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Prospective Audit (prospective + audit)
Selected AbstractsRISK FACTORS FOR PERI-OPERATIVE STROKE COMPLICATING CAROTID ENDARTERECTOMY: SELECTIVE ANALYSIS OF A PROSPECTIVE AUDIT OF 1000 CONSECUTIVE OPERATIONSANZ JOURNAL OF SURGERY, Issue 1 2000J. E. Frawley Background: The aim of the present study was to investigate the role of potential clinical risk factors in the causation of peri-operative stroke associated with carotid endarterectomy. With the change in carotid endarterectomy practice from the use of a shunt to high-dose thiopental for cerebral protection (a previously undocumented method), it was essential to identify accurately the causes of all peri-operative strokes. Methods: A prospective audit was undertaken of 1000 carotid endarterectomies in which the causes and pathology of all peri-operative strokes were documented. The roles of advanced age, female gender, hypertension, previous stroke, contralateral carotid stenosis > 70%, and contralateral carotid occlusion as potential causes of peri-operative stroke were defined. Results were statistically analysed using odds ratio and Fisher's exact test. Results: None of the potential risk factors was statistically significant for peri-operative stroke. Female gender was associated with a significant risk of peri-operative stroke due to operative site thrombosis. Complications at the endarterectomy site were the commonest cause of stroke. Conclusions: Prospective audit is a useful tool for identifying causes of peri-operative stroke and indicating the need for modifications to surgical clinical management which might improve outcomes for carotid endarterectomy. [source] Does the standard intravenous solution of fentanyl (50 µg/mL) administered intranasally have analgesic efficacy?EMERGENCY MEDICINE AUSTRALASIA, Issue 1 2010Dianne Crellin Abstract Background: Intranasal (IN) fentanyl provides rapid and powerful non-parenteral analgesia in the ED. A concentrated solution of fentanyl (300 µg/mL) has been used in prior trials, yet many ED use the standard solution at a concentration of 50 µg/mL, which is widely available and of low cost. We set out to determine if this lower concentration of fentanyl is also efficacious. Methods: Prospective audit in children aged 5,18 years presenting with upper limb injuries. Patients received IN fentanyl (50 µg/mL) at 1.5 µg/kg. Patient assessed pain scores were collected 5, 10, 20, 30 and 60 min following IN fentanyl administration using a visual analogue scale or Bieri Faces , Revised scale. Parental scores were used if patients were unable to provide a score. Results: Of the 59 eligible patients, 36 were enrolled; median age was 6.8 years (range 5,15 years), and 89% (32/36) ultimately required fracture reduction. Median first dose of IN fentanyl was 1.4 µg/kg. Median pain scores dropped from 7 (interquartile range 5,10) pre-fentanyl to 5 (interquartile range 4,8) at 5 min and 2 (interquartile range 1,4) at 30 and 60 min. A total of 21 (58%) children did not require further analgesia in the ED. There were no adverse events. Conclusions: Standard i.v. concentration IN fentanyl (50 µg/mL) appears to have analgesic efficacy in children with upper limb injuries. [source] Economic costs of cataract surgery using a rigid and a foldable intraocular lens,OPHTHALMIC AND PHYSIOLOGICAL OPTICS, Issue 4 2001Asfa J. Afsar Summary Optimal delivery of healthcare requires consideration of various costs. A foldable intraocular lens (IOL) is more expensive than an equivalent rigid IOL. However, surgical and post-operative costs may make a foldable IOL economically preferable. We compared the economic costs of cataract surgery plus implantation of a foldable IOL with implantation of a rigid IOL. Prospective audit of the clinical records of 82 pseudophakes; 39 implanted with a rigid IOL and 43 implanted with a foldable IOL by one surgeon. Average follow-up periods were 25±7 months and 23±5 months respectively. There was no difference between the two groups for the follow-up period (P=0.55), number of post-operative complications (P=0.25) or cost of post-operative visits (P=0.83). The cost of single-use theatre equipment was greater for the rigid-IOL group (P=0.0001). The total identified cost per patient was greater for the foldable-IOL group (P=0.0001). Despite possible technical advantages, implantation of the foldable IOL did not provide an economic benefit, either in the initial cost or in the costs of post-operative care. Over the 2-year period, implanting with the rigid IOL cost, on average, £57 less per patient. Despite this economic difference, a cost-benefit analysis is required, since other factors may be more important. [source] RISK FACTORS FOR PERI-OPERATIVE STROKE COMPLICATING CAROTID ENDARTERECTOMY: SELECTIVE ANALYSIS OF A PROSPECTIVE AUDIT OF 1000 CONSECUTIVE OPERATIONSANZ JOURNAL OF SURGERY, Issue 1 2000J. E. Frawley Background: The aim of the present study was to investigate the role of potential clinical risk factors in the causation of peri-operative stroke associated with carotid endarterectomy. With the change in carotid endarterectomy practice from the use of a shunt to high-dose thiopental for cerebral protection (a previously undocumented method), it was essential to identify accurately the causes of all peri-operative strokes. Methods: A prospective audit was undertaken of 1000 carotid endarterectomies in which the causes and pathology of all peri-operative strokes were documented. The roles of advanced age, female gender, hypertension, previous stroke, contralateral carotid stenosis > 70%, and contralateral carotid occlusion as potential causes of peri-operative stroke were defined. Results were statistically analysed using odds ratio and Fisher's exact test. Results: None of the potential risk factors was statistically significant for peri-operative stroke. Female gender was associated with a significant risk of peri-operative stroke due to operative site thrombosis. Complications at the endarterectomy site were the commonest cause of stroke. Conclusions: Prospective audit is a useful tool for identifying causes of peri-operative stroke and indicating the need for modifications to surgical clinical management which might improve outcomes for carotid endarterectomy. [source] Glove perforations during open surgery for gynaecological malignanciesBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 8 2008AP Manjunath Objective, To audit glove perforations at laparotomies for gynaecological cancers. Setting, Gynaecological oncology unit, cancer centre, London. Design, Prospective audit. Sample, Twenty-nine laparotomies for gynaecological cancers over 3 months. Methods, Gloves used during laparotomies for gynaecological cancer were tested for perforations by the air inflation and water immersion technique. Parameters recorded were: type of procedure, localisation of perforation, type of gloves, seniority of surgeon, operation time and awareness of perforations. Main outcome measure, Glove perforation rate. Results, Perforations were found in gloves from 27/29 (93%) laparotomies. The perforation rate was 61/462 (13%) per glove. The perforation rate was three times higher when the duration of surgery was more than 5 hours. The perforation rate was 63% for primary surgeons, 54.5% for first assistant, 4.7% for second assistant and 40.5% for scrub nurses. Clinical fellows were at highest risk of injury (94%). Two-thirds of perforations were on the index finger or thumb. The glove on the nondominant hand had perforations in 54% of cases. In 50% of cases, the participants were not aware of the perforations. There were less inner glove perforations in double gloves compared with single gloves (5/139 versus 26/154; P = 0.0004, OR = 5.4, 95% CI 1.9,16.7). The indicator glove system failed to identify holes in 44% of cases. Conclusions, Glove perforations were found in most (93%) laparotomies for gynaecological malignancies. They are most common among clinical fellows, are often unnoticed and often not detected by the indicator glove system. [source] Prospective audit of major amputations for peripheral vascular diseaseBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 4 2001S. R. Vallabhaneni Background: Primary amputation followed by prosthetic fitting has been proposed as an alternative worth considering if lower limb bypass has poor prospects of patency. This is an outcome audit of major amputations at a single centre where amputations were performed only if limb salvage was not possible. Methods: Consecutive major amputations (n = 162) for peripheral vascular disease from January 1996 to December 1998 were studied prospectively. Duration of hospital stay, causes of morbidity and mortality, and reasons for being unsuitable for prosthesis were recorded. Mobility at admission and after rehabilitation was documented using a standard grading system (grades 1,6). Results: There were 114 above-knee, 45 below-knee and three through-knee amputations. The 30-day mortality rate was 14 per cent (22 patients), increasing to 29 per cent (47) at 9 months. Some 57 patients (35 per cent) were rehabilitated with a prosthetic limb (30 above knee, 27 below knee). Mobility with prosthesis was better or maintained in 24 patients, worse by one grade in 17, and by two or more grades in the remaining 16. Fifty-eight patients (36 per cent) were unsuitable for an artificial limb; in four this was because of stump-related problems, and the rest because of co-morbidity. Cardiorespiratory events were the most frequent cause of morbidity and mortality. The mean hospital stay after amputation was 37 days in survivors. Conclusion: Perioperative and late mortality rates following amputation are high. A large proportion of amputees were not suitable for prosthesis, mainly because of co-morbidity. Of the patients receiving a prosthesis, only 42 per cent (15 per cent of the total) maintained or improved their mobility. The results are unlikely to be different if a policy of selective primary amputation were to be adopted. The outcome of amputation is worse than widely perceived despite the improvements in prostheses and a well executed rehabilitation process. © 2001 British Journal of Surgery Society Ltd [source] Interobserver agreement between primary graders and an expert grader in the Bristol and Weston diabetic retinopathy screening programme: a quality assurance auditDIABETIC MEDICINE, Issue 8 2009S. Patra Abstract Aims, To assess the quality and accuracy of primary grading in the Bristol and Weston diabetic retinopathy screening programme and to set standards for future interobserver agreement reports. Methods, A prospective audit of 213 image sets from six fully trained primary graders in the Bristol and Weston diabetic retinopathy screening programme was carried out over a 4-week period. All the images graded by the primary graders were regraded by an expert grader blinded to the primary grading results and the identity of the primary grader. The interobserver agreement between primary graders and the blinded expert grader and the corresponding Kappa coefficient was determined for overall grading, referable, non-referable and ungradable disease. The audit standard was set at 80% for interobserver agreement with a Kappa coefficient of 0.7. Results, The interobserver agreement bettered the audit standard of 80% in all the categories. The Kappa coefficient was substantial (0.7) for the overall grading results and ranged from moderate to substantial (0.59,0.65) for referable, non-referable and ungradable disease categories. The main recommendation of the audit was to provide refresher training for the primary graders with focus on ungradable disease. Conclusion, The audit demonstrated an acceptable level of quality and accuracy of primary grading in the Bristol and Weston diabetic retinopathy screening programme and provided a standard against which future interobserver agreement can be measured for quality assurance within a screening programme. [source] Justifying the expense of the cancer Clinical Nurse SpecialistEUROPEAN JOURNAL OF CANCER CARE, Issue 1 2010C.A. POLLARD ba POLLARD C.A., GARCEA G., PATTENDEN C.J., CURRAN R., NEAL C.P., BERRY D.P. & DENNISON A.R. (2009) European Journal of Cancer Care19, 72,79 Justifying the expense of the cancer Clinical Nurse Specialist In order to maximise patient care, assessment of the adequacy of the service provision by the Clinical Nurse Specialist (CNS) must be regularly undertaken. This study attempted to determine whether CNSs were providing an adequate service via retrospective and prospective audit. The results of a comprehensive audit of the work of the CNS within a tertiary referral Hepatobiliary Unit are presented. The audit involved postal and telephone questionnaires as well as prospective collection of data. The majority of responses from patients were positive, with many finding the CNS a useful and well-utilised contact. Overall, the CNSs performed well in each of their designated tasks; however, areas were still identified which could be further improved. Audit is essential in providing feedback to the CNS and to identify areas which require improvement. The CNS has evolved to meet a clinical gap in patient care, and as a result, the role of a CNS is frequently nebulous or poorly defined. This renders evaluation of the CNS problematic and fraught with difficulties. However, a thorough assessment can still be made using carefully constructed audit looking at each task of the CNS. [source] Perioperative fluid management: prospective auditINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 3 2008S. R. Walsh Summary Background:, Postoperative fluid management is a core surgical skill but there are few data regarding current fluid management practice and the incidence of potential fluid-related complications in general surgical units. We conducted a prospective audit of postoperative fluid management and fluid-related complications in a consecutive cohort of patients undergoing midline laparotomy. Methods:, Over a 6-month period, the peri-operative fluid management of 106 consecutive patients was prospectively audited. Serum electrolyte data, fluid balance data, co-morbidities, operative and anaesthetic variables and quantities of fluid and electrolytes prescribed were recorded. The development of fluid-related and other complications was noted. Results:, There were no correlations between routinely available fluid balance parameters and the quantities of fluid and electrolytes prescribed, suggesting that doctors do not consult fluid balance data when prescribing. Fifty-seven patients (54%) developed at least one fluid-related complication. These patients received significantly greater volumes of fluid and sodium each day postoperatively. They had higher rates of other non-fluid-related complications and death. They had a longer hospital stay. In a multivariate model, mean daily fluid load predicted the development of fluid-related complications. Conclusion:, Fluid prescription practice in general surgical units is sub-optimal, resulting in avoidable iatrogenic complications. Involvement of senior staff, education and possibly the introduction of prescribing protocols may improve the situation. [source] Evaluation of glargine group-start sessions in patients with type 2 diabetes as a strategy to deliver the serviceINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 2 2007A. A. Tahrani Summary Improving glycaemic control in patients with type 2 diabetes reduces microvascular complications. The national service framework for diabetes and the new general medical service contract have been aiming to direct more focus on improving HbA1c. These measures have resulted in increasing number of patients being initiated on insulin therapy, which increases the workload of diabetes specialist nurses (DSNs). Initiating insulin on a one-to-one basis is time consuming. As a result DSN-led insulin group-start sessions were introduced. To evaluate DSN-led glargine group-start and self-titration as a strategy of providing service. We assessed the impact of this method on the use of DSNs time, HbA1c and on patients' satisfaction. A prospective audit in a district general hospital. Groups of 5,7 patients received two 2-h sessions at weeks 0 and 2. During these sessions, patients were initiated on insulin glargine and received an educational package and a self-titration protocol. DSNs did not see patients after week 2. Patients were able to phone the DSNs for advice till the end of the titration period. Patients completed Diabetes Treatment Satisfaction Questionnaire (DTSQ) at baseline, week 2 and 12 months. Weight and HbA1c were assessed at base line and 12 months later. Twenty-nine consecutive patients were included. Baseline HbA1c improved at 6 months and remained stable at 12 months (medians 10.0, 8.7 and 8.9 respectively, p < 0.001). DTSQ score improved between week 0 and 2 and this was maintained at 12 months (medians 26, 35 and 34 respectively, p < 0.001). After week 2, the DSNs spent a median of 21 min advising patients by phone during the titration period. Weight did not increase significantly. In our centre, DSN-led insulin group-start sessions and self-titration improved glycaemic control. Patients were satisfied with this method of starting insulin. This was achieved with minimal DSNs time and input and proved to be effective, yet less time consuming. [source] Yield from colonoscopic screening in people with a strong family history of common colorectal cancerJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 8 2000Damian J Dowling Abstract Background and Aims: People with a strong family history of common (so-called ,sporadic') colorectal cancer are generally advised to undergo colonoscopic screening, but the starting age for this is unclear. An audit was performed to study the age-related yield of screening colonoscopy in this risk group. Methods: A prospective audit of the outcome of screening colonoscopy was performed on a cohort of 232 people with a strong family history of common colorectal cancer. All were registrants in a familial bowel cancer service solely because of their family medical history. They had no bowel symptoms and no prior endoscopic investigation of the large bowel. Results: Neoplastic lesions were detected by using colonoscopy in 33 participants. In 27 participants, the major lesion was a small tubular adenoma, four had an advanced adenoma and two had cancer. More neoplastic (P = 0.02) and advanced neoplastic (P = 0.03) lesions were found in those patients aged , 50 years. Only one advanced adenoma was detected in a participant below the age of 50 years. Conclusion: The yield from screening colonoscopy in young people (< 50 years) with a strong family history of common colorectal cancer is low, placing doubt on the need for colonoscopic screening before the age of 50 years. [source] Management of post-operative bladder spasmJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 1-2 2005D Chiang Objective: Pain management following bladder surgery in children is often complicated by bladder spasm. The overall severity of spasm can be reduced with opioids, anticholinergic medication and sedatives, although breakthrough spasms often occur. At the Royal Children's Hospital, Melbourne, intravesical bupivacaine has been used to manage postoperative bladder spasm to good effect. The administration of intravesical bupivacaine is analysed in this prospective audit of locally applied intravesical anaesthetic and compared with other methods. Method: From February to August 2003, histories of 58 patients who had intravesical bupivacaine were studied and compared with six other methods of management of postoperative bladder spasm. Conclusion: Data showed that epidural anaesthesia was the most effective treatment of pain, with a pain score reduction of 6.6, compared with a reduction of 6.1 with intravesical bupivacaine, and 4.5 using intravenous morphine. However, intravesical bupivacaine was the most effective method for the relief of bladder spasm. [source] Re: Yianni et al., Globus pallidus internus deep brain stimulation for dystonic conditions: A prospective auditMOVEMENT DISORDERS, Issue 1 2004Niall P. Quinn MD [source] Review of ICU nutrition support practices: implementing the nurse-led enteral feeding algorithmNURSING IN CRITICAL CARE, Issue 3 2007Kirsty Dobson Abstract Many intensive care units (ICUs) have standard feeding protocols which promote safe early initiation of enteral feeding. The use of these protocols has been shown to increase the incidence of enteral feeding and achieve greater adequacy of nutrition support. A multidisciplinary working party developed and implemented a nurse-led enteral feeding algorithm which enabled senior nursing staff to set safe and nutritionally adequate target feed volumes based upon patient body weight. The algorithm incorporated best practice-based referral criteria so that patients at nutritional risk were referred for tailored dietetic assessment. The aims were to determine compliance with the ICU nurse-led enteral feeding algorithm and to ascertain its safety and efficacy. A 3-month prospective audit was conducted by specialist ICU dietitians. Data were obtained from electronic patient records and through observing feeding practices. Data collected included prescribed feed type and infusion rate versus volume received, frequency of gastric aspiration and prokinetic usage. In all, 90% (n = 43) of referrals received by the dietitian met the referral criteria. Absolute compliance with patients receiving correct type and volumes of feed, with a correct feed prescription and an accurate documented weight was just 2% (n = 1). Despite this finding, 60% of patients were actually receiving the correct feed regimen. If the nurse-led enteral feeding algorithm is wholly adhered to, the ICU dietitian need not formally assess every ICU patient. Nursing staff require further support in assessing patient body weight alongside an ongoing intensive educational programme for the multidisciplinary team and regular reaudit. [source] APA national audit of pediatric opioid infusionsPEDIATRIC ANESTHESIA, Issue 2 2010FFPMRCA, FRCPCH, NEIL S. MORTON MD Summary Introduction:, A prospective audit of neonates, infants, and children receiving opioid infusion techniques managed by pediatric acute pain teams from across the United Kingdom and Eire was undertaken over a period of 17 months. The aim was to determine the incidence, nature, and severity of serious clinical incidents (SCIs) associated with the techniques of continuous opioid infusion, patient-controlled analgesia, and nurse-controlled analgesia in patients aged 0,18. Methods:, The audit was funded by the Association of Paediatric Anaesthetists (APA) and performed by the acute pain services of 18 centers throughout the United Kingdom. Data were submitted weekly via a web-based return form designed by the Document Capture Company that documented data on all patients receiving opioid infusions and any SCIs. Eight categories of SCI were identified in advance, and the reported SCIs were graded in terms of severity (Grade 1 (death/permanent harm); Grade 2 (harm but full recovery and resulting in termination of the technique or needing significant intervention); Grade 3 (potential but no actual harm). Data were collected over a period of 17 months (25/06/07-25/11/08) and stored on a secure server for analysis. Results:, Forty-six SCIs were reported in 10 726 opioid infusion techniques. One Grade 1 incident (1 : 10 726) of cardiac arrest occurred and was associated with aspiration pneumonitis and the underlying neurological condition, neurocutaneous melanosis. Twenty-eight Grade 2 incidents (1 : 383) were reported of which half were respiratory depression. The seventeen Grade 3 incidents (1 : 631) were all drug errors because of programming or prescribing errors and were all reported by one center. Conclusions:, The overall incidence of 1 : 10 000 of serious harm with opioid infusion techniques in children is comparable to the risks with pediatric epidural infusions and central blocks identified by two recent UK national audits (1,2). Avoidable factors were identified including prescription and pump programming errors, use of concurrent sedatives or opioids by different routes and overgenerous dosing in infants. Early respiratory depression in patients with specific risk factors, such as young age, neurodevelopmental, respiratory, or cardiac comorbidities, who are receiving nurse-controlled analgesia or continuous opioid infusion suggests that closer monitoring for at least 2 h is needed for these cases. As a result of this audit, we can provide parents with better information on relative risks to help the process of informed consent. [source] Ulceration and antihypertensive use are risk factors for infection after skin lesion excisionANZ JOURNAL OF SURGERY, Issue 9 2010Anthony Penington Abstract Background:, A prospective audit was performed of wound complications of skin lesion excision in a private practice setting. Methods:, For 924 consecutive skin lesion excisions performed by a single surgeon, information was collected on tumour size and site, closure method and on risk factors of age, known diabetes, use of steroids, antihypertensives or anticoagulants and ulceration of the lesion. Patients were given written instructions to wet the wound in the shower after one or two days. A wound ,infection' event was recorded if the wound appeared inflamed or if the patient had been treated with antibiotics by any practitioner. Wound bleeding was recorded if the patient returned or attended elsewhere for management of bleeding. Results:, Sixty-seven wounds (7.25%) met the broad definition of ,infection' and 18 (1.9%) wounds suffered bleeding. Ulceration (odds ratio (OR) 3.15, P= 0.008) and use of antihypertensives (OR 2.5, P= 0.006) were independent risk factors for infection along with site and closure method. The patients who did not wet their wounds post-operatively were also at an increased risk of infection (OR 2.1, P= 0.018). Aspirin caused a slight, non-statistically significant increase in bleeding rate, and warfarin caused a larger, but still not statistically significant, increase in bleeding. Use of other anticoagulants caused a significant increase in bleeding (OR 10.9, P= 0.006). Conclusion:, Ulceration of the skin lesion and use of antihypertensives are significant risk factors for wound infection. Wetting surgical wounds with clean tap water does not increase, and may even reduce, wound infection rate. [source] Delays in discharge of vascular surgical patients: a prospective auditANZ JOURNAL OF SURGERY, Issue 6 2010Senarath Edirimanne Abstract Aim:, To quantify delays in discharge for vascular surgical patients and identify causes of such delays. Methods:, A prospective audit of delays in discharge of vascular surgical admissions over a 6-month period was performed. Expected date and time of discharge was compared with actual date and time of discharge. Day-case patients, patients who died during admission and patients not under the direct care of the vascular team were excluded. Results:, There were 99 elective and 51 acute admissions accounting for 729 hospital bed days. The median (range) age was 72 years (21,92) and 94% of patients were living independently in the community. Forty-seven percent of patients were discharged on the planned day and time, 21% on the planned day but at a later-than-predicted time and 32% were delayed by more than 1 day. Delays identified in this audit accounted for 135 bed days. Fifteen percent of delays were due to causes that can be improved by internal organization (e.g. delayed paperwork). The majority of the delays (85%) were due to external factors such as lack of rehabilitation beds or lack of placement facilities in nursing homes. Elderly patients and acute admissions were more likely to have long delays in discharge. Conclusion:, Delays in discharge of vascular surgical patients use a lot of acute surgical bed days. Strategies to prevent delays in discharge should include not only improving internal organization and early identification and referral of patients who require rehabilitation/placement but also increased funding for such essential non-acute services. [source] Bilateral ankle blocks: A prospective auditANZ JOURNAL OF SURGERY, Issue 1-2 2005Glenda E Rudkin Background: There are significant advantages to the practice of bilateral ankle block. However, clinicians are reluctant to employ this technique due to concerns over reliability, local anaesthetic longevity and toxicity, surgical efficiency, and patient comfort. Methods: Sixty-six patients undergoing bilateral ankle blocks during mid- and forefoot surgery were audited to determine success rate, local anaesthetic safety and efficacy, and patient acceptance. Intravenous sedation was administered both during insertion of ankle blocks and intraoperatively, as requested by the patient and as deemed necessary by the anaesthetist. The choice of local anaesthesia was either a 50/50 mixture of lignocaine 1.5% plain and ropivacaine 7.5 mg/mL, ropivacaine 7.5 mg/mL alone or ropivacaine 7.5 mg/mL and clonidine 1 µg/kg. Results: A total of 89% of patients had a successful bilateral ankle block. Ropivacaine and clonidine combination, ropivacaine, and ropivacaine and lignocaine combination provided a mean length of action of 17 h, 14 h and 8 h, respectively. No adverse local anaesthetic events were reported. Sixty-one per cent of patients remembered intraoperative events; only one patient would choose not to have the procedure performed again under ankle blocks. Conclusions: The present audit demonstrates that bilateral ankle blocks are a safe and efficient technique. With appropriate doses of sedative drugs both during insertion of the ankle block and surgery, patients remain comfortable. [source] RISK FACTORS FOR PERI-OPERATIVE STROKE COMPLICATING CAROTID ENDARTERECTOMY: SELECTIVE ANALYSIS OF A PROSPECTIVE AUDIT OF 1000 CONSECUTIVE OPERATIONSANZ JOURNAL OF SURGERY, Issue 1 2000J. E. Frawley Background: The aim of the present study was to investigate the role of potential clinical risk factors in the causation of peri-operative stroke associated with carotid endarterectomy. With the change in carotid endarterectomy practice from the use of a shunt to high-dose thiopental for cerebral protection (a previously undocumented method), it was essential to identify accurately the causes of all peri-operative strokes. Methods: A prospective audit was undertaken of 1000 carotid endarterectomies in which the causes and pathology of all peri-operative strokes were documented. The roles of advanced age, female gender, hypertension, previous stroke, contralateral carotid stenosis > 70%, and contralateral carotid occlusion as potential causes of peri-operative stroke were defined. Results were statistically analysed using odds ratio and Fisher's exact test. Results: None of the potential risk factors was statistically significant for peri-operative stroke. Female gender was associated with a significant risk of peri-operative stroke due to operative site thrombosis. Complications at the endarterectomy site were the commonest cause of stroke. Conclusions: Prospective audit is a useful tool for identifying causes of peri-operative stroke and indicating the need for modifications to surgical clinical management which might improve outcomes for carotid endarterectomy. [source] Driving and dementia: a prospective audit of clients referred to an aged care assessment teamAUSTRALASIAN JOURNAL ON AGEING, Issue 4 2003Robert Bunt Objective: Many people with dementia or cognitive Impairment continue to drive. Given Australia's ageing population, this raises safety concerns for the driver in the community. This paper presents data collected by the NS W Central Coast Aged Care Assessment Team (ACAT), outlining the extent of the problem on the Central Coast and offers some suggestions about dealing with this issue. Method: A prospective audit of clients referred to Central Coast ACAT over a seven month period. Data describing the clients' cognitive state and also their driving habits were collected during routine ACAT assessments. Results: 1203 people were referred to ACAT during the study period. 100 (8%) of these were driving and 34% of those driving had some form of cognitive impairment. In some cases the impairment was quite severe. Most of these drivers were male. In a majority of the cases, concerns were expressed by someone familiar with the person, regarding their capacity to drive safely. Conclusion: The results support findings from other studies, which suggest there is a small but significant number of elderly people with cognitive impairment who are still driving. We propose that a safety first policy should be adopted and where there is doubt about the persons ability to drive safely, an Occupationul Therapy driving test in conjunction with a detailed cognitive assessment needs to be performed. [source] Outpatient hysteroscopy: Factors influencing post-procedure acceptability in patients attending a tertiary referral centreAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 6 2009Kate MCILWAINE Background:, Ambulatory hysteroscopy is a safe, reliable and cost-effective alternative to hysteroscopy under a general anaesthetic for the diagnosis of abnormal uterine bleeding. Aim:, The objective of this study was to assess which factors influenced patients' willingness to attend for future outpatient hysteroscopy. The outpatient hysteroscopy service commenced at the Mercy Hospital for Women in 2000. It provides women with the opportunity to have the cause of abnormal uterine bleeding diagnosed in an outpatient setting. Methods:, A prospective audit was conducted of 283 women attending for outpatient hysteroscopy at the Mercy Hospital for Women over a period of almost five years (May 2003 through February 2008). Results:, Of the women audited, 88.7% stated that they would accept the procedure in future, whilst 11.3% would not. There was a significant difference between the two groups with respect to their median visual analogue pain scale (VAS) pain scores during the procedure (3.00 versus 6.50 P < 0.0001) with the higher score in the group who would not re-attend for the procedure. There was also a significant difference between the two groups with respect to the change in median VAS score from pain anticipated to pain experienced (0.00 versus 3.50 P = 0.0001). The rate of unsuccessful procedures was significantly higher (40.6% versus 0.8%P < 0.05) in future non-attendees as well as a higher rate of clinical vasovagal episodes (25% versus 5.2%P = 0.01) in women who stated that they would not re-attend for the procedure. Preprocedure analgesia and type of anaesthetic administered during the procedure did not seem to influence whether women would attend for outpatient hysteroscopy in future. Conclusions:, The acceptability rate for women attending for outpatient hysteroscopy during the audit period was 88.7%. Pain was a significant determinant of procedure acceptability; however, the acceptability rate was not influenced by analgesia or type of anaesthetic administered. [source] The incidence of chronic scrotal pain after vasectomy: a prospective auditBJU INTERNATIONAL, Issue 6 2007Thomas A. Leslie OBJECTIVE To assess the extent of scrotal pain in men before and after vasectomy, to produce accurate data for the benefit of men considering this procedure, and hence improved informed consent about the outcomes, as chronic scrotal pain after vasectomy is a poorly quantified clinical problem. PATIENTS AND METHODS Between November 2004 and January 2006 nine surgeons carried out vasectomies in 625 men (mean age 39.9 years, sd 5.6) under local anaesthesia. A questionnaire was devised to establish the presence of any scrotal or testicular pain, and to characterize this discomfort; 6 months after the procedure a modified version of the same questionnaire was administered. RESULTS In all, 593 (94.7%) men returned the preoperative questionnaires and were entered into the study; 488 (82.2%) of these completed the follow-up questionnaire, giving a mean (sd) follow-up of 6.8 (1.6) months. In all, 65 men reported new-onset scrotal pain at 7 months (14.7%). The mean visual analogue score for this pain was 3.4/10. Four men (0.9%) in the responding group described pain after vasectomy as ,quite severe and noticeably affecting their quality of life'. CONCLUSION At 7 months after vasectomy about 15% of previously asymptomatic men have some degree of scrotal discomfort. These early data indicate that chronic scrotal pain after vasectomy is a genuine entity, but a longer-term follow-up in this group will be important to allow further evaluation of how this pain develops with time. [source] The early pregnancy assessment project: The effect of cooperative care in the emergency department for management of early pregnancy complicationsAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 1 2009David O'ROURKE Background: Early pregnancy assessment clinics (EPAC) have been introduced and accepted as the gold standard for management of early pregnancy problems (EPP). However, EPAC are not universally available and management of EPP within the emergency department (ED) can result in prolonged waiting times, inappropriate use of resources and no clear treatment or follow-up plan being implemented. Aim: To assess the effect of an early pregnancy assessment protocol (EPAP) in the ED, designed to create a cultural change among doctors in relation to EPP in order to minimise use of resources, improve treatment times for patients and establish a clear management plan where dedicated EPAC services are not available. Methods: An intervention, the EPAP was introduced to the ED and retrospective and prospective audits of the patients were carried out to assess the effect. Results: Implementation of the EPAP decreased treatment time by 55%, representations by 48%, pathology blood tests by 56% and formal imaging services by 85%. Gynaecological consultation increased by 37% for each patient visit to the ED and by 9% for each EPP. Total direct cost saving was 63% per patient and no adverse outcomes were recorded. Conclusion: Introduction of the EPAP was successful in creating cultural change and delivering clinical and financial benefits to the hospital, patients and staff. Early gynaecological consultation and bedside ultrasound scanning within the ED were key factors. Similar benefits could be reproduced in other institutions and for other clinical scenarios where a need has been identified. [source] | ||||||||||||||||||||||||||||