Implementation of clinical audit to improve adherence to guideline-recommended therapy in acute coronary syndrome

Background Despite global consensus on the management of acute coronary syndrome (ACS), implementation of strategies to improve adherence of guideline-directed medical therapy (GDMT) remains sub-optimal, especially in developing countries. Thus, we aimed to assess the effect of clinical pharmacist-led clinical audit to improve the compliance of discharge prescriptions in patients admitted with ACS. It is a prospective clinical audit of ACS patients which was carried out for 12 months. The discharge prescriptions were audited by clinical pharmacists for the appropriateness in the usage of statins, dual antiplatelet therapy (DAPT), beta-blockers, and angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blocker (ARB). A feedback report was presented every month to the cardiologists involved in the patient care, and the trend in the adherence to GDMT was analyzed over 12 months. Results The discharge prescriptions of 1072 ACS patients were audited for the justifiable and non-justifiable omissions of mandated drugs. The first-month audit revealed unreasonable omissions of DAPT, statin, ACE-I/ARB, and beta-blockers in 1%, 0%, 14%, and 11% respectively, which reduced to nil by the end of the 11th month of the audit–feedback program. This improvement remained unchanged until the end of the 12th month. Conclusions The study revealed that periodic clinical audit significantly improves adherence to GDMT in patients admitted with ACS.

Fast-track hospital end-of-life discharge pathway: is it actually fast? National clinical audit

ObjectivesTo determine adherence to Department of Health and Social Care target of fast-track pathway discharge for end-of-life care within 48 hours.MethodsMulticentre audit in England using retrospective analysis of patient records for fast-track pathway tools submitted between 1 March 2019 and 31 March 2019.ResultsMost patients (72%) were not discharged within the 48-hour target. There was significant variability in success between hospital sites. Delays in discharge were most frequently considered to be secondary to delays in sourcing packages of care and 24-hour care facility placements. Involvement of specialist discharge nurses in paperwork submission improved rates by Commissioning Care Groups. Patients who died in hospital had significantly longer admissions than those who were discharged (discharged 19 days (IQR 11–28) vs died 28 days (IQR 18–42); p=0.039). This was entirely accounted for by increased numbers of days between admission and first suggestion of fast-track pathway discharge in those who died in hospital (discharged 9 days (IQR 5–19), died 15 days (IQR 9–33); p=0.003).ConclusionsWe demonstrated a delay in the fast-track pathway discharge process with significant variation in success of the discharge process at different geographical locations.

CAVITY PROBLEMS AND THEIR MANAGEMENT IN POST MODIFIED RADICAL MASTOIDECTOMY IN PEDIATRIC POPULATION - A CLINICAL AUDIT

Objective: To find out the intensity and frequency of cavity problems of persistent and recurrent ear discharge in young children and their management in post Modified Radical Mastoidectomy (MRM). Study Design: Cross sectional study. Place and Duration of Study: Department of ENT Head & Neck Surgery, Lady Reading Hospital MTI Peshawar Pakistan, from Jan 2015 to Dec 2019. Methodology: Fifty-four patients with cavity problems of persistent and recurrent ear discharge needing treatment were included in the study (out of the total patients 234 operated upon). Patients were followed up for one year for any discharge of the mastoid cavity. Patients of both gender of age 15 years or younger were included in the study. Results: In this study the cavity problems were found in 23.1% (54 out of 234) of the post modified radical mastoidectomy in pediatric population. There were no surgery related problems in 61.1% patients. In 38.9% (21 out of 54) percent patients repeat mastoidectomy was performed. Where as in 37% (20 out of 54) excision of granulation and conservative management was sufficient in curing the disease. High facial ridge was found to be the most common cause of persistent/recurrent discharge 9 out of 54 (16.7%). The independent variables (Indications for repeat mastoidectomy, Factors causing discharge, Surgery related problems) support the dependent variable treatment outcome. The sig/p-value was zero therefore the result was significant. Conclusion: In post Modified Radical Mastoidectomy, the cavity can be dry provided meticulous care is given to complete exenteration of disease from all areas........

Analysis of Pain Manifestation and Its Management in Adults

Introduction: Pain is link with significant disable due mobility, avoidance of activity, falls, depression and anxiety, sleep impairment, and isolation. Objectives: The main objective of the study is to clinically analyse the pain manifestation and its management in adults. Methods: This cross sectional clinical audit was done in Services hospital Lahore during January 2020 till June 2020. The data was collected from a large number of patients undergoing intermediate to major surgery and thus have high analgesic requirements. Medical folders that were not available or had missing notes were excluded. The folders were requested from the Medical Records Department and reviewed by four investigators. Results: The data was collected from 169 patients. The mean age of the patients was 38 years. Pain was assessed in 85 of the 168 patients (51%) (62 of the 110 urogynaecology patients; 23 of the 58 orthopaedic patients) and reassessed in 55 of the 85 patients (65%) who had received an initial pain assessment. The ward doctor (intern, registrar or specialist) assessed pain in 67% of the 85 patients evaluated. Conclusion: It is concluded that a significant proportion of the pain interventions appeared to be based on the professional knowledge of the practitioner and not supported by evidence-based guidelines of pain management.

Embedded trials within national clinical audit programmes: A qualitative interview study of enablers and barriers

Background Audit and feedback entails systematic documentation of clinical performance based on explicit criteria or standards which is then fed back to professionals in a structured manner. There are potential significant returns on investment from partnerships between existing clinical audit programmes in coordinated programmes of research to test ways of improving the effect of their feedback to drive greater improvements in health care delivery and population outcomes. We explored barriers to and enablers of embedding audit and feedback trials within clinical audit programmes. Methods We purposively recruited participants with varied experience in embedded trials in audit programmes. We conducted qualitative semi-structured interviews, guided by behavioural theory, with researchers, clinical audit programme staff and health care professionals. Recorded interviews were transcribed, and data coded and thematically analysed. Results We interviewed 31 participants (9 feedback researchers, 14 audit staff and 8 healthcare professionals, many having dual roles). We identified barriers and enablers for all 14 theoretical domains but no relationship between domains and participant role. We identified four optimal conditions for sustainable collaboration from the perspectives of stakeholders: resources, that is, recognition that audit programmes need to create capacity to participate in research, and research must be adapted to fit within each programme’s constraints; logistics, namely, that partnerships need to address data sharing and audit quality, while securing research funding to ensure operational success; leadership, that is, enthusiastic and engaged audit programme leaders must motivate their team and engage local stakeholders; and relationships, meaning that trust between researchers and audit programmes must be established over time by identifying shared priorities and meeting each partner’s needs. Conclusion Successfully embedding research within clinical audit programmes is likely to require compromise, logistical expertise, leadership and trusting relationships to overcome perceived risks and fully realise benefits.