MAAGs: the next generation. A study of the development of medical audit advisory groups and the arrangements for supporting clinical audit in primary care

Background: MAAGs have, historically, been disparate organisations with a lack of central direction, albeit with the same goal: to develop and support the performance of audit in primary care. This goal has been (and is being) achieved in a number of ways all over the country. In the last two years, MAAGs have witnessed many changes in primary care and are adapting themselves to suit these new arrangements at a local level.

Aim: To formalise our knowledge of where MAAGs are going, how they are getting there and the support they are receiving.

Method: A postal questionnaire to the 104 MAAGs in England and Wales, addressing 6 main issues of relevance to the development of MAAGs and the support they are receiving.

Results: At least two MAAGs have dissolved, leaving a possible total of 102 still in existence. Of these, 76 (74.5%) responded to the survey. The composition of the MAAG committee has changed dramatically since the inception of MAAGs in 1990, and staffing levels appear to have risen substantially. MAAGs appear to be more adequately funded by their health authorities than has previously been reported and many are actively seeking additional sources of funding. There is still large variation in levels of MAAG funding. Furthermore, funding is unrelated to the number of GPs or practices served. Security for MAAG staff appears to have been addressed in many areas, with 84% of MAAGs having at least one member of staff on a permanent employment contract. Many MAAGs are developing rolling programmes in an attempt to eliminate the short-sighted approach to the development of clinical audit that has existed since MAAGs were first set up.

Conclusion: Many MAAGs (with the obvious exception of those that have been dissolved) appear to be thriving without central direction or initiative. It is now evident that we were a little hasty in our concerns for the future of MAAGs beyond April 1996. It would seem that many organisations have taken the situation which arose two years ago as an opportunity to grow and develop in ways that may not have been possible within the confines of the Health Circular.

Doctors under the microscope: the birth of medical audit

In 1989 a UK government White Paper introduced medical audit as a comprehensive and statutory system of assessment and improvement in quality of care in hospitals. A considerable body of research has described the evolution of medical audit in terms of a struggle between doctors and National Health Service managers over control of quality assurance. In this paper we examine the emergence of medical audit from 1910 to the early 1950s, with a particular focus on the pioneering work of the American surgeons Codman, MacEachern and Ponton. It is contended that medical professionals initially created medical audit in order to articulate a suitable methodology for assessing individual and organisational performance. Rather than a means of protecting the medical profession from public scrutiny, medical auditing was conceived and operationalised as a managerial tool for fostering the active engagement of senior hospital managers and discharging public accountability. These early debates reveal how accounting was implicated in the development of a system for monitoring and improving the work of medical professionals, advancing the quality of hospital care, and was advocated in ways, which included rather than excluded managers.

Discharge communication from inpatient care: an audit of written medical discharge summary procedure against the new National Health Service Standard for clinical handover

OBJECTIVE: To audit written medical discharge summary procedure and practice against Standard Six (clinical handover) of the Australian National Safety and Quality Health Service Standards at a major regional Victorian health service. METHODS: Department heads were invited to complete a questionnaire about departmental discharge summary practices. RESULTS: Twenty-seven (82%) department heads completed the questionnaire. Seven (26%) departments had a documented discharge summary procedure. Fourteen (52%) departments monitored discharge summary completion and 13 (48%) departments monitored the timeliness of completion. Seven (26%) departments informed the patient of the content of the discharge summary and six (22%) departments provided the patient with a copy. Seven (26%) departments provided training for staff members on how to complete discharge summaries. Completing discharge summaries was usually delegated to the medical intern. CONCLUSIONS: The introduction of the National Service Standards prompted an organisation-wide audit of discharge summary practices against the external criterion. There was substantial variation in the organisation's practices. The Standards and the current audit results highlight an opportunity for the organisation to enhance and standardise discharge summary practices and improve communication with general practice.

An audit of first-aid treatment of pediatric burns patients and their clinical outcome

This study describes the first aid used and clinical outcomes of all patients who presented to the Royal Children's Hospital, Brisbane, Australia in 2005 with an acute burn injury. A retrospective audit was performed with the charts of 459 patients and information concerning burn injury, first-aid treatment, and clinical outcomes was collected. First aid was used on 86.1% of patients, with 8.7% receiving no first aid and unknown treatment in 5.2% of cases. A majority of patients had cold water as first aid (80.2%), however, only 12.1% applied the cold water for the recommended 20 minutes or longer. Recommended first aid (cold water for >or=20 minutes) was associated with significantly reduced reepithelialization time for children with contact injuries (P=.011). Superficial depth burns were significantly more likely to be associated with the use of recommended first aid (P=.03). Suboptimal treatment was more common for children younger than 3.5 years (P<.001) and for children with friction burns. This report is one of the few publications to relate first-aid treatment to clinical outcomes. Some positive clinical outcomes were associated with recommended first-aid use; however, wound outcomes were more strongly associated with burn depth and mechanism of injury. There is also a need for more public awareness of recommended first-aid treatment.

Therapeutic upper gastrointestinal endoscopy in children : An audit of 443 procedures and literature review

The safety, effectiveness and capabilities of therapeutic upper fibreoptic endoscopy in children undergoing therapeutic endoscopic procedures (n = 443) was studied. Therapy for gastrointestinal bleeding formed the major group (injection sclerotherapy for varices, n = 197 procedures; thermocoagulation for haemorrhagic gastritis, n = 1; and photocoaulation for Dieulafoy's disease, n = 1). Sclerotherapy was 97% effective in controlling acute bleeding and 84% effective in obliterating varices with no serious complications or deaths. Oesophageal dilatations for surgical, caustic, congenital and peptic strictures and achalasia (n = 193) were performed with no oesophageal perforations or deaths. Foreign bodies were retrieved (n = 34) with no failures or complications. Percutaneous endoscopic gastrostomy was performed (n = 11) with one failure, proceeding to an unsuccessful surgical gastrostomy. Miscellaneous procedures included endoscopic transpyloric tube placement (n = 5) and endoscopic diathermy of pyloric web (n = 1). Therapeutic fibreoptic endoscopy is therefore concluded to be safe and effective in children, replacing rigid oesophagoscopy and some traditional surgical approaches.

Uptake of new treatment strategies for deep vein thrombosis: an international audit.

OBJECTIVE: Study of the uptake of new medical technologies provides useful information on the transfer of published evidence into usual practice. We conducted an audit of selected hospitals in three countries (Canada, France, and Switzerland) to identify clinical predictors of low-molecular-weight (LMW) heparin use and outpatient treatment, and to compare the pace of uptake of these new therapeutic approaches across hospitals. DESIGN: Historical review of medical records. SETTING AND PARTICIPANTS: We reviewed the medical records of 3043 patients diagnosed with deep vein thrombosis (DVT) in five Canadian, two French, and two Swiss teaching hospitals from 1994 to 1998. Measures. We explored independent clinical variables associated with LMW heparin use and outpatient treatment, and determined crude and adjusted rates of LMW heparin use and outpatient treatment across hospitals. RESULTS: For the years studied, the overall rates of LMW heparin use and outpatient treatment in the study sample were 34.1 and 15.8%, respectively, with higher rates of use in later years. Many comorbidities were negatively associated with outpatient treatment, and risk-adjusted rates of use of these new approaches varied significantly across hospitals. CONCLUSION: There has been a relatively rapid uptake of LMW heparins and outpatient treatment for DVT in their early years of availability, but the pace of uptake has varied considerably across hospitals and countries.

Audit of the Douglas Hocking Research Institute bone bank : ten years of non-irradiated bone graft

Background:  An audit performed in the use of non-irradiated femoral head bone graft at the Geelong Hospital over a 10-year period. While it is thought the non-irradiated bone graft provides a better structural construct there is theoretical increased risk of infection transmission.

Methods:  We performed a retrospective review of prospectively collected data in the use of non-irradiated bone allograft used from the Geelong Hospital Douglas Hosking Research Institute bone bank over a 10-year period. The review was performed using data collected from the bone bank and correlating it with the patient’s medical record. All complications, including infections, related to the use of the allograft were recorded.

Results:  We found that over the 10 years to 2004 that 811 femoral heads were donated, with 555 being used over 362 procedures in 316 patients. We identified a total of nine deep infections, of which seven were in joint replacements. Overall this was a 2.5% deep infection rate, which was lowered to 1.4% if the previously infected joints that were operated on were excluded.

Conclusion:  The use of non-irradiated femoral head bone graft was safe in a regional setting.

Wheeze, asthma diagnosis and medication use : a national adult survey in a developing country

Background As relatively little is known about adult wheeze and asthma in developing countries, this study aimed to determine the predictors of wheeze, asthma diagnosis, and current treatment in a national survey of South African adults. Methods A stratified national probability sample of households was drawn and all adults (>14 years) in the selected households were interviewed. Outcomes of interest were recent wheeze, asthma diagnosis, and current use of asthma medication. Predictors of interest were sex, age, household asset index, education, racial group, urban residence, medical insurance, domestic exposure to smoky fuels, occupational exposure, smoking, body mass index, and past tuberculosis. Results A total of 5671 men and 8155 women were studied. Although recent wheeze was reported by 14.4% of men and 17.6% of women and asthma diagnosis by 3.7% of men and 3.8% of women, women were less likely than men to be on current treatment (OR 0.6; 95% confidence interval (CI) 0.5 to 0.8). A history of tuberculosis was an independent predictor of both recent wheeze (OR 3.4; 95% CI 2.5 to 4.7) and asthma diagnosis (OR 2.2; 95% CI 1.5 to 3.2), as was occupational exposure (wheeze: OR 1.8; 95% CI 1.5 to 2.0; asthma diagnosis: OR 1.9; 95% CI 1.4 to 2.4). Smoking was associated with wheeze but not asthma diagnosis. Obesity showed an association with wheeze only in younger women. Both wheeze and asthma diagnosis were more prevalent in those with less education but had no association with the asset index. Independently, having medical insurance was associated with a higher prevalence of diagnosis. Conclusions Some of the findings may be to due to reporting bias and heterogeneity of the categories wheeze and asthma diagnosis, which may overlap with post tuberculous airways obstruction and chronic obstructive pulmonary disease due to smoking and occupational exposures. The results underline the importance of controlling tuberculosis and occupational exposures as well as smoking in reducing chronic respiratory morbidity. Validation of the asthma questionnaire in this setting and research into the pathophysiology of post tuberculous airways obstruction are also needed.

Sistema Único de Saúde: de que sistema se trata?

Constata-se que a reforma sanitária brasileira representa um avanço na direção de uma concepção avançada de sistema de saúde. Entretanto o SUS, com toda a materialidade das reformas ao nível macro induzidas a partir dos avanços na legislação, a implantação da regionalização e hierarquização da assistência, e dos instrumentos de gestão, assim como todas as grandes organizações modernas, padece de problemas de coordenação na operação de suas ações. Este trabalho pretende discutir as possibilidades e limites das mudanças organizacionais induzidas pela implementação do SUS na configuração dos sistemas locoregionais de saúde, à luz das experiências internacionais e das contribuições mais recentes das teorias organizacionais, no contexto da transição do fordismo à acumulação flexível. A partir do referencial da teoria dos sistemas, considera-se a contribuição das teorias organizacionais fordistas, pós-fordistas e pós-modernistas na especificidade do campo da saúde coletiva, para discutir a efetividade dos seus subsistemas cibernéticos do SUS: controle, avaliação, regulação, auditoria e vigilância em saúde, no complexo contexto da configuração do poder deste setor. Verifica-se que o SUS, constituído a partir de culturas organizacionais fordistas, do antigo INAMPS e da Saúde Pública tradicional, não tem obtido êxito em configurar estruturas organizacionais competentes, na medida em que reproduz os modelos tradicionais nos seus sistemas de controle. Esta dificuldade em parte deve-se ao momento histórico, que fez coincidir o momento dos avanços na legislação, em direção à ampliação do direito à saúde, com o momento das reestruturações dos aparelhos estatais decorrente da crise global do modo de produção fordista, e com as profundas transformações demográficas, epidemiológicas e da tecnologia da assistência médica. Por outro lado, a disponibilidade de soluções pósfordistas propicia um padrão para a conformação de novas regras e novos modos de regulação do sistema de saúde, que induzam a comportamentos auto-reguladores por parte dos prestadores de serviços de saúde, considerando as metas de equidade e de melhoria da saúde da população. Conclui-se que a necessária reforma do setor saúde demanda o fortalecimento de uma tecno-burocracia protegida contra injunções político-partidárias, que possibilite a incubação uma cultura organizacional profissional em todas as esferas de governo e níveis de gestão, que incentive um trabalho em saúde competente e moralmente comprometido com as finalidades do SUS nesse país.

Health problems among detainees in Switzerland: a study using the ICPC-2 classification.

BACKGROUND: Little is known about the health status of prisoners in Switzerland. The aim of this study was to provide a detailed description of the health problems presented by detainees in Switzerland's largest remand prison. METHODS: In this retrospective cross-sectional study we reviewed the health records of all detainees leaving Switzerland's largest remand prison in 2007. The health problems were coded using the International Classification for Primary Care (ICPC-2). Analyses were descriptive, stratified by gender. RESULTS: A total of 2195 health records were reviewed. Mean age was 29.5 years (SD 9.5); 95% were male; 87.8% were migrants. Mean length of stay was 80 days (SD 160). Illicit drug use (40.2%) and mental health problems (32.6%) were frequent, but most of these detainees (57.6%) had more generic primary care problems, such as skin (27.0%), infectious diseases (23.5%), musculoskeletal (19.2%), injury related (18.3%), digestive (15.0%) or respiratory problems (14.0%). Furthermore, 7.9% reported exposure to violence during arrest by the police. CONCLUSION: Morbidity is high in this young, predominantly male population of detainees, in particular in relation to substance abuse. Other health problems more commonly seen in general practice are also frequent. These findings support the further development of coordinated primary care and mental health services within detention centers.

Establecer la calidad de los exámenes médicos ocupacionales de ingresos reaIizados en las instituciones prestadoras de servicios de salud ocupacional en las ciudades de Tunja e Ibagué durante el segundo semestre del año 2009

¿Las instituciones prestadoras de servicios de salud ocupacional de las ciudades de Ibagué y Tunja realizan el examen ocupacional de ingreso cumpliendo con los requisitos mínimos de calidad establecidos en el marco jurídico vigente?

Reduced emergency calls and improved weekend discharge after introduction of a new electronic handover system

Objectives: To measure the frequency and content of electronic handover before and after implementation of the Blue BARRWUE handover system, and to measure its effect on patient safety and hospital efficiency over weekends.

Design, setting and participants: Point-prevalence study comparing outcomes for general medical inpatients present over weekends before implementation (1 May 2008 to 30 April 2009) and after implementation (1 May 2009 to 30 April 2010) of the Blue BARRWUE handover system at Geelong Hospital.

Intervention: Implementation of the Blue BARRWUE handover system and its components (updated working diagnosis, background, alerts, resuscitation status, requests, who to do what and when, updates and executable discharge plan).
Main outcome measures: Presence of any written handover notes or updated working diagnoses in the BOSSnet clinical information system, content of handover notes, frequency of weekend discharges and medical emergency team (MET) calls before and after implementation.

Results: In the 12 months before implementation of the Blue BARRWUE handover system, 976 patients (47.98%) had a handover note in BOSSnet, versus 1646 patients (95.09%) in the 12 months after implementation (P< 0.001; rate ratio [RR], 20.75; 95% CI, 16.33–26.44). Before implementation, 289 patients (14.21%) were discharged over weekends, versus 353 patients (20.39%) after implementation, (P < 0.001; RR, 1.44; 95% CI, 1.25–1.65). MET calls were made for 152 general medical patients before implementation (7.47%), versus 95 general medical patients (5.49%) after implementation (P= 0.01; RR, 0.73; 95% CI, 0.57–0.94).

Conclusions: The Blue BARRWUE system has sustainably improved written handover in our organisation and was associated with improvement in both patient safety and hospital efficiency.

Effects of patient-, environment- and medication-related factors on high-alert medication incidents.

To measure the rate of medication incidents associated with the prescription and administration of high-alert medications and to identify patient-, environment- and medication-related factors associated with these incidents.

Oxygen delivery to patients after cardiac surgery : a medical record audit

OBJECTIVE: To describe how intensive care nurses manage the administration of supplemental oxygen to patients during the first 24 hours after cardiac surgery.
METHODS: A retrospective audit was conducted of the medical records of 245 adult patients who underwent cardiac surgery between 1 January 2005 and 31 May 2008 in an Australian metropolitan hospital. Physiological data (oxygen saturation measured by pulse oximetry and respiratory rate) and intensive care unit management data (oxygen delivery device, oxygen flow rate and duration of mechanical ventilation) were collected at hourly intervals over the first 24 hours of ICU care.
RESULTS: Of the 245 patients whose records were audited, 185 were male; mean age was 70 years (SD, 10), and mean APACHE II score was 17.5 (SD, 5.14). Almost half the patients (122, 49.8%) were extubated within 8 hours of ICU admission. The most common oxygen delivery device used immediately after extubation was the simple face mask (214 patients, 87%). Following extubation, patients received supplemental oxygen via, on average, two different delivery devices (range, 1-3), and had the delivery device changed an average of 1.38 times (range, 0-6) during the 24 hours studied. Twenty-two patients (9%) received non-invasive ventilation or high-flow oxygen therapy, and 16 (7%) experienced one or more episode of hypoxaemia during mechanical ventilation. A total of 148 patients (60%) experienced one or more episodes of low oxygenation or abnormal respiratory rate during the first 24 hours of ICU care despite receiving supplemental oxygen.
CONCLUSION: These findings suggest that the ICU environment does not protect cardiac surgical patients from suboptimal oxygen delivery, and highlights the need for strategies to prompt the early initiation of interventions aimed at optimising blood oxygen levels in cardiac surgical patients in the ICU.