INTRODUCTION: Maternal mortality and morbidity from eclampsia continues to be seen around the globe. Local Key Performance Index on recurrence of eclamptic fits did not meet targets, thus this raised the issue whether the care provided adhered to the standard management for eclampsia.
METHODS: This clinical audit was conducted to assess and improve the quality of the service being offered to patient, particularly in managing eclampsia cases. It was conducted according to the audit cycle. It begins with the development of 12 standardized criteria for eclampsia management. First audit was conducted by retrospectively reviewing eclampsia cases from year 2008 till 2012. Strategies for changes were formulated and implemented following the results of the first audit. Second audit was conducted six months after the changes.
RESULTS: The overall incidence rate of eclampsia was 9.17 per 10,000 deliveries. A first seizure occurred during the antepartum period in 52.9% of cases (n=27), intrapartum in 24% (n=11) and postpartum in 21% of cases (n=13). Suboptimal care was mainly on delay of activation of Red Alert system and no treatment for uncontrolled blood pressure. Several strategies were implemented, mainly on improving working knowledge of the staffs and reengineering hospital Red Alert system. Positive achievements observed during the second audit, shown by a reduction in the number of patients with recurrence eclamptic fits and perinatal mortality rate.
CONCLUSION: Conducting an audit is essential to evaluate local performance against the standardized criteria. Improvement can be achieved with inexpensive solutions and attainable within a short period of time.
Study site: Sultan Abdul Halim Hospital, Sungai Petani, Kedah, Malaysia
58 cases of sputum smear negative pulmonary tuberculosis (PTB) were reported to Kinta Health Department between January and June 2011. It was found that 47 cases (81%) were sputum smear negative cases. Six cases (10.3%) were actually sputum smear positive but were wrongly reported as smear negative. Five cases (8.6%) were misdiagnosed as tuberculosis. Majority of these patients (82.7%) sought consultation and treatment after two weeks of having cough. Only 6.9% sought treatment for cough that was less than two weeks old. Accurate diagnosis of PTB is crucial and the Perak State Health Department needs to quickly adopt steps to improve the situation.
The timing of ABG procedure in a cleft patient is crucial to provide room and bony
support for the eruption of canine. However, there seems to be a delay in execution of this
procedure in certain centres. Material and Methods: Sample consists of records of cleft patients
treated from 2000-2016. The date and age for commencement of active orthodontic treatment,
date referred for ABG and date ABG done were retrieved. The centres that conducted these
surgeries identified. (Copied from article).
Intraoral periapical radiographic film is essential and aids in diagnosis, treatment
planning, monitoring treatment and monitoring lesion development. A poor image quality of
radiographic film and poor record keeping of these radiographs can affect the clinician's decision
making. This first audit was to evaluate the quality of radiographic images and the compliance in
following the standard of recording and labeling of radiographic films. The objectives of this audit
were; firstly to highlight any potential problems involving quality of radiographic films within the
department. Second, to assess the compliance of record keeping and labeling of intraoral
radiographs. Materials and Methods: The study was conducted in a retrospective manner in the
year 2017 with a sample of 100 intraoral periapical radiographic films from the year 2015 to 2016 in
Hospital Sultanah Bahiyah. Results: This first audit cycle demonstrated: Good quality of
radiographic films: 13% (n= 13/100), Good compliance of record keeping and labeling of radiograph: 32% (n= 32/100).
It is not uncommon for lateral cephalometric radiographs to be outsourced for orthodontic treatment, as not all orthodontic clinics in Malaysia have their own cephalometric radiograph machine. Since the quality of outsourced radiographs is not within the governance of the clinician, there is a need to monitor the quality of cephalometric radiographs received. Aim: To audit the quality of lateral cephalometric radiographs received at the Orthodontic Specialist Unit, Klinik Pergigian Cahaya Suria, Kuala Lumpur, Malaysia. Methodology: Lateral cephalometric records of patients with registration numbers up to 200 in 2015 were selected and assessed using a light box. The quality of good radiographs were based on 15 parameters: correct head position; presence of the scale; important structures centered on the film; patient’s name; date taken; patient’s identifier; label not obscuring radiograph; soft tissue visible; teeth in occlusion; good contrast; ‘A’ point identifiable; ‘B’ point identifiable; nasion identifiable; sella identifiable; incisors visible and their angulation measureable. Standard was set at 100%, as radiographs received should contain all parameters. Results: Five records were excluded (2 had no radiographs, 2 had digital radiographs, and 1 record could not be traced). 64.5% radiographs had all 15 parameters, 30.3%, 3.9% and 1.3% with 14, 13 and 12 parameters, respectively. Patient’s name, identifier, date taken, soft tissue visible, ‘B’ point identifiable, nasion identifiable were present in all radiographs (100%). Incisor visible and their angulation measurable were present in 99%; good contrast and ‘A’ point identifiable in 98%; presence of scale, important structures centred on films and sella identifiable in 97%, label not obscuring radiographs in 96%; correct head position in 86%; and teeth in occlusion in 88% of radiographs. Conclusion: There is a need to liaise with the radiology unit to improve the quality of radiographs taken.
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.
We evaluated the use of Desflurane anaesthesia in this prospective observational audit in the University of Malaya Medical Centre Day Surgery Unit. Fifty ASA I-II unpremedicated day surgery patients received fentanyl and propofol induction after preoxygenation. Desflurane was introduced initially at 2% and the concentration was increased gradually to 4%, then 6%, 8% and 10% in nitrous oxide and oxygen. Patients breathed spontaneously throughout the surgery. Desflurane was switched off at the end of surgery and patients breathed 100% oxygen. The haemodynamic effect, perioperative complications and recovery profiles were recorded. Systolic arterial pressure and heart rate decreased after induction of anaesthesia but returned to baseline value at discharge. Adverse airway event such as coughing and postoperative nausea and vomiting are two unwanted complications. KEYWORDS: Desflurane, day surgery, propofol induction
INTRODUCTION: Diabetes care at different healthcare facilities varied from significantly better at one setting to no difference amongst them. We examined type 2 diabetes patient profiles, disease control and complication rates at four public health facilities in Malaysia.
MATERIALS AND METHODS: This study analyzed data from diabetes registry database, the Adult Diabetes Control and Management (ADCM). The four public health facilities were hospital with specialist (HS), hospital without specialist (HNS), health clinics with family physicians (CS) and health clinic without doctor (CND). Independent risk factors were identified using multivariate regression analyses.
RESULTS: The means age and duration of diabetes in years were significantly older and longer in HS (ANOVA, p< 0.0001). There were significantly more patients on insulin (31.2%), anti-hypertensives (80.1%), statins (68.1%) and antiplatelets (51.2%) in HS. Patients at HS had significantly lower means BMI, HbA1c, LDL-C and higher mean HDL-C. A significant larger proportion of type 2 diabetes patients at HS had diabetes-related complications (2-5 times). Compared to the HS, the CS was more likely to achieve HbA1c ≤ 6.5% (adjusted OR 1.2) and BP target < 130/80 mmHg (adjusted OR 1.4), the HNS was 3.4 times more likely not achieving LDL-C target < 2.6 mmol/L.
CONCLUSION: Public hospitals with specialists in Malaysia were treating older male Chinese type 2 diabetes patients with more complications, and prescribed more medications. Patients attending these hospitals achieved better LDL-C target but poorer in attaining BP and lower HbA1c targets as compared to public health clinics with doctors and family physicians.
Newborn screening for congenital hypothyroidism (CH) was implemented in Hospital UKM in December 2004 using cord blood sample. From the audit over a period of 25 months, a total of 13,875 newborn babies were screened with a coverage of 98.8%. From this cohort, the mean recall rate was 0.32%; unfortunately the mean percentage of recalled babies that came for retesting was only 79.5%. In addition, the mean sample rejection rate was high, i.e. 2.2%. Two babies were diagnosed to have CH. These findings implied that whilst the coverage of screening was good, there is a need for regular surveillance of performance of both clinical and laboratory personnel. In addition, a more concerted effort should be carried out to promote community awareness of such a programme.
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.
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
Medical audit is vital to ensure continuous quality assurance and quality improvements. We did a retrospective study to ascertain the adequacy of clinical documentation and the factors hindering early discharge after an acute stroke in a restructured hospital. The medical records of all patients with acute stroke who died or were discharged from a restructured hospital in Singapore in January and February 1999 were reviewed retrospectively. Demographic data and the presence or absence of clinical documentation were noted. Factors hindering the discharge of patients at Day 5, Day 10 of stroke and at final discharge were noted and classified into: stroke-related, complications of stroke, medical-related and social factors. There were 101 patients in the study cohort, 55 males (54.5%) and 46 females (45.5%). The mean age was 67.9 years (SD 12.3). Documentation in Barthel scores (0%), presence of depression (0%), mental scores (1.0%), visual problems (10.0%), bladder continence (39.6%), admission functional status (37.6%) and dysphagia (52.5%) were deficient. The mean length of stay (LOS) was 13.0 (SD 14.2) days. The main factor hindering discharge at Day 5 (90.4%), Day 10 (95.2%) and at final discharge (82.1%) was stroke-related problems. Poor function (60.3%) and dysphagia (15.8%) were the 2 most common stroke-related problems hindering final discharge. Complications of stroke, medical-related problems and social reasons hindered final discharge in 10.8%, 17.8% and 2.9% of patients respectively. This audit revealed inadequacy in clinical documentation in patients with acute stroke. The main hindrance to final discharge of patients was stroke-related problems. The 2 most important stroke-related problems were poor function and dysphagia.
This audit report assessed the structure, processes and outcome of the pulmonary tuberculosis (PTB) management in adults conducted at eight government health clinics within the high TB burden Gombak district. All newly diagnosed PTB patients from November 2012 to November 2013 were identified from the tuberculosis registry. Patients less than 18 years old, were transferred out or extrapulmonary tuberculosis was excluded from the study. The assessment criteria for PTB were defined according to the latest Malaysian TB clinical practice guidelines (TB CPG) 2012. A total of 117 patients were included in this report and data were extracted and analysed using SPSS version 20.0. The mean age of patients was 40.4 ± 14.4 SD. Majority was men (63.2%). Out of 117 patients, 82.1% were Malaysian citizens and 17.9% were foreigners. Malays were the majority (65%) followed by 7.7% Chinese, 10.3% Indian and 17.1% others. The most common clinical feature was cough (88.0%) followed by loss of weight (58.1%), loss of appetite (57.3%), fever (56.4%), night sweat (30.8%) and haemoptysis (32.5%). Acid-fast bacilli (AFB) smear was positive in 94% of cases. Chest X-ray and human immunodeficiency virus (HIV) screening results were available for 89.1 and 82.1% cases respectively. The results for the sputum culture were available in 27.4% of patients and 54.7% were documented as done but pending results. The clinics have a successful directly observed therapy (DOT) program with 94.0% patients documented under DOT. Out of 53 patients on maintenance phase, 47.2% were identified as cured. Cure rate for those completed treatment was 100%. The defaulter rate was 17.1%. This audit demonstrated the attempt made by the clinics to adhere to the recommended guidelines. However, improvements are to be made in the documentation of medical records, tracing of investigation results and reduction of the number of defaulters.
INTRODUCTION: T-piece resuscitator (TPR) has many advantages compared to self-inflating bag (SIB). Early Continuous Positive Airway Pressure (CPAP) during newborn resuscitation (NR) with TPR at delivery can reduce intubation rate.
METHODS: We speculated that the intubation rate at delivery room was high because SIB had always been used during NR and this can be improved with TPR. Intubation rate of newborn <24 hours of life was deemed high if >50%. An audit was carried out in June 2010 to verify this problem using a check sheet.
RESULTS: 25 neonates without major congenital anomalies who required NR with SIB at delivery were included. Intubation rate of babies <24 hours of life when SIB was used was 68%. Post-intervention audit (August to November 2010) on 25 newborns showed that the intubation rate within 24 hours dropped to 8% when TPR was used. Proportion of intubated babies reduced from 48.3% (2008-2009) to 35.1% (2011-2012), odds ratio 0.58 (95% CI 0.49-0.68). Proportion of neonates on CPAP increased from 63.5% (2008-2009) to 81.0% (2011-2012), odds ratio 2.44 (95% CI 2.03-2.93). Mean ventilation days fell to below 4 days after 2010. Since then, all delivery standbys were accompanied by TPR and it was used for all NR regardless of settings. There was decline in intubation rate secondary to early provision of CPAP with TPR during NR. Mean ventilation days, mortality and length of NICU stay were reduced.
CONCLUSION: This practice should be adopted by all hospitals in the country to achieve Millennium Development Goal 4 (2/3 decline of under 5 mortality rate) by 2015.
Study site: Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, 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).