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Medical record audit

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https://www.readbyqxmd.com/read/29776982/variable-effectiveness-of-stepwise-implementation-of-nudge-type-interventions-to-improve-provider-compliance-with-intraoperative-low-tidal-volume-ventilation
#1
Vikas N O'Reilly-Shah, George S Easton, Craig S Jabaley, Grant C Lynde
BACKGROUND: Identifying mechanisms to improve provider compliance with quality metrics is a common goal across medical disciplines. Nudge interventions are minimally invasive strategies that can influence behavioural changes and are increasingly used within healthcare settings. We hypothesised that nudge interventions may improve provider compliance with lung-protective ventilation (LPV) strategies during general anaesthesia. METHODS: We developed an audit and feedback dashboard that included information on both provider-level and department-level compliance with LPV strategies in two academic hospitals, two non-academic hospitals and two academic surgery centres affiliated with a single healthcare system...
May 18, 2018: BMJ Quality & Safety
https://www.readbyqxmd.com/read/29771994/prevalence-outcome-and-quality-of-care-among-children-hospitalized-with-severe-acute-malnutrition-in-kenyan-hospitals-a-multi-site-observational-study
#2
Susan Gachau, Grace Irimu, Philip Ayieko, Samuel Akech, Ambrose Agweyu, Mike English
BACKGROUND: Severe acute malnutrition (SAM) remains a major cause of admission and inpatient mortality worldwide in children aged less than 5 years. In this study, we explored SAM prevalence and outcomes in children admitted in 13 Kenyan hospitals participating in a Clinical Information Network (CIN). We also describe their immediate in-patient management. METHODS: We analyzed data for children aged 1-59 months collected retrospectively from medical records after discharge...
2018: PloS One
https://www.readbyqxmd.com/read/29750227/facilitators-context-of-and-barriers-to-acute-coronary-syndrome-care-at-kenyatta-national-hospital-nairobi-kenya-a-qualitative-analysis
#3
Ehete Bahiru, Tecla Temu, Julia Mwanga, Kevin Ndede, Sophie Vusha, Bernard Gitura, Carey Farquhar, Frederick Bukachi, Mark D Huffman
BACKGROUND: The prevalence of ischaemic heart disease and its acute manifestation, acute coronary syndrome (ACS), is growing throughout sub-Saharan Africa, including Kenya. To address this increasing problem, we sought to understand the facilitators, context of and barriers to ACS care at Kenyatta National Hospital, with the aim of improving the quality of care of ACS. METHODS: We conducted in-depth interviews with healthcare providers involved in the management of ACS patients from January to February 2017 at Kenyatta National Hospital in Nairobi, Kenya...
April 20, 2018: Cardiovascular Journal of Africa
https://www.readbyqxmd.com/read/29741519/addressing-prescription-discrepancies-in-renal-patients-a-prospective-audit
#4
S Lam, S Docherty, J E Taylor
Background Management of chronic renal failure requires complex medication regimens to manage hypertension, hyperlipidaemia, diabetes, phosphate, anaemia and acidosis. Patient engagement in medicine management is essential to avoid potential harm. Methods We prospectively audited the rate of discrepancies between our hospital record of patient medications and their current prescription. We investigated whether changes to appointment letters reduced the number of discrepancies. Results The proportion of patients attending renal outpatient clinics failing to bring a list or unable to recall their medications fell over a 3-year period following changes to appointment letters (median proportion: 0...
March 2018: Journal of the Royal College of Physicians of Edinburgh
https://www.readbyqxmd.com/read/29740931/antimicrobial-prescription-in-patients-dying-from-chronic-obstructive-pulmonary-disease
#5
John Taverner, Lauren Ross, Claire Bartlett, M Luthe, J Ong, Louis Irving, Natasha Smallwood
INTRODUCTION: Despite rising antimicrobial resistance, treatment guidelines for COPD exacerbations are frequently ignored. Patients with terminal conditions are often prescribed antimicrobials despite the goal of care to reduce burdensome treatments. The appropriateness of antimicrobials in patients dying from an exacerbation of COPD is unknown. AIM: To review antimicrobial prescription at the time of death in patients who died from COPD. METHODS: A retrospective medical record audit was performed for 475 patients who died over twelve years (2004-2015)...
May 9, 2018: Internal Medicine Journal
https://www.readbyqxmd.com/read/29737196/changing-characteristics-of-a-psychiatric-emergency-care-centre-an-eight-year-follow-up-study
#6
Joanne Seymour, Tristan Chapman, Vladan Starcevic, Kirupamani Viswasam, Vlasios Brakoulias
OBJECTIVE: The objective of this study was to report changes in characteristics of admissions to an established Psychiatric Emergency Care Centre (PECC) eight years after its opening. METHOD: Key clinical characteristics of admissions to the PECC were documented for 327 patients in 2015 and compared with the 477 patients in 2007, which is when the centre first opened. The characteristics of admission were evaluated using an audit of medical records from June to December in both 2007 and 2015...
May 1, 2018: Australasian Psychiatry: Bulletin of Royal Australian and New Zealand College of Psychiatrists
https://www.readbyqxmd.com/read/29735826/cytomegalovirus-reactivation-and-disease-amongst-patients-with-allogeneic-haematopoietic-stem-cell-transplantation-in-eastern-india-epidemiology-outcome-and-healthcare-cost
#7
Meet Kumar, Mita Roychowdhury, Jeevan Kumar, Anusha Harishankar, Subir Sinha, Saurabh Jayant Bhave, Anupam Chakrapani, Vivek Radhakrishnan, Reena Nair, Sanjay Bhattacharya, Mammen Chandy
Purpose: Data from developing countries about incidence, prognosis and healthcare cost of cytomegalovirus (CMV) reactivation amongst patients with allogeneic hematopoietic stem cell transplantation (AHSCT) remain scarce. The purpose of the study was to describe the epidemiology, outcome and cost implications of CMV reactivation and CMV disease amongst patients with AHSCT in cancer hospital in Eastern India. Materials and Methods: The study design was a retrospective audit of clinical records...
January 2018: Indian Journal of Medical Microbiology
https://www.readbyqxmd.com/read/29733870/prevalence-and-geographical-distribution-of-insulin-pump-therapy-in-the-central-denmark-region-and-its-association-with-metabolic-parameters
#8
Ulla Kampmann, Lene Ring Madsen, Lasse Bjerg, Daniel R Witte, Kjeld Hasselstrøm, Torben Østergård, Kirsten Alstrup, Marianne Kleis Møller, Dorrit Dylmer, Klavs Würgler Hansen
AIMS: Insulin treatment in type 1 diabetes encompasses multiple daily insulin injections (MDI) or continuous subcutaneous insulin infusion (CSII). Both population-based studies and comparative studies regarding CSII use are sparse. The aim of the current study was to describe the prevalence and distribution of CSII use among adults with type 1 diabetes in the Central Denmark Region and to compare metabolic control in CSII-treated patients to those treated with MDI. METHODS: A database was constructed using the Danish Adult Diabetes Registry in 2014/2015 in combination with an audit of the patients' medical records...
May 4, 2018: Diabetes Research and Clinical Practice
https://www.readbyqxmd.com/read/29730103/value-of-routine-preoperative-tests-for-coagulation-before-elective-cranial-surgery-results-of-an-institutional-audit-and-a-nationwide-survey-of-neurosurgical-centers-in-pakistan
#9
Naveed Zaman Akhunzada, Muhammad Bilal Tariq, Saad Akhtar Khan, Sidra Sattar, Wajeeha Tariq, Muhammad Shahzad Shamim, Samie Asghar Dogar
Routine preoperative blood testing has become a dogma. The general practice is to order preoperative work up as a knee jerk response rather than individualize it for each patient. The fact that the bleeding brain tends to swell, which coupled with limited options for proximal control, packing and overall hemostasis, leads to an over emphasis on preoperative coagulation profile. MATERIAL AND METHODS: This is a retrospective review of the medical records of patients admitted at Aga Khan University Hospital from January 2010 to December 2015 for an elective craniotomy...
May 3, 2018: World Neurosurgery
https://www.readbyqxmd.com/read/29725636/treatment-of-hyperkalemia-with-a-low-dose-insulin-protocol-is-effective-and-results-in-reduced-hypoglycemia
#10
Bairbre A McNicholas, Mai H Pham, Katrina Carli, Chang Huei Chen, Nancy Colobong-Smith, Arthur Eric Anderson, Hien Pham
Introduction: Complications associated with insulin treatment for hyperkalemia are serious and common. We hypothesize that, in chronic kidney disease (CKD) and end-stage renal disease (ESRD), giving 5 units instead of 10 units of i.v. regular insulin may reduce the risk of causing hypoglycemia when treating hyperkalemia. Methods: A retrospective quality improvement study on hyperkalemia management (K+  ≥ 6 mEq/l) from June 2013 through December 2013 was conducted at an urban emergency department center...
March 2018: KI Reports
https://www.readbyqxmd.com/read/29721670/non-verbal-communication-in-a-neonatal-intensive-care-unit-a-video-audit-using-non-verbal-immediacy-scale-nis-o
#11
Somashekhar Marutirao Nimbalkar, Himalaya Raval, Satvik Chaitanya Bansal, Utkarsh Pandya, Ajay Pathak
Effective communication with parents is a very important skill for pediatricians especially in a neonatal setup. The authors analyzed non-verbal communication of medical caregivers during counseling sessions. Recorded videos of counseling sessions from the months of March-April 2016 were audited. Counseling episodes were scored using Non-verbal Immediacy Scale Observer Report (NIS-O). A total of 150 videos of counseling sessions were audited. The mean (SD) total score on (NIS-O) was 78.96(7.07). Female counseled sessions had significantly higher proportion of low scores (p < 0...
May 3, 2018: Indian Journal of Pediatrics
https://www.readbyqxmd.com/read/29720209/cluster-randomised-controlled-trial-of-a-theory-based-multiple-behaviour-change-intervention-aimed-at-healthcare-professionals-to-improve-their-management-of-type-2-diabetes-in-primary-care
#12
Justin Presseau, Joan Mackintosh, Gillian Hawthorne, Jill J Francis, Marie Johnston, Jeremy M Grimshaw, Nick Steen, Tom Coulthard, Heather Brown, Eileen Kaner, Marko Elovainio, Falko F Sniehotta
BACKGROUND: National diabetes audits in the UK show room for improvement in the quality of care delivered to people with type 2 diabetes in primary care. Systematic reviews of quality improvement interventions show that such approaches can be effective but there is wide variability between trials and little understanding concerning what explains this variability. A national cohort study of primary care across 99 UK practices identified modifiable predictors of healthcare professionals' prescribing, advising and foot examination...
May 2, 2018: Implementation Science: IS
https://www.readbyqxmd.com/read/29716772/an-audit-of-the-reliability-of-influenza-vaccination-and-medical-information-extracted-from-ehealth-records-in-general-practice
#13
Annette K Regan, Robyn A Gibbs, Paul V Effler
To evaluate the reliability of information in general practice (GP) electronic health records (EHRs), 2100 adult patients were randomly selected for interview regarding the presence of specific medical conditions and recent influenza vaccination. Agreement between self-report and data extracted from EHRs was compared using Cohen's kappa coefficient (k) and interpreted in accordance with Altman's Kappa Benchmarking criteria; 377 (18%) patients declined participation, and 608 (29%) could not be contacted. Of 1115 (53%) remaining, 856 (77%) were active patients (≥3 visits to the GP practice in the last two years) who provided complete information for analysis...
April 28, 2018: Vaccine
https://www.readbyqxmd.com/read/29704977/outcomes-of-an-innovative-evidence-based-practice-project-building-a-difficult-access-team-in-the-emergency-department
#14
Madeleine Whalen, Barbara Maliszewski, Rebecca Sheinfeld, Heather Gardner, Diana Baptiste
PROBLEM: Difficult venous access is a common problem in health care-especially in the emergency setting-that relies on quick diagnostics to differentiate patient acuities and administer critical medications. The creation of a dedicated team to address difficult venous access (DVA) is a possible solution to the problems of delayed venous access, yet no studies have been published on implementing such a team in the emergency department. METHODS: This was a quasi-experimental study in an urban emergency department...
April 25, 2018: Journal of Emergency Nursing: JEN: Official Publication of the Emergency Department Nurses Association
https://www.readbyqxmd.com/read/29701885/physical-deterioration-in-an-acute-mental-health-unit-a-quantitative-retrospective-analysis-of-medical-emergencies
#15
Joanne E Porter, Robyn Cant, Karen Missen, Anita Raymond, Anne Churchill
Nursing management of physical deterioration of patients within acute mental health settings is observed, recorded, and actively managed with the use of standardized Adult Deterioration Detection System (ADDS) charts. Patient deterioration may require the urgent assistance of a hospital rapid response or Medical Emergency Team. A five-and-a-half-year (2011-2016) audit of hospital-wide Medical Emergency Team attendances was conducted in an acute mental health unit of a single large 250 bed regional hospital in Victoria, Australia...
April 27, 2018: International Journal of Mental Health Nursing
https://www.readbyqxmd.com/read/29696473/impact-of-pacs-emr-integration-on-radiologist-usage-of-the-emr
#16
John Mongan, David Avrin
The purpose of this study was to objectively quantify the impact of implementing picture archiving and communication system-electronic medical record (PACS-EMR) integration on the time required to access data in the EMR and the frequency with which data are accessed by radiologists. Time to access a clinic note in the EMR was measured before and after integration with a stopwatch and compared by t test. An IRB-approved, HIPAA-compliant retrospective review of EMR access data from security audit logs was conducted for a 14-month period spanning the integration...
April 25, 2018: Journal of Digital Imaging: the Official Journal of the Society for Computer Applications in Radiology
https://www.readbyqxmd.com/read/29694456/a-matter-of-urgency-reducing-clinical-text-message-interruptions-during-educational-sessions
#17
Arielle Mendel, Anthony Lott, Lisha Lo, Robert Wu
BACKGROUND: Text messaging is increasingly replacing paging as a tool to reach physicians on medical wards. However, this phenomenon has resulted in high volumes of nonurgent messages that can disrupt the learning climate. OBJECTIVE: Our objective was to reduce nonurgent educational interruptions to residents on general internal medicine. DESIGN, SETTING, PATIENTS: This was a quality improvement project conducted at an academic hospital network...
April 25, 2018: Journal of Hospital Medicine: An Official Publication of the Society of Hospital Medicine
https://www.readbyqxmd.com/read/29691950/adapting-evidence-based-clinical-practice-guidelines-at-university-teaching-hospitals-a-model-for-the-eastern-mediterranean-region
#18
Yasser S Amer, Hayfaa A Wahabi, Manal M Abou Elkheir, Ghada A Bawazeer, Shaikh M Iqbal, Maher A Titi, Aishah Ekhzaimy, Khalid A Alswat, Rasmieh A Alzeidan, Lubna A Al-Ansary
RATIONALE, AIMS, AND OBJECTIVES: Clinical practice guidelines (CPGs) are significant tools for evidence-based health care quality improvement. The CPG program at King Saud University was launched as a quality improvement program to fulfil the international accreditation standards. This program was a collaboration between the Research Chair for Evidence-Based Healthcare and Knowledge Translation and the Quality Management Department. This study aims to develop a fast-track method for adaptation of evidence-based CPGs and describe results of the program...
April 24, 2018: Journal of Evaluation in Clinical Practice
https://www.readbyqxmd.com/read/29687753/cleaning-up-the-paper-trail-our-clinical-notes-in-open-view
#19
Gerard Lambe, Niall Linnane, Ian Callanan, Marcus W Butler
Purpose Ireland's physicians have a legal and an ethical duty to protect confidential patient information. Most healthcare records in Ireland remain paper based, so the purpose of this paper is to: assess the protection afforded to paper records; log highest risk records; note the variations that occurred during the working week; and observe the varying protection that occurred when staff, students and public members were present. Design/methodology/approach A customised audit tool was created using Sphinx software...
April 16, 2018: International Journal of Health Care Quality Assurance
https://www.readbyqxmd.com/read/29682538/root-cause-analysis-of-persistently-high-maternal-mortality-in-a-rural-district-of-indonesia-role-of-clinical-care-quality-and-health-services-organizational-factors
#20
Mohammad Afzal Mahmood, Ismi Mufidah, Steven Scroggs, Amna Rehana Siddiqui, Hafsa Raheel, Koentijo Wibdarminto, Bernardus Dirgantoro, Jorien Vercruyssen, Hayfaa A Wahabi
Background: Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. Method: Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays...
2018: BioMed Research International
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