Referral of patients to an anticoagulant clinic: implications for better management.
The quality of anticoagulant treatment of ambulatory patients is affected by the content of referral letters and administrative processes. To assess these influences a method was developed to audit against the hospital standard the referral of patients to one hospital anticoagulant clinic in a prospective study of all (80) new patients referred to the clinic over eight months. Administrative information was provided by the clinic coordinator, and the referral letters were audited by the researchers. Referral letters were not received by the clinic for 10% (8/80) of patients. Among the 72 referral letters received, indication for anticoagulation and anticipated duration of treatment were specified in most (99%, 71 and 81%, 58 respectively), but only 3% (two) to 46% (33) reported other important clinical information (objective investigations, date of starting anticoagulation, current anticoagulant dose, date and result of latest international normalised ratio, whether it should be the anticoagulant clinic that was eventually to stop anticoagulation, patients' other medical problems and concurrent treatment. Twenty two per cent (16/80) of new attenders were unexpected at the anticoagulant clinic. Most patients' case notes were obtained for the appointment (61%, 47/77 beforehand and 30% 23/77 on the day), but case notes were not obtained for 9% (7/77). The authors conclude that health professionals should better appreciate the administrative and organisational influences that affect team work and quality of care. Compliance with a well documented protocol remained below the acceptable standard. The quality of the referral process may be improved by using a more comprehensive and helpful referral form, which has been drawn up, and by educating referring doctors. Measures to increase the efficiency of the administrative process include telephoning the clinic coordinator directly, direct referrals through a computerised referral system, and telephone reminders by haematology office staff to ward staff to ensure availability of the hospital notes. The effect of these changes will be assessed in a repeat audit. (+info)
Evaluation of audit of medical inpatient records in a district general hospital.
OBJECTIVE: To evaluate an audit of medical inpatient records. DESIGN: Retrospective comparison of the quality of recording in inpatients' notes over three years (1988, 1989, 1990). SETTING: Central Middlesex Hospital. MATERIALS: Random sample of 188 notes per year drawn systematically from notes from four selected one month periods and audited by two audit nurses and most hospital physicians. MAIN MEASURES: General quality of routine clerking, assessment, clinical management, and discharge, according to a standardised, criterion based questionnaire developed in the hospital. RESULTS: 1988 was the year preceding the start of audit in the hospital, 1989 the year of active audit with implicit and loosely defined criteria, and 1990 the year after introduction and circulation of explicit criteria for note keeping. There was a significant trend over the three years in 21/56 items of the questionnaire, including recording of alcohol intake (x2 = 8.4, df = 1, p = 0.01), ethnic origin (x2 = 57, df = 1, p = 0.001), allergies and drug reactions (x2 = 10, df = 1, p = 0.01) at admission and of chest x ray findings (x2 = 8, df = 1, p = 0.01), final diagnosis (x2 = 5.6, df = 1, p = 0.025), and signed entries (x2 = 11.3, df = 1, p = 0.001). Documentation of discharge and notification of discharge to general practitioners was not significantly improved. CONCLUSIONS: Extended audit of note keeping failed to sustain an initial improvement in practice; this may be due to coincidental decline in feedback to doctors about their performance. (+info)
Survey of outpatient sputum cytology: influence of written instructions on sample quality and who benefits from investigation.
OBJECTIVES: To evaluated quality of outpatient sputum cytology and whether written instructions to patients improve sample quality and to identify variables that predict satisfactory samples. DESIGN: Prospective randomised study. SETTING: Outpatient department of a district general hospital. PATIENTS: 224 patients recruited over 18 months whenever their clinicians requested sputum cytology, randomized to receive oral or oral and written advice. INTERVENTIONS: Oral advice from nurse on producing a sputum sample (114 patients); oral advice plus written instructions (110). MAIN MEASURES: Percentages of satisfactory sputum samples and of patients who produced more than one satisfactory sample; clinical or radiological features identified from subsequent review of patients' notes and radiographs associated with satisfactory samples; final diagnosis of bronchial cancer. RESULTS: 588 sputum samples were requested and 477 received. Patients in the group receiving additional written instructions produced 75(34%) satisfactory samples and 43(39%) of them one or more sets of satisfactory samples. Corresponding figures for the group receiving only oral advice (80(31%) and 46(40%) respectively)were not significantly different. Logistic regression showed that radiological evidence of collapse or consolidation (p<0.01) and hilar mass (p<0.05) were significant predictors of the production of satisfactory samples. Sputum cytology confirmed the diagnosis in only 9(17%) patients with bronchial carcinoma. CONCLUSIONS: The quality of outpatients' sputum samples was poor and was not improved by written instructions. Sputum cytology should be limited to patients with probable bronchial cancer unsuitable for surgery. IMPLICATIONS: Collection of samples and requests for sputum cytology should be reviewed in other hospitals. (+info)
Need to measure outcome after discharge in surgical audit.
OBJECTIVE: To assess the accuracy of outcome data on appendicectomy routinely collected as part of a surgical audit and to investigate outcome in the non-audited period after discharge. DESIGN: Retrospective analysis of audit data recorded by the Medical Data Index (MDI) computer system for all patients undergoing emergency appendicectomy in one year; subsequent analysis of their hospital notes and notes held by their general practitioners for patients identified by a questionnaire who had consulted their general practitioner for a wound complication. SETTING: One district general hospital with four consultant general surgeons serving a population of 250,000. PATIENTS: 230 patients undergoing emergency appendicectomy during 1989. MAIN MEASURES: Comparison of postoperative complications recorded in hospital notes with those recorded by the MDI system and with those recorded by patients' general practitioners after discharge. RESULTS: Of the 230 patients, 29 (13%) had a postoperative complication recorded in their hospital notes, but only 14 (6%) patients had these recorded by the MDI system. 189 (82%) of the patients completed the outcome questionnaire after discharge. The number of wound infections as recorded by the MDI system, the hospital notes, and notes held by targeted patients' general practitioners were three (1%), eight (3%), and 18 (8%) respectively. None of 12 readmissions with complications identified by the hospital notes were identified by the MDI system. CONCLUSIONS: Accurate audit of postoperative complications must be extended to the period after discharge. Computerised audit systems must be able to relate readmissions to specific previous admissions. (+info)
Lack of knowledge in health professionals: a barrier to providing information to patients?
OBJECTIVE: To assess obstetricians' and midwives' knowledge of routine prenatal screening tests for fetal abnormality and factors associated with such knowledge. DESIGN: Questionnaire assessment of antenatal clinic staff. SETTING: Six hospitals within the United Kingdom (four district general hospitals in London, one district general hospital in Wales, and one teaching hospital in Wales), offering routine prenatal screening tests. SUBJECTS: 29 obstetricians and 97 midwives were invited to participate, of whom 21 and 70 respectively responded to the questionnaire. MAIN MEASURES: Knowledge of prenatal tests, according to 19 item multiple choice questionnaire, reluctance to disclose uncertainty, and clinical experience. RESULTS: The overall response rate was 72% (91/126). In all, 43% of midwives and 14% of obstetricians obtained correct responses on fewer than half the items. Reluctance to disclose uncertainty to patients was associated in obstetricians with having less knowledge about prenatal testing (r = -0.50; p < 0.025, Pearson product moment correlation) and in midwives with more clinical experience (r = 0.43; p < 0.001). CONCLUSIONS: Lack of knowledge and greater clinical experience seem to be important barriers to providing patients with information about prenatal screening tests. (+info)
Evaluation of patients' knowledge about anticoagulant treatment.
OBJECTIVE: To develop a questionnaire to evaluate patients' knowledge of anticoagulation. DESIGN: Anonymous self completed questionnaire study based on hospital anticoagulant guidelines. SETTING: Anticoagulant clinic in a 580 bed district general hospital in London. SUBJECTS: 70 consecutive patients newly referred to the anticoagulant clinic over six months. MAIN MEASURES: Information received by patients on six items of anticoagulation counselling (mode of action of warfarin, adverse effects of over or under anticoagulation, drugs to avoid, action if bleeding or bruising occurs, and alcohol consumption), the source of such information, and patients' knowledge about anticoagulation. RESULTS: Of the recruits, 36 (51%) were male; 38(54%) were aged below 46 years, 22(31%) 46-60, and 10(14%) over 75. 50 (71%) questionnaires were returned. In all, 40 respondents spoke English at home and six another language. Most patients reported being clearly advised on five of the six items, but knowledge about anticoagulation was poor. Few patients could correctly identify adverse conditions associated with poor control of anticoagulation: bleeding was identified by only 30(60%), bruising by 23(56%), and thrombosis by 18(36%). Only 26(52%) patients could identify an excessive level of alcohol consumption, and only seven (14%) could identify three or more self prescribed agents which may interfere with warfarin. CONCLUSION: The questionnaire provided a simple method of determining patients' knowledge of anticoagulation, and its results indicated that this requires improvement. IMPLICATIONS: Patients' responses suggested that advice was not always given by medical staff, and use of counselling checklists is recommended. Reinforcement of advice by non-medical counsellors and with educational guides such as posters or leaflets should be considered. Such initiatives are currently being evaluated in a repeat survey. (+info)
Bone densitometry at a district general hospital: evaluation of service by doctors and patients.
OBJECTIVE: To assess doctors' and patients' views about a district general hospital bone densitometry service and to examine existing practice to influence future provision. DESIGN: Three postal surveys: (a) of doctors potentially using the service, (b) of patients undergoing a bone densitometry test during a six month period, and (c) of the referring doctors of the patients undergoing the test. SETTING: Bone densitometry service at South Cleveland Hospital, Middlesbrough and two district health authorities: South Tees and Northallerton. SUBJECTS: All general practitioners (n=201) and hospital consultants in general medicine, rheumatology, obstetrics and gynaecology, orthopaedics, radio therapy and oncology, haematology, and radiology (n=61); all patients undergoing an initial bone densitometry test (n=309) during a six month period; and their referring doctors. MAIN MEASURES: Service awareness and use, knowledge of clinical indications, test results, influence of test results on patient management, satisfaction with the service and its future provision. RESULTS: The overall response rates for the three surveys were 87%, 70%, and 61%. There was a high awareness of the service among doctors and patients; 219(84%) doctors were aware and 155 of them (71%) had used it, and patients often (40%) suggested the test to their doctor. The test was used for a range of reasons including screening although the general use was consistent with current guidelines. Two hundred (65%) bone densitometry measurements were normal, 71(23%) were low normal, and 38(12%) were low. Although doctors reported that management of patients had been influenced by the test results, the algorithm for decision making was unclear. Patients and doctors were satisfied with the service and most (n=146, 68%) doctors wanted referral guidelines for the service. CONCLUSIONS: There was a high awareness of, use of, and satisfaction with the service. Patients were being referred for a range of reasons and a few of these could not be justified, many tests were normal, and clinical decision making was not always influenced by the test result. It is concluded that bone densitometry services should be provided but only for patients whose management will be influenced by test results and subject to guidelines to ensure appropriate use of the technology. (+info)
Preliminary assessment of patients' opinions of queuing for coronary bypass graft surgery at one Canadian centre.
OBJECTIVES: To explore psychological and socioeconomic concerns of patients who queued for coronary artery bypass surgery and the effectiveness of support existing in one Canadian cardiovascular surgical center. DESIGN: Standardised questionnaire and structured interview. SETTING: Victoria General Hospital, Halifax, Nova Scotia. SUBJECTS: 100 consecutive patients awaiting non-emergency bypass surgery. RESULTS: Most patients (96%) found the explanation of findings at cardiac catheterisation and the justification given for surgery satisfactory. However, 84 patients complained that waiting for surgery was stressful and 64 registered at least moderate anxiety. Anger over delays was expressed by 16%, but only 4% thought that queuing according to medical need was unfair. Economic hardship, attributed to delayed surgery, was declared by 15 patients. This primarily affected those still working--namely, blue collar workers and younger age groups. Only 41% of patients were satisfied with existing institutional supports. Problems related mainly to poor communication. CONCLUSIONS: Considerable anxiety seems to be experienced by most patients awaiting bypass surgery. Better communication and education might alleviate some of this anxiety. Economic hardship affects certain patient subgroups more than others and may need to be weighed in the selection process. A more definitive examination of these issues is warranted. (+info)