高能电子线TLD剂量质量核查

目的：基于国家专项经费的支持,开展江苏、河南和湖北3省常用临床治疗条件高能电子线水中吸收剂量的核查工作。方法：采用平行板电离室和指型电离室完成高能电子线水中吸收剂量的测量,剂量核查使用的热释光剂量计（TLD）在电子线下照射。TLD系统使用60Coγ射线校准。结果：DEAG/DUSER的平均比值为1.012,最大值为1.056,最小值为0.961。结论：按照国际原子能机构（IAEA）的要求,TLD扩展不确定度（k=2）≤5%。核查结果表明,参加此次核查的医院高能电子线合格率为94.2%。     

The cerebral palsy transition clinic: administrative chore,clinical responsibility,or opportunity for audit and clinical research?

Purpose

The majority of children with orthopaedic conditions in childhood survive to adult life, and there is a need for many of them to transition to adult services. This includes children with disorders such as club foot or developmental dislocation of the hip as well as those with complex syndromic conditions, bone dysplasias or neuromuscular disorders such as cerebral palsy and myelomeningocele. In many tertiary paediatric centres, transition has become a formal process in which clinicians document and communicate the status of patients who have been under their care to ensure a smooth transfer to adult services. The purpose of this report is to support the need for clear communication when children with cerebral palsy transition to adult services and to suggest that this transition represents a significant opportunity for audit and clinical research.

Methods

Some of the factors to be considered in developing a minimum data sheet for the transfer or transition of children with cerebral palsy to adult services are described.

Conclusion

Using the model of adolescents with cerebral palsy transitioning to adult services, orthopaedic surgeons can be encouraged to develop similar methodology and documentation for many other conditions for the purposes of communication, facilitation of transition, audit and clinical research.     

Reliability of indicators of nursing care quality: testing interexaminer agreement and reliability

Objective

this study sought to test the interexaminer agreement and reliability of 15 indicators of nursing care quality.

Methods

this was a quantitative, methodological, experimental, and applied study conducted at a large, tertiary, public teaching hospital in the state of Paraná. For data analysis, the Kappa (k) statistic was applied to the categorical variables - indicators 1 to 11 and 15 - and the interclass correlation coefficient (ICC) to the continuous variables - indicators 12, 13, and 14, with the corresponding 95% confidence intervals. The categorical data were analyzed using the Lee software, elaborated by the Laboratory of Epidemiology and Statistics of Dante Pazzanese Institute of Cardiology - Brazil, and the continuous data were assessed using BioEstat 5.0.

Results

the k-statistic results indicated excellent agreement, which was statistically significant, and the values of the ICC denoted excellent and statistically significant reproducibility/agreement relative to the investigated indicators.

Conclusion

the investigated indicators exhibited excellent reliability and reproducibility, thus showing that it is possible to formulate valid and reliable assessment instruments for the management of nursing care.     

Impact of cardiology referral: clinical outcomes and factors associated with physicians' adherence to recommendations

OBJECTIVES:

Cardiology referral is common for patients admitted for non-cardiac diseases. Recommendations from cardiologists may involve complex and aggressive treatments that could be ignored or denied by other physicians. The purpose of this study was to compare the outcomes of patients who were given recommendations during cardiology referrals and to examine the clinical outcomes of patients who did not follow the recommendations.

METHODS:

We enrolled 589 consecutive patients who received in-hospital cardiology consultations. Data on recommendations, implementation of suggestions and outcomes were collected.

RESULTS:

Regarding adherence of the referring service to the recommendations, 77% of patients were classified in the adherence group and 23% were classified in the non-adherence group. Membership in the non-adherence group (p<0.001; odds ratio: 10.25; 95% CI: 4.45-23.62) and advanced age (p = 0.017; OR: 1.04; 95% CI: 1.01-1.07) were associated with unfavorable outcomes. Multivariate analysis identified four independent predictors of adherence to recommendations: follow-up notes in the medical chart (p<0.001; OR: 2.43; 95% CI: 1.48-4.01); verbal reinforcement (p = 0.001; OR: 1.86; 95% CI: 1.23-2.81); a small number of recommendation (p = 0.001; OR: 0.87; 95% CI: 0.80-0.94); and a younger patient age (p = 0.002; OR: 0.98; 95% CI: 0.96-0.99).

CONCLUSIONS:

Poor adherence to cardiology referral recommendations was associated with unfavorable clinical outcomes. Follow-up notes in the medical chart, verbal reinforcement, a limited number of recommendations and a patient age were associated with greater adherence to recommendations.     

Effects of audit and feedback on professional practice in Geriatric Acute Care Units

PurposeTo evaluate the effects of audit and feedback on service delivery and patient functioning in Austrian Geriatric Acute Care Units.MethodsQuality initiative based on a standardised documentation form (core and optional data set) and a web-based performance feedback with peer comparison in 18 Geriatric Acute Care Units, representing 40% of all Austrian units. Main outcome measures were compliance with desired practice of geriatric care (comprehensive geriatric assessment [CGA], therapeutic consequences), discharge characteristics and mortality.ResultsOverall 22,279 patient records were documented between 2008 and 2010. Active involvement in the web-based feedback system was indicated by a high frequency of data queries per year, 1401, 3148 and 2883 for 2008, 2009 and 2010, respectively. The mean completion rate for CGA tests increased from 73% in 2008 to 78% in 2010 (P < 0.05). For centres with completion of core and optional data (n = 8), the average number of documented therapeutic interventions increased from 4.4 to 5.0 (P < 0.05). Those aspects of CGA focusing on activities of daily living, mobility and cognition prompted the greatest degree of corresponding therapeutic interventions (> 90%). A lower intervention rate was induced by the nutritional assessment (< 20%). Mortality and discharge characteristics such as level of care and percentage of patients living at home after discharge did not change over the time.ConclusionFollowing implementation of a web-based performance feedback with peer comparison in Austrian Geriatric Acute Care Units, an improvement in health care professionals’ compliance with desired practice of geriatric care, but not in patients’ discharge characteristics, was observed.     

Improving performance in the management of severely injured patients in critical care

OBJECTIVE: To determine opportunities for improvement (OI) in the critical care management of severely injured patients in a general adult intensive care unit through a performance improvement (PI) process. METHODS: Retrospective review of patient records from intensive care patients who had sustained traumatic injuries, except isolated head injury, over a 1-year period. Three assessors independently audited the notes using performance improvement methodology to determine complications, errors in management and preventability. Complications were included when two or more assessors independently detected the complication. MEASUREMENTS AND RESULTS: Records from 90 patients with a diagnosis of 'trauma' were reviewed, 14 patients with isolated head injury were excluded. The mean injury severity score was 23 (range 4-43). No complications or errors of management were identified from 41 patients, including ten patients who died. Seventy-two complications were identified in 35 patients including 15 pneumonias, 6 cases of peri-operative hypothermia and 5 recurrent pneumothoraces. Fourteen preventable complications were identified. CONCLUSIONS: The PI OI process highlighted specific opportunities for the improvement of critical care management of trauma patients in our unit. These will be addressed through the introduction of formal tertiary surveys and clinical management guidelines addressing hypothermia and management of coagulopathy.     

Delays in open fracture management: where do they occur?

We audited the delays in the management of 29 patients presenting to our department with 30 open fractures over a 1-year-period to ascertain where the most lengthy delays were occurring. Gold standard treatment is the surgical debridement and stabilisation of the fracture within 6h of injury. In our series only 14 patients achieved this standard. The lengthiest delays were in getting a patient to the operating theatre following orthopaedic assessment. We have introduced an "open fracture proforma" to highlight the time-critical nature of the injury in an effort to speed-up the process.