Journal of quality in clinical practice最新文献

Abstract The use of oral anticoagulation therapy (ACT) is expanding. Due to the combination of the narrow therapeutic range and relatively unpredictable pharmacokinetics and pharmacodynamics, there are relatively high risks involved in using this treatment. The purpose of this paper is to present the results of a focus group’s canvassing of ways to improve the management of the use of oral anticoagulants. Recommendations proposed include: (i) better patient selection; (ii) more patient involvement and research into the appropriateness of the current use of ACT in Australia; (iii) increased production, dissemination and implementation of ACT guidelines; (iv) assessment of home and practice ACT monitoring; and (v) research into the effectiveness of academic detailing and the use of management plans by dedicated ACT educators.

Abstract A voluntary, anonymous incident-monitoring study was set up to identify and characterize events or circumstances which could have or did harm a patient in general practice. The study included 673 practitioners who made 2582 reports, of which half (n = 1294) involved medication problems. Amongst these reports, 1556 adverse drug events (ADE) were identified. More common in general practice than in hospitals were problems with therapeutic use (26% vs. 8%), and prescribing of contraindicated medications (15% vs. 5%). In the latter group, 64 reports (4%) involved the prescription of a medication to which the patient was known to be allergic, 66 (4%) involved medication for which there was a recognized potential for a drug interaction, and 68 (4%) involved contraindicated medications due to pathophysiological factors. It was estimated that computer-based prescribing with decision support could eliminate at least a third of these problems in general practice. Further studies are needed to develop this and other preventive strategies.

Abstract Musculoskeletal conditions afflict most of us at some time in our lives, and we all have relatives and friends who suffer the pain and disability sometimes associated with conditions such as back or neck pain, fibrositis and osteoarthritis. The goal of those of us who try to help individuals with these conditions is to achieve effective, but also safe, management of their musculoskeletal disorders, the commonest symptom of which is pain. This goal can be achieved by better diagnosis and problem formulation (allowing better selection of treatment options); informed selection of non-drug and drug therapeutic options, based on relative cost-benefit considerations; and the judicious, appropriate and safe use of drugs, particularly non-steroidal anti-inflammatory drugs (NSAID). Setting realistic goals and maintaining regular surveillance of patients are also important considerations. Finally, the active involvement of the patient in their own management is associated with better and safer outcomes.

Abstract Clinical pathways have been introduced in many hospitals with the aims of improving efficiency, reducing costs, and improving the quality and outcomes of care. However, there is a shortage of research evidence regarding the extent to which they do in fact achieve such aims. This paper describes the development and testing of a patient-perceived quality-of-care questionnaire for use in relation to the assessment of clinical pathways. Issues of validity and reliability are addressed and illustrative examples of results for two pilot hospitals are presented.

Abstract There is a growing realization in the health system that integration of effort may be the best way of ensuring optimal outcomes of management both for clinicians and for people using the health system. It is also hypothesized that the impact of diabetes (chronic disease) and its sequelae could be reduced by the provision of well-organized care, based on agreed evidence-based guidelines for best practice, incorporating patient education and early detection of complication. This paper defines the characteristics of an integrated model of providing care to people with diabetes.

Abstract The aim of the study was to examine the characteristics of asthma education programs within NSW. A cross-sectional questionnaire survey concerning the aims and characteristics of 42 asthma education programs was administered to members of the Asthma Educators Association (AEA) of NSW. While most programs sought to improve asthma knowledge (78%), only a small number sought to improve asthma management skills (38%), asthma control (33%) and attitudes (10%). Most programs performed one-to-one (69%) education. Medical intervention was under-utilized by most programs and only 4% gave feedback to the referring doctor. Program evaluation was incompletely linked to program aims. There was incomplete evaluation of knowledge gain as an outcome. The study reviewed the characteristics of education programs within NSW. Existing programs appropriately employ a variety of educational methods and target a broad range of people with asthma. There remains a need to use a combined approach utilizing education and medical management, and to employ methods to evaluate programs.

Critical Incident Monitoring (CIM) as an instrument of quality assurance (QA) has received increasing attention in recent years. The present study was developed to explore a potential role for CIM in QA for clinical psychiatry. A questionnaire was sent to psychiatrists and requested retrospective reporting of clinical incidents, and a pilot study of an inpatient-based incident reporting system was performed. All Fellows of the Royal Australian and New Zealand College of Psychiatry (RANZCP) were sent a questionnaire. Eight psychiatric inpatient services were invited to participate in the pilot study. The returns of the questionnaires were aggregated and analysed to reveal a relatively small number of separate incident types, with little difference between the ‘adverse outcome’ and ‘near-miss’ categories. Similar results were found with the pilot study. It was concluded that the development of a unified incident reporting system for use by psychiatric clinicians and psychiatric services may add usefully to existing quality improvement processes.

This study examined the impact of the introduction of laparoscopic cholecystectomy (LC) on the rate and pattern of cholecystectomy in New South Wales, Australia. An analysis of the hospital data for the period 1981–94/95 was performed, which encompassed patients of both public and private hospitals. Cholecystectomy rates in the years after the introduction of LC in mid-1990 were 24% higher on average than rates in the prior years and rose from an average 1.68–2.09 per 1000. In the 5-year period of the study after the introduction of LC, the average age of private hospital patients increased from 50.6 to 53.4^·years, while that of public hospital patients declined slightly from 53.5 to 52.4^·years. Laparoscopic cholecystectomy was introduced more rapidly in private than public hospitals. By June 1995, 96% of private compared with 71% of public hospitals had introduced LC, and cholecystectomy patients in private hospitals were more likely to have laparoscopic surgery than patients in public hospitals (92% compared with 80%). The introduction of LC has been accompanied by a marked and sustained increase in the cholecystectomy rate. While the unit cost for the laparoscopic procedure is lower because of a shorter length of stay, the increase in the number of procedures means that there have been no net savings for the health system from the increased efficiency. While the new procedure offers superior advantages to patients with symptomatic gallbladder disease, the effect of the apparent lower threshold for surgery needs investigation.

Abstract Functional status indicators have been proposed as instruments to aid health service planning for patients. This study examines functional status at three points surrounding an acute health episode: admission, discharge and 3 months post discharge from a community hospital. The aim of the study is to determine the most appropriate time to measure functional status to assist health service planning. A longitudinal cohort study was conducted at Manly Hospital, Australia. Four hundred patients aged 65 years and over representing a 10% random sample of all hospital admissions in a 10-month period were interviewed on admission, discharge and 3 months post discharge. Repeated measure multiple analysis of variance identified a decline in functional status between admission and discharge. At 3 months post discharge functional status had improved to levels higher than admission. Functional status assessment at discharge can assist consumers, clinicians, health planners and health insurers to make effective decisions to maximize health outcomes.

The microbiology and severity of suspected infections in children with cancer admitted to the John Hunter Children’s Hospital was determined in order to assess whether any alteration to the infection treatment protocol was required. All children with cancer aged 1–17 years who had an episode of suspected or proven infection that required parenteral treatment at John Hunter Children’s Hospital (JHCH) during 1994/95 were reviewed. Thirty-seven children were treated for cancer at JHCH; 62 admissions for suspected infection which involved 26 children were reviewed. Sixteen of these children had a permanent central line. Children with a central line had an increase in the number of days of inpatient treatment required for the treatment of suspected infection, and they had more episodes of infection. A pathogen was isolated more frequently with blood cultures being positive more often and Gram- positive species were methicillin resistant more often. These differences were not statistically significant. A pathogen was isolated in 52% of admissions. Sixteen pathogens were Gram positive; 12 were Gram negative, two were fungal and two were viral. Blood cultures were positive in 21 of 62 admissions, skin swabs in four admissions, urine cultures in three admissions, stool in two admissions and one species was isolated from an epidural catheter tip and from the sputum. In 16% of admissions, the identified organism was resistant to the initial empirical therapy of tobramycin and piperacillin. In a further 13%, flucloxacillin was added to the empirical regimen when a sensitive Staphylococcus was identified. No significant differences between the culture-negative and culture-positive groups were observed in admission pulse, fever or admission neutrophil count. However, those patients with a central line had a higher incidence of having a pathogen isolated if their temperature was > 39.5°C. The median length of stay was longer for patients with a pathogen isolated on blood culture. Admission blood cultures were positive in 53% of admissions with an initial neutrophil count > 1000 × 10⁹/mL. Each of these children had a central line. Only one child died of infection during the 2-year study period. This review supports the observations that Gram-positive infection is now more common than Gram-negative infection in children with cancer. Despite the management advantages a permanent central line affords it is clear those children with a central line have an increased rate of infection and there needs to be caution in their use. The most important is the observation that any fever > 39.5°C in a child with a central line is likely to be associated with a documented infection irrespective of the neutrophil count. The clinical outcomes observed in the present study indicate that tobramycin and piperacillin are effective empirical treatments for suspected infection in children with cancer.