%). Day surgery was generally well accepted. Of all the respondents, 78.4% would recommend day surgery to others and 94.2% would recommend the day surgery unit that they used. Respondents found their day surgery experience to be as they had expected or less worrying than expected in 87.0% of cases. The proportion requiring hospital readmission in the seven day postoperative period was 2.7%. The survey showed that the units operated quite differently in two aspects of day surgery provision: the scheduling of patient admissions; and post-discharge contact with patients to check on their recovery.

The introduction of Total Parenteral Nutrition (TPN) in the treatment of malnourished patients with unusable gastrointestinal tracts has become commonplace throughout the world. However there are significant metabolic (4.2 to 7.7%) and septic (7 to 27%) complications associated with this therapy. In 1984 a TPN committee was formed at Royal Newcastle Hospital and a TPN nurse was appointed. This series documents the use of TPN at Royal Newcastle Hospital from August 1984 to July 1989. There were 251 patients who received TPN, representing 3422 days of TPN. The primary catheter sepsis rate was 10.4% at the commencement of the series and decreased appreciably to 3.2%. The formation of the TPN committee and the appointment of a TPN nurse have represented a considerable cost in time and money but this action has been justified by the drop in the sepsis rate resulting in a decrease in morbidity and mortality associated with TPN.