Journal of quality in clinical practice最新文献

Abstract Improving quality of health-care requires a systematic approach at many different levels within a health system. The levels range from the interactions between individual patient–health provider to the international stage. The provision of care within and between each level needs to be systematically organised if the quality of our health-care is to improve. There is a need to develop a systematic approach to the multiple systems within health care. An organisational structure similar to the Cochrane Collaboration may provide the mechanism to better co-ordinate all our efforts to improve health-care quality.

Abstract Hospitalized patients who require admission to residential care are often thought to make prolonged and inappropriate use of hospital resources. There are no Australian data on the factors that contribute to length of hospital stay for such patients. The aim of this study was to determine the timing of critical steps in discharge planning for hospitalized patients who need residential care. We prospectively audited 100 consecutive referrals to an Aged Care Assessment Team (ACAT) from one acute hospital in South Australia. Case notes were examined to determine the timings of critical events in discharge planning. We found 47% of patients were discharged to a nursing home, 16% to a hostel, 11% died, 10% returned home and 16% went to another facility. The average length of hospital stay was 27.2 days, and an average of 8.4 days elapsed before a decision to seek residential care was first recorded. A further 4.5 days elapsed before ACAT referral, 4.6 days before ACAT approval and 9.7 days before a residential care bed became available. We conclude that people admitted to our hospital from the community and who subsequently need residential care, spend 36% of their stay awaiting a residential care bed. Most of their hospital stay has elapsed before residential care is considered necessary and referral and approval processes have been activated. Strategies to reduce length of stay should perhaps focus on the earlier recognition of the need for residential care and accelerated referral and assessment processes. Earlier involvement by social work and occupational therapy should be considered.

Abstract Clinical pathways are being increasingly used for daily patient care. The pathways consist of a sequence of critical treatment events matched to the patient’s recovery. Variance analysis identifies deviations from the pathway and can be used for quality improvement and clinical audit. The aim of this study is to analyse the variances from clinical pathways in two common elective orthopaedic operations. A prospective variance analysis was performed from the clinical pathways of all patients undergoing total hip and total knee arthroplasty over a 12 month period. Variances were categorised according to their source and then further divided into serious and non-serious variances. A total of 65 patients underwent total knee replacement during the study. Eleven serious variances were recorded in eight of these patients (12.3%) with a surprisingly high number of cardiac events. A total of 52 patients underwent total hip replacement with nine serious variances recorded in seven of these patients (13.5%). Clinical pathways can be used as a means of incorporating evidence-based medicine into clinical practice. Variance analysis of the pathways can be utilised as a process of quality control and to improve patient outcomes. Serious variances within this study were higher than anticipated.

Abstract There are considerable opportunities for improving quality of health-care but also significant impediments. Identifying, investigating and responding to adverse events in a way that will limit their chance of recurrence is probably the single greatest opportunity for quality improvement. However, this requires a shift from a culture of blame to one that recognises such events as almost always a system failure. A general rule, the shorter the duration of a hospital admission, the safer it will be, but regrettably this is not well understood by the community. The considerable variation in rates of many medical and surgical interventions between private and public patients and between patients living in different localities provides a great opportunity for determining what rates produce the best health outcomes. It is probable that reducing the health problems of the socioeconomically disadvantaged, a major quality issue, will require innovative approaches to delivery of their health-care.

Abstract The incidence and management of pressure ulcers in hospitalised patients is an ongoing concern for nurses. Efforts to prevent pressure ulcer development are plagued with inconsistencies and a general lack of best practice guidelines. Establishing current practice approaches to the assessment, prevention and management of pressure ulcers is a necessary first step in the implementation of evidence-based/best practice guidelines. Anecdotal evidence suggested a range of different approaches were being used in a Sydney metropolitan area health service (AHS) to assess patients to identify those at risk, to prevent pressure ulcers and to treat existing ulcers. A collaborative research project was undertaken to examine current practice and to explore the apparent clinical variance. It involved the distribution of a questionnaire to registered nurses working within the AHS (n = 2113) and a review of nursing policy documents in the various hospitals in the health service area. While the overall response rate was satisfactory (40%) many of the returned questionnaires were incomplete. Only 21% (n = 444) of the questionnaires were deemed suitable for analysis. The findings highlight a range of inconsistencies within and across nursing practice domains. Nurses generally do not use a tool to assess pressure ulcer risk potential, but rely on a range of practice procedures and risk indicators to determine risk potential of developing pressure ulcers. Repositioning patients is the most common approach used in an attempt to prevent the development of pressure ulcers, but additional measures are diverse. Most nurses seem to be familiar with modern wound dressings such as hydrocolloids, foams and alginates in the treatment of second and third stage ulceration. However, the care provided by some nurses reflects an adherence to outdated practices, including the use of water filled gloves, povidone iodine and gauze packing.

Abstract Hip fractures are a growing problem and new models of care have been called for. However, patients from residential care are rarely considered in these discussions. Hip fracture is a common serious problem for older people in residential care with profound effects on subsequent mobility and quality-of-life. There are no Australian data documenting differences in hospital treatments offered to patients from the community and residential care to inform discussions. In a prospective audit we describe the treatment and 4 month outcomes of patients with fractured hips who were admitted to Flinders Medical Centre in South Australia from the community and residential care between August 1998 and June 1999. Information was collected on prefracture health, types of surgical and rehabilitation treatments and dependency. Of the 215 older adults who were admitted during this time, 183 agreed to participate (119 from community and 64 from residential care). Surgical management of the fracture was not affected by admission accommodation. Those from residential care had short hospital stays, less rehabilitation and access to physiotherapy. Although 61% of those from residential care were classified as independently mobile prefracture, by 4 months this had declined to 32% of survivors. Strategies to improve outcomes in those from residential care include: early identification of those walking independently prefracture with assessment by rehabilitation teams. Inclusion of liaison with community therapists in the clinical pathway and in selected cases use of ‘rehabilitation at home’ services to provide physiotherapy services should be considered.

Abstract Organizations that have engaged consumers in their work using traditional patient satisfaction tools have accomplished a number of significant outcomes. However, organizations are now being challenged to move into more meaningful collaborations with consumers regarding evaluating and improving services. This study describes and evaluates the effectiveness of consumer partnerships established to cover a project that lasted for about 4 months. Surveys were conducted with staff and consumers involved in the project. Structured questionnaires were used for both groups and the consumers were invited to focus interviews to explore specific issues. Issues regarding recruitment, preparation and management of consumers are important if satisfactory outcomes are to be realised. Further, staff attitudes and behaviours were examined that indicated staff shared the view that engagement of consumers was a worthwhile exercise. Quality consumer collaborations can bring about organizations being a highly valued community assets.

Abstract A retrospective audit to compare the performance of a colposcopy clinic with the standards set by National Health Service Cervical Screening Programme (NHSCSP) was carried out at Caerphilly District Miners Hospital, South Wales, United Kingdom. The study sample size consisted of 150 women who underwent colposcopy and diathermy large loop excision of the transformation zone (LLETZ) for abnormal cytology during January l995 to January 1998. The results showed deficiencies in the areas of communication for clinic appointments for women with high-grade cytology and in information given to general practitioners about test results. The services fell short of the standards in recording of colposcopy findings and grading of lesions. The rest of the parameters audited reached the NHSCSP standards. Recommendations to improve communication and to increase the objectivity of recording colpscopy findings were made. A more practical approach to set standards in areas of communication was suggested.

Abstract The Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S) project has been established to form a register of new surgical procedures which have been assessed for their safety and efficacy. The ASERNIP-S project systematically reviews the evidence and produces recommendations on the future use of surgical procedures in clinical practice. Further data may be collected to provide information on the outcomes of procedures in use in Australia. Horizon Scanning of new and emerging techniques and technologies complements the ASERNIP-S process. This research identifies procedures that will impact on clinical practice in the near future. Dissemination of information from ASERNIP-S assessments, both locally and internationally, is important for quality improvement. The ultimate aim is for appropriate changes in practice to ensure the highest quality of Australian healthcare.