An audit of diabetes care was done in a hospital to assess its effectiveness. The results revealed that diabetic patients received less than adequate care. Only 9% of the patients achieved good glycaemic control; 39% had hypertriglyceridemia and 65% had undesirable weight gain while on treatment. The average duration of diabetes in this group of young diabetic patients under study was only 4.5 years, yet 12% of them had evidence of diabetic retinopathy. Few patients possessed adequate knowledge and skills of diabetes self-care. No patients could draw up and mix insulin adequately. Only one patient could self-inject insulin correctly. Few understood the nature of hypoglycaemia, hence few took adequate precaution against it. Patients had frequent hypoglycaemia; 61% had at least one episode per week and 56% of the diabetic drivers admitted to occurrence of hypoglycaemia while driving. No patient understood the principle of diabetic diet therapy, nor did they carry out regular home-monitoring of their diabetes. Good diabetes care requires organisation with supportive patient education. The less than adequate standard of care achieved by the hospital under study is probably explained by the absence of both.
Study site: Outpatient clinic, Hospital Mentakab, Pahang, Malaysia
An audit to assess the adequacy of hypertension care was performed by examining the records and interviewing 55 selected hypertensive patients on treatment and follow-up at the outpatient department of a hospital. The patients selected had no previous record of drop out of treatment and had excellent compliance with drug therapy, so that ineffective blood pressure control cannot be attributable to these two reasons. Adequacy of care was measured by the number of patients whose management as indicated in their records complied with pre-defined criteria of adequate care. Only 18% of patients had achieved adequate blood pressure control. Assessment of patients was inadequate. None of the patients had been screened for secondary causes though 16% of patients had some basic investigations (urinalysis, blood urea and serum potassium), 5% had an assessment of target-organ damage, and 2% had been screened for other cardiovascular risk factors. Only 5% had a surveillance of side-effects from drug-therapy, 45% of the patients demonstrate adequate knowledge concerning complications of hypertension. The use of non-drug treatment was non-existent. The results of this study suggest that there were considerable deficiencies in the management of hypertension. Measures needed to overcome this are discussed.
A study was undertaken to determine the extent of morbidity associated with asthma and to audit the management of asthma in two out-patient clinics of two district hospitals. Patients were recruited for the study during a 3-month period from December 1990 to February 1991. Seventy asthmatic patients were studied. Eighty-six percent of the patients had their sleep disturbed by asthma, 77% took daily medication regularly, 63% felt that their activities were restricted by asthma, 60% had at least one acute exacerbation in the preceding six months. Of those who had their peak expiratory flow rate (PEFR) measured, 40% had a PEFR below 50% predicted, and only 11% had normal PEFR (greater than 80% predicted). The morbidity of asthma was thus considerable. On the other hand, the drug treatment of these asthmatics was grossly inadequate. They were prescribed on average 2.1 item of drugs, which for most patients comprised an oral beta agonist and a theophylline. Only 43% of the patients received inhaler therapy, but no patients were given steroids, inhaled or oral. The drug treatment was unrelated to the severity of patients' asthma. Further, objective measurement of severity was under-used in the assessment of asthma, only 8.5% of patients ever had their PEFR recorded. This study has found that asthma is poorly managed in out-patient clinics. We need to improve the training of doctors in the optimal management of asthma.
Study site: General outpatient clinics, district hospitals, Pahang, Malaysia
A medical audit is defined as a systematic and critical analysis carried out by doctors looking at the things that doctors do. The concept of auditing is relatively new to the medical profession. It is indeed an excellent instrument to institute change to medical practices which have been "institutionalized". A properly carried out audit can provide highly revealing data that can often sway an administrator to institute change. At the University Hospital Kuala Lumpur we chose to audit the paediatric attendances at high risk deliveries. High risk deliveries were defined as any delivery to which the obstetrician requested a paediatric attendance prior to delivery. A paediatrician must be on hand at all high risk deliveries to ensure proper resuscitation of the new born. The aim of the audit was to determine if paediatric attendance at high risk deliveries were optimal at the University Hospital. (Copied from article).
Audit has improved certain aspects of management of typhoid fever detected through Klinik Perubatan Masyarakat at Hospital Universiti Sains Malaysia. We audited records of clinic patients who were blood culture positive for Salmonella typhi. For August to October 1992, we found 10 out of 31 cases (32%) were not admitted. Some of these were patients who defaulted, while some were managed as outpatients but not notified. We took action to educate the medical officers. For November 1992 - March 1993 we found 8 out of 24 cases (33%) were not admitted. Although the admission rate was no better, there was a non significant improvement in rate of notification by doctors. Defaulters were now the main problem, and so we took action to improve their follow-up, by using the clinic staff nurse. For April - August 1993, only 1 out of 16 cases (6%) was not admitted. This was a significant improvement (p=0.03)
Study site: Klinik Perubatan Masyarakat at Hospital Universiti Sains Malaysia
An audit was done on 54 tuberculosis patients presenting to Penang Hospital who died during 1993. Active tuberculosis was the cause of death in 29 (53.7%) and 48.3% were aged under 50 years. Tuberculosis was a contributory cause of death in 8 patients and in 17 patients tuberculosis was irrelevant to the cause of death. The diagnosis of tuberculosis was made after death in 17 patients (31.5%). Late diagnosis was the most important factor resulting in death. Only 41.4% of the deaths from active tuberculosis were correctly certified in government hospitals. Medically inspected and certified deaths from tuberculosis is an unreliable indicator of tuberculosis mortality because of inaccuracies in death certification, tuberculosis deaths occurring outside hospital and tuberculosis patients undiagnosed until after death.
The clinical, haematological and biochemical profiles of all domestic and imported malaria cases admitted to the Hospital Kuala Lumpur were analysed. The most common malaria types were Plasmodium falciparum (39.5%) and Plasmodium vivax (42%). The most common patient type was men aged 29-40 years (reflecting the high mobility of this group, many of whom were illegal immigrants). Misdiagnosis on admission was frequently due to the variable clinical presentation of the disease and the difficulties of obtaining an accurate history. Associated haematological abnormalities were common. Chloroquine resistance was diagnosed in four P. falciparum patients and in one P. falciparum/vivax patient. Overall, imported malaria did not seem more severe than domestic. The three patients with cerebral malaria survived. One patient died of acute liver failure. The large influx of illegal immigrants to Malaysia has resulted in a surge in malaria infection; illegal immigrants remain a source of chloroquine resistance.
A study was undertaken to determine the assessment and management of adult asthmatic patients presenting to the Accident and Emergency department. The records of 50 consecutive adult asthmatic patients presenting to A & E with acute bronchial asthma between June 1993 to April 1994 were reviewed. Patients were also interviewed on their subsequent visit to hospital. Observations and measurements used to assess the severity of asthma were recorded with variable frequency--cyanosis 8%, inability to speak 2%, chest auscultation 64%, heart rate 10%, blood pressure 6%, respiratory rate 4%. The failure to record more objective measurements of severity of asthma and in particular extent of airflow obstruction is cause for concern. The drugs used to treat acute asthma in order of frequency were Beta agonists by nebuliser, 49 patients; intravenous aminophylline, 8 patients; and intravenous corticosteroids, 6 patients. 15 patients were admitted to the medical ward. The decision to admit patients appeared to be due to a lack of symptomatic improvement after treatment. Of the 35 patients who were discharged from A & E, 13 (37%) had an acute relapse within 10 days. None of the patients on discharge from A & E were given a short course of oral steroids or were advised an increase in steroid inhaler therapy. There was therefore a gross underuse of corticosteroids.
Study site: Emergency department, Hospital Muar, Johor, Malaysia
A quality assurance exercise for non-insulin dependent diabetes mellitus in the Family Practice Clinic, University Hospital Kuala Lumpur, was conducted using HbA1c as an indicator. We found that about 60% of the 163 patients with non-insulin dependent diabetes mellitus had fair to optimal control. The HbA1c correlated well with fasting and post-prandial blood glucose level (r=0.79 and r=0.54, respectively, p<0.001). The mean HbA1c was significantly higher in Malay compared to the other races, in those with longer duration of diabetes and in patients on two types of oral hypoglycaemic agent.
Study site: Family Practice Clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
The objectives of this study were to evaluate the time delays between the onset of symptoms and admission to hospital and provision of thrombolytic therapy in patients with suspected acute myocardial infarction; and to examine the accuracy of the clinical diagnosis and the therapeutic decision on thrombolysis in these patients. An observational study of 96 patients with suspected myocardial infarction was undertaken over a period of 15 months in the Coronary Care Unit of Hospital Kuala Terengganu. Seventy per cent of the patients arrived in the hospital within 6 hours of the onset of symptoms. After arrival in the emergency room, it took a median time of 85 minutes before the administration of thrombolytic therapy. Of the 67 patients who were given thrombolysis, 46 were treated within 6 hours of the onset of symptoms. About a quarter of patients said that they had delayed seeking treatment at the hospital. Treatment delays occurring in the hospital were mainly due to admission procedures as well as late diagnosis. Eighty-one patients had confirmed myocardial infarction of whom 59 received thrombolytic therapy. Eight patients receiving thrombolytic therapy had no confirmation of myocardial infarctions. Improvements in diagnostic accuracy and reduction of delays in the provision of thrombolytic therapy could be achieved by better training of health care staff as well as by further streamlining of admission procedures.
We report a cross-sectional descriptive study of 90 new long-stay patients (NLS) (i.e. those who had been resident for six months to three years in Permai Mental Hospital, Johor) and studied from April to June, 1995. The age of this sample ranged from 18 to 85 years. Two subgroups were observed (i.e. younger NLS patients aged 18 to 34 years and older NLS patients aged 35 to 85 years). Among the younger NLS patients, the commonest diagnosis was schizophrenia (51.2%), followed by mental retardation with related problems (24.4%). Sixty-one percent of these younger patients had a history of serious violence or dangerous behaviour. Older NLS patients were likely to have a diagnosis of schizophrenia (79.6%), followed by mood disorder (6.1%) and dementia (4.1%). Forty seven percent of these older group had history of danger to others and 57.1% were at moderate or severe risk of non-deliberate self-harm. Focusing on the schizophrenic patients, all of them had some form of psychopathology, either positive, negative or general symptoms and about one-fourth were assessed to pose a risk for aggression.
Fifty-five patients were followed up after day surgery for breast lumpectomy. It was found that local infiltration with bupivacaine significantly decreased analgesic requirement in recovery. Almost half of the patients could not be contacted during the 24 hour post-operative follow-up by telephone. 7.1% complained of severe pain despite oral analgesics. 14.3% of patients had queries regarding wound care and 78.6% of the patients were willing to undergo day surgery again. Ongoing patient education and good post operative analgesia are crucial to enable successful establishment of ambulatory surgery. Post-operative follow-up is encouraged to audit clinical and social outcomes of day surgery.
Adequacy of diabetic management in 5 Perak outpatient departments was studied in April 1996. Two hundred diabetic patients' records were analysed. All doctors and 100 patients answered questionnaires on diabetes. Fifty five percent of doctors had adequate knowledge. Patients' knowledge varied between centres (13% to 80% adequacy). Most records had insufficient data to determine adequacy of early detection. Centres with screeners had adequate weight and blood pressure measurement. Overall control and monitoring of diabetes were inadequate. Referral of complications were delayed in 2 centres. Refresher courses for doctors, patient health education, protocols, screeners and physician visits are recommended.
Study site: Klinik kesihatan, outpatient clinics, hospitals, Perak, Malaysia
This is a study of 54 intravenous drug user's (IVDUs) with infected pseudoaneurysms undergoing ligation and debridement at the Vascular Unit, Hospital Kuala Lumpur (HKL) from February 1993 to February 1996. The median age was 37 years with a male preponderance (53:1). Chinese form the largest ethnic group with 57.4% of the cases. Staphylococcus aureus was the most common organism cultured. Human immunodeficiency virus (HIV) positive cases numbered 21 (38.9%). Four of the patients had to have an above-knee amputation after surgery. Simple ligation and debridement of all necrotic tissue is an acceptable mode of therapy in these patients with low amputation rates.
An audit of all perioperative deaths within seven days of surgery in 14 major public hospitals is presented. This study is part of a quality assurance programme examining the surgical and anaesthetic practices in these hospitals. During the study period from July 1992 till June 1994, 211,354 surgeries were performed and 715 deaths were reported out of which 699 were available for analysis. The data was obtained by confidential enquiry using predetermined questionnaires filled by participating surgeons and anaesthetists and analysed by a group of peers. The overall crude mortality rate was 0.34% and the majority of the deaths occurred in severely ill patients in whom the clinical management was satisfactory. Polytrauma including head, intra-abdominal and skeletal trauma accounted for 253 of the deaths (36.19%). The other causes were bowel obstruction with sepsis, burns, ischaemic limbs, congenital malformations in neonates and pregnancy-related hemorrhage. 62.52% of the deaths occurred within two days of surgery and 85.87% were related to emergency procedures. The review identified some shortfalls in perioperative care and these were lack of adequate critical care facilities, lack of supervision, unnecessary surgery in the moribund and inadequate preoperative optimisation. The results of the study have been forwarded to all participating hospitals for implementation of remedial measures.
The demographic characteristics, risk behaviourand prevalence of other sexually transmitted diseases (STDs) were determined in 132 HIV-infected individuals seen in a Dermatology cum Genitourinary Clinic, Hospital Sultanah Aminah Johor Bahru. Sixty-one (46.2%) were Malays, 37.9% Chinese, 10.6% Indians and 5.3% were of other ethnic groups. The male to female ratio was 4.5:1. Most of the patients (82.5%) were between 20 to 40 years-old. Seventy (53.0%) were single, 34.1% were married and 7.5% were divorcees. The majority of them (97.7%) were heterosexual. Fifty seven (53.3%) of our male patients patronised commercial workers. Eighty-one (61.8%) were not intravenous drug users (IVDU). Of the 50 IVDUs, 24 had multiple sexual exposures. Fifty-three (48.2%) of the 109 patients screened for STDs had one or more other STDs. Thirty-four patients (31.9%) reported one STD in the past and 3.6% reported two STDs in the past. Fifty-six patients (42.4%) had developed AIDS. Thirteen had passed away. The main mode of transmission of HIV infection in this population is through heterosexual intercourse and the prevalence of STDs is high. These findings indicate a need to advocate responsible sexual behaviour and to detect as well as treat STDs early to prevent the sexual transmission of HIV.
Study site: Dermatology cum Genitourinary Clinic, Hospital Sultanah Aminah Johor Bahru
A study was carried out in Kuala Lumpur Hospital to review the adequacy of documentation of bio-data and clinical data including clinical examination, progress review, discharge process and doctor's identification in ten of our clinical departments. Twenty criteria were assessed in a retrospective manner to scrutinize the contents of medical notes and subsequently two prospective evaluations were conducted to see improvement in case notes documentation. Deficiencies were revealed in all the criteria selected. However there was a statistically significant improvement in the eleven clinical data criteria in the subsequent two evaluations. Illegibility of case note entries and an excessive usage of abbreviations were noted during this audit. All clinical departments and hospitals should carry out detailed studies into the contents of their medical notes.