Effect of using protocols on medical care: randomised trial of three methods of taking an antenatal history

The surgical admission proforma: the impact on quality and completeness of surgical admission documentation

BACKGROUND

Inadequate medical documentation has been associated with a higher rate of adverse events and may have medicolegal consequences. An accurate admission note is critical as it is frequently referred to during inpatient stay, particularly when the patient is acutely unwell and during handover of care.

AIM

We set out to implement a surgical admission proforma and evaluate its impact on the quality of acute surgical admission notes.

METHODS

A standardised, structured admission proforma for use with all emergency general surgery patients in a busy model 3 hospital was designed and implemented. Previously, all admission notes were performed freehand. The quality and completeness of admission notes was evaluated both before and after implementation of the proforma over two separate 4-week periods by assessing documentation across 19 criteria.

RESULTS

Two hundred and fifty-one admission notes before proforma implementation and 273 admission notes after implementation were assessed. Proforma uptake was 97%. Documentation improved in all 19 criteria, with statistical significance achieved in 17 of these. These include past medical history, medication lists, allergy status, physical examination findings, blood results, vital signs and management plan. The proforma showed evidence of improved communication with both nursing staff and senior colleagues.

CONCLUSIONS

The surgical admission proforma has significantly improved the quality and completeness of admission documentation, ensuring improved patient safety and efficiency of care. Structured admission proformas have a positive impact on patient outcomes, doctors' performance, hospital efficiency, communication and audit quality control, thus providing multiple clear benefits in comparison to freehand admission notes.

Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes

BACKGROUND

Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care.

OBJECTIVES

1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies.

SELECTION CRITERIA

We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects.

AUTHORS' CONCLUSIONS

Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.

Patient and healthcare provider knowledge, attitudes and barriers to handover and healthcare communication during chronic disease inpatient care in India: a qualitative exploratory study

OBJECTIVES

1) To investigate patient and healthcare provider (HCP) knowledge, attitudes and barriers to handover and healthcare communication during inpatient care. 2) To explore potential interventions for improving the storage and transfer of healthcare information.

DESIGN

Qualitative study comprising 41 semi-structured, individual interviews and a thematic analysis using the Framework Method with analyst triangulation.

SETTING

Three public hospitals in Himachal Pradesh and Kerala, India.

PARTICIPANTS

Participants included 20 male (n=10) and female (n=10) patients with chronic non-communicable disease (NCD) and 21 male (n=15) and female (n=6) HCPs. Purposive sampling was used to identify patients with chronic NCDs (cardiovascular disease, chronic respiratory disease, diabetes or hypertension) and HCPs.

RESULTS

Patient themes were (1) public healthcare service characteristics, (2) HCP to patient communication and (3) attitudes regarding medical information. HCP themes were (1) system factors, (2) information exchange practices and (3) quality improvement strategies. Both patients and HCPs recognised public healthcare constraints that increased pressure on hospitals and subsequently limited consultation times. Systemic issues reported by HCPs were a lack of formal handover systems, training and accessible hospital-based records. Healthcare management communication during admission was inconsistent and lacked patient-centredness, evidenced by varying reports of patient information received and some dissatisfaction with lifestyle advice. HCPs reported that the duty of writing discharge notes was passed from senior doctors to interns or nurses during busy periods. A nurse reported providing predominantly verbal discharge instructions to patients. Patient-held medical documents facilitated information exchange between HCPs, but doctors reported that they were not always transported. HCPs and patients expressed positive views towards the idea of introducing patient-held booklets to improve the organisation and transfer of medical documents.

CONCLUSIONS

Handover and healthcare communication during chronic NCD inpatient care is currently suboptimal. Structured information exchange systems and HCP training are required to improve continuity and safety of care during critical transitions such as referral and discharge. Our findings suggest that patient-held booklets may also assist in enhancing handover and patient-centred practices.

Using rubber stamps and mobile phones to help understand and change antibiotic prescribing behaviour in private sector primary healthcare clinics in Kenya

Background

Antibiotic use in primary care can drive antimicrobial resistance (AMR) in the community. However, our understanding of antibiotic prescribing in low- and middle-income countries (LMICs) stems mostly from hospital-based studies or prescription/sales records, with little information available on routine primary care practices. We used an innovative, paper-to-digital documentation approach to deliver routine data and understand antibiotic use for common infections in low-resource primary healthcare clinics (PHCs).

Methods

Rubber stamps were introduced in nine private sector PHCs serving Nairobi’s informal settlements to ‘print-on-demand’ clinical documentation templates into paper charts. The intervention included one mobile phone per PHC to take and share images of filled templates, guideline compilation booklets and monthly continuing medical education (CME) sessions. Templates for upper respiratory tract (URTI), urinary tract (UTI), sexually transmitted (STI) and gastrointestinal infection (GI) management were used in eight PHCs. Information in templates from 889 patient encounters was digitised from smartphone images, analysed, and fed back to clinicians during monthly CME sessions. UTI charts (n=130 and 96, respectively) were audited preintervention and postintervention for quality of clinical documentation and management.

Results

Antibiotics were prescribed in 94.3%±1.6% of all patient encounters (97.3% in URTI, 94.2% in UTI, 91.6% in STI and 91.3% in GI), with 1.4±0.4 antibiotics prescribed per encounter. Clinicians considered antibiotic use appropriate in only 58.6% of URTI and 47.2% of GI cases. While feedback did not affect the number of antibiotics prescribed for UTIs, the use of nitrofurantoin, an appropriate, narrow-spectrum antibiotic, increased (9.2% to 29.9%; p<0.0001) and use of broad spectrum quinolones decreased (30.0% to 16.1%; p<0.05).

Conclusion

Antibiotic use for common infections is high in private sector PHCs in Kenya, with both knowledge and ‘know-do’ gaps contributing to inappropriate prescription. Paper-based templates in combination with smartphone technologies can sustainably deliver routine primary care case management data to support the battle against AMR.

Investigating clinical handover and healthcare communication for outpatients with chronic disease in India: A mixed-methods study

OBJECTIVES

Research concentrating on continuity of care for chronic, non-communicable disease (NCD) patients in resource-constrained settings is currently limited and focusses on inpatients. Outpatient care requires attention as this is where NCD patients often seek treatment and optimal handover of information is essential. We investigated handover, healthcare communication and barriers to continuity of care for chronic NCD outpatients in India. We also explored potential interventions for improving storage and exchange of healthcare information.

METHODS

A mixed-methods design was used across five healthcare facilities in Kerala and Himachal Pradesh states. Questionnaires from 513 outpatients with cardiovascular disease, chronic respiratory disease, or diabetes covered the form and comprehensiveness of information exchange between healthcare professionals (HCPs) and between HCPs and patients. Semi-structured interviews with outpatients and HCPs explored handover, healthcare communication and intervention ideas. Barriers to continuity of care were identified through triangulation of all data sources.

RESULTS

Almost half (46%) of patients self-referred to hospital outpatient clinics (OPCs). Patient-held healthcare information was often poorly recorded on unstructured sheets of paper; 24% of OPC documents contained the following: diagnosis, medication, long-term care and follow-up information. Just 55% of patients recalled receiving verbal follow-up and medication instructions during OPC appointments. Qualitative themes included patient preference for hospital visits, system factors, inconsistent doctor-patient communication and attitudes towards medical documents. Barriers were hospital time constraints, inconsistent referral practices and absences of OPC medical record-keeping, structured patient-held medical documents and clinical handover training. Patients and HCPs were in favour of the introduction of patient-held booklets for storing and transporting medical documents.

CONCLUSIONS

Deficiencies in communicative practices are compromising the continuity of chronic NCD outpatient care. Targeted systems-based interventions are urgently required to improve information provision and exchange. Our findings indicate that well-designed patient-held booklets are likely to be an acceptable, affordable and effective part of the solution.

The surgical admissions proforma: Does it make a difference?

Admissions records are essential in communicating key information regarding unwell patients and at handover of care. We designed, implemented and evaluated the impact of a standardised surgical clerking proforma on documentation and clinician acceptability in comparison to freehand clerking. A clerking proforma was implemented for all acute general surgical admissions. Documentation was assessed according to 32 criteria based on the Royal College of Surgeons of England guidelines, for admissions before (n = 72) and after (n = 96) implementation. Fisher's exact test and regression analysis were used to compare groups. Surgical team members were surveyed regarding attitudes towards the new proforma. Proforma uptake was 73%. After implementation, documentation increased in 28/32 criteria. This was statistically significant in 17 criteria, including past surgical history (p < 0.01), medication history (p = 0.03), ADLs (p = 0.02), systems review (p < 0.01), blood pressure (p < 0.01), blood results (p = 0.02) and advice given to the patient (p = 0.02). The proforma remained beneficial after regression analysis accounted for differences in time of day, seniority of the doctor and nights or weekends (coefficient = 0.12 [p < 0.01]). 89% of the surgical team felt the form improved quality of documentation and preferred its use to freehand clerking. 94% felt it was beneficial on the post-take ward-round. Audit quality control was also more reliable with the proforma (inter-observer agreement = 99.3% [κ = 0.997]) versus freehand clerking (97.1% [κ = 0.941]). Our study demonstrates that a standardised surgical clerking proformas improves the quantity and quality of documentation in comparison to freehand clerking, is preferred by health professionals and improves reliability of the audit quality control process.

Implementation of an obstetric hemorrhage risk assessment: validation and evaluation of its impact on pretransfusion testing and hemorrhage outcomes

OBJECTIVE

To evaluate the impact of an obstetric hemorrhage risk assessment on pretransfusion testing and hemorrhage outcomes at a tertiary care, academic medical center.

METHODS

A retrospective cohort study was performed among women delivering neonates≥24 weeks from 2009 to 2011. Demographics, pretransfusion testing rates and hemorrhage outcomes were compared between those delivering before and after implementation of the risk assessment. Multivariable analyses were used to determine predictors of postpartum hemorrhage and transfusion.

RESULTS

There were 1388 women delivering before and 2121 women delivering after implementation of the risk assessment. More pretransfusion testing occurred after the assessment was initiated (22.8% versus 15.0%). Those who were considered high-risk were more likely to experience hemorrhage outcomes. In multivariable analyses, physician ordering practice in the pre-risk assessment period was a better prognosticator of both postpartum hemorrhage (aOR 9.98, 95% CI 5.02-19.82) and transfusion (aOR 31.14, 95% CI 14.97-64.82) than completion of a cross-match after implementation of the risk assessment (postpartum hemorrhage: aOR 2.10, 95% CI 1.20-3.66, transfusion: aOR 6.31, 95% CI 3.34-11.94).

CONCLUSIONS

Pre-risk assessment practice may be better at identifying those in need of blood transfusion, strictly due to the necessity for pretransfusion orders for transfusion to occur. In contrast, the obstetric hemorrhage risk assessment accurately predicted those who were more likely to experience hemorrhage outcomes. Optimal utilization of the risk assessment has yet to be determined.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

Development of a standardised pro forma for specialist palliative care multidisciplinary team meetings

A pro forma of the caseload of the community palliative care clinical nurse specialists in the Central Lancashire Community Specialist Palliative Care Team was devised to provide a brief overview of each patient's plan of care for use in the multidisciplinary team meetings and as a consequence of preparing for the UK Department of Health's peer review process. The pro forma was also designed to be used in everyday clinical practice in Gold Standards Framework meetings in the community. It has been evaluated by the team and found to be helpful for highlighting key issues in clinical practice, such as symptoms, psychological and emotional needs, and Preferred Priorities of Care. Over the past 2 years, it has also complemented the organisation's drive to become ‘paperless’. This article looks at how the pro forma was developed, how it has evolved over time, and how it works today. Consideration has also been given to its benefits and limitations.

Data re-entry overload: time for a paradigm shift in maternity IT?

This paper provides an overview of maternity information technology (IT) in Britain, questioning the usability, effectiveness and cost efficiency of the current models of implementation of electronic maternity records. UK experience of hand-held paper obstetric notes and computerized records reveals fundamental problems in the relationship between the two complementary methods of recording maternity data. The assumption that paper records would inevitably be replaced by electronic substitutes has proven false; the rigidity of analysable electronic records has led to immense incompatibility problems. The flexibility of paper records has distinct advantages that have so far not been sufficiently acknowledged. It is suggested that continuing work is needed to encourage the standardization of electronic maternity records, via a new co-creative, co-development approach and continuing international electronic community debate.

Decision tools in health care: focus on the problem, not the solution

Background

Systematic reviews or randomised-controlled trials usually help to establish the effectiveness of drugs and other health technologies, but are rarely sufficient by themselves to ensure actual clinical use of the technology. The process from innovation to routine clinical use is complex. Numerous computerised decision support systems (DSS) have been developed, but many fail to be taken up into actual use. Some developers construct technologically advanced systems with little relevance to the real world. Others did not determine whether a clinical need exists. With NHS investing £5 billion in computer systems, also occurring in other countries, there is an urgent need to shift from a technology-driven approach to one that identifies and employs the most cost-effective method to manage knowledge, regardless of the technology. The generic term, 'decision tool' (DT), is therefore suggested to demonstrate that these aids, which seem different technically, are conceptually the same from a clinical viewpoint.

Discussion

Many computerised DSSs failed for various reasons, for example, they were not based on best available knowledge; there was insufficient emphasis on their need for high quality clinical data; their development was technology-led; or evaluation methods were misapplied. We argue that DSSs and other computer-based, paper-based and even mechanical decision aids are members of a wider family of decision tools. A DT is an active knowledge resource that uses patient data to generate case specific advice, which supports decision making about individual patients by health professionals, the patients themselves or others concerned about them. The identification of DTs as a consistent and important category of health technology should encourage the sharing of lessons between DT developers and users and reduce the frequency of decision tool projects focusing only on technology. The focus of evaluation should become more clinical, with the impact of computer-based DTs being evaluated against other computer, paper- or mechanical tools, to identify the most cost effective tool for each clinical problem.

Summary

We suggested the generic term 'decision tool' to demonstrate that decision-making aids, such as computerised DSSs, paper algorithms, and reminders are conceptually the same, so the methods to evaluate them should be the same.

The Leeds University Maternity Audit Project

OBJECTIVES

To measure levels of and changes in compliance with evidence-based recommendations in obstetrics in the UK. To identify barriers to and factors associated with compliance.

DESIGN

A quantitative case-note audit for 1988 and 1996, and a qualitative interview study of key staff.

SETTING

Twenty maternity units, selected at random from all UK units

SUBJECTS

Fifty consecutive cases of pre-term delivery (PTD), Caesarean section (CS), instrumental delivery (ID), and perineal repair (PR) operations in each period in each unit. The lead clinician, midwifery manager, a senior midwife, neonatologist, and middle-grade obstetrician in each unit.

MAIN OUTCOME MEASURES

Maternal steroid use in PTD, antibiotic use in CS, use of the ventouse (vacuum extractor) rather than forceps as instrument of first choice for ID, and use of polyglycolic acid (PGA) sutures for PR in each time period. Facilities for implementing, staff attitudes to, and the degree of planning to follow each recommendation.

MAIN RESULTS

The median proportion of ventouse as instrument of first choice in each unit was 8% (range 0-32%) in 1988, rising to 64% (range 0-98%) in 1996. PGA use for PR was 0% (range 0-30%) in 1988, and 72% (range 0-100%) in 1996. Steroid use for eligible PTD was median 0% (range 0-23%) in 1988, rising to 82% (range 63-95%) in 1996. Antibiotic use for CS was 7% (range 0-25%) rising to 84% (range 10-100%) in 1996. There was no relationship between unit size, type of unit, facilities, staff attitudes or degree of planning, and compliance with the recommendations, nor was the level of adherence to one standard typically correlated with adherence to the others. However, there was a positive correlation (R = 0.6, P < 0.005) between local availability of the Cochrane database of perinatal trials and unit compliance with the audit standards in the latter time period.

CONCLUSIONS

We have documented a massive shift in practice in line with the evidence, although many units still have substantial room for improvement. About 2000 wound infections, 200 deaths due to prematurity, nearly 8000 women in pain from catgut sutures, and 1500 cases of severe perineal trauma from forceps remain preventable. The reasons why units vary remain obscure, although the qualitative interviews often revealed local factors such as key enthusiastic staff. There was no sign of evidence being positively driven into practice by any systematic managerial process. The relationship between Cochrane availability and high-standard care may be simply a marker of commitment to the evidence, but it remains plausible that if senior staff make Cochrane available for their juniors, audit compliance improves.

Improving communication between health professionals and women in maternity care: a structured review

OBJECTIVE

To review trials of the effectiveness of interventions aimed at improving communication between health professionals and women in maternity care.

SEARCH STRATEGY

The electronic databases Medline, PsycLit, The Cochrane Library, BIDS Science and Social Science Indexes, Cinahl and Embase were searched. Final searches were carried out in April 2000.

INCLUSION CRITERIA

Controlled trials of interventions explicitly aimed at improving communication between health professionals and women in maternity care were included. Other trials were included where two reviewers agreed that this was at least part of the aim.

DATA EXTRACTION AND SYNTHESIS

95 potentially eligible papers were identified, read by one reviewer and checked against the inclusion criteria. The 11 included trials were read, assessed for quality and summarized in a structured tabular form.

RESULTS

The included trials evaluated interventions to improve the presentation of information about antenatal testing, to promote informed choice in maternity care, woman-held maternity records and computer-based history taking. Four trials in which women were provided with extra information about antenatal testing in a variety of formats suggested that this was valued by women and may reduce anxiety. Communication skills training for midwives and doctors improved their information giving about antenatal tests. The three trials of woman-held maternity records suggested that these increase women's involvement in and control over their care.

CONCLUSIONS

The trials identified by this review addressed limited aspects of communication and focused solely on antenatal care. Further research is required in several areas, including trials of communication skills training for health professionals in maternity care and other interventions to improve communication during labour and in the postnatal period.

Guidelines in gynaecology: evaluation in menorrhagia and in urinary incontinence

OBJECTIVE

To evaluate the effectiveness of national guidelines and local protocols in improving hospital care (process and outcome) for women with menorrhagia and for women with urinary incontinence.

DESIGN

2 x 2 balanced incomplete block controlled before and after study.

SETTING

Gynaecology units in four district general hospitals across Scotland.

INTERVENTION

National guidelines were adapted locally to protocols, which were disseminated at specific local educational meetings and implemented by placing a copy of the appropriate protocol in women's hospital casenotes prior to consultation.

POPULATION

Four hundred and ninety-seven women with menorrhagia and 449 women with urinary Incontinence.

MAIN OUTCOME MEASURES

Process of care within six key areas of clinical practice: initial hospital assessment; appropriate use of hospital investigations; inappropriate use of hospital investigations; appropriate first line treatments; appropriate pre-surgery assessment; and use of surgical treatments. Outcome of care using condition-specific outcome measures and four domains of SF-36 at zero, six and twelve months following intervention.

RESULTS

There were significant improvements with the introduction of guidelines and protocols in two (initial hospital assessment and appropriate pre-surgery assessment) of the six key areas of clinical practice assessed. In the other areas there were no significant improvements or deteriorations observed. There was no evidence of effect of guidelines and protocols on the condition-specific outcome measures or on the four domains of the SF-36.

CONCLUSIONS

There were only very modest benefits observed from the introduction of guidelines and protocols on the hospital management of the two conditions. The reasons for this lack of impact of the guidelines is unclear. Experience of this study raises important methodological issues for future research in this area.

Automated personal health inventory for dentistry: a pilot study

BACKGROUND

The authors conducted a study to investigate the feasibility of having patients enter their health histories, or HHs, directly into a computer so the HHs then can be transferred into computer-based patient records. The authors examined a patient-completed, pen-based computerized HH questionnaire to determine if it is acceptable to patients, if patients answer sensitive questions on the HH questionnaire more forthrightly using a computer than a pen and paper, and if the availability of explanations and examples provided for each question on the computer questionnaire results in more accurate responses than on the paper version.

METHODS

Fifty subjects completed two almost identical versions of a 78-item HH questionnaire, completing either the pen-based, computerized version first or the paper version first. After the subjects finished the questionnaires, they completed an opinion survey about using the computer to provide their HHs.

RESULTS

Subjects responded favorably to the use of a pen-based computer questionnaire to provide their HH; 73 percent indicated that they would prefer to use it in the future rather than complete a paper questionnaire. The authors found that the overall reliability of answers was 93 percent with an average of 5.4 inconsistent answers between the two HH questionnaires.

CONCLUSIONS

HHs can be collected efficiently and reliably from patients using a computer. It is important, however, that oral health care professionals review the data provided on HHs with their patients regardless of method used to collect them.

CLINICAL IMPLICATIONS

Practices can expand the use of computers into more areas of patient care by having patients complete a computerized HH questionnaire. Computerized data capture is more legible, complete and efficient than a paper HH and can be imported directly into clinical data systems, thus avoiding data entry.

Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department

STUDY OBJECTIVE

To determine whether use of the T-System (Emergency Services Consultants, Irving, TX) template-generated medical documentation system (1) decreases physician evaluation time in the emergency department, (2) increases gross billing under the 1997 Health Care Financing Administration guidelines by minimizing downcoding caused by inadequate documentation, and (3) increases physician satisfaction with the documentation process, compared with the undirected written narrative format.

METHODS

A prospective, randomized, unblinded, controlled, convenience trial of documentation with the T-System of ED templates versus undirected written documentation was conducted in the ED of a county-owned, university-affiliated hospital. All patients seen between the hours of 7 AM and 10 PM during a 16-day period were included. The intervention was varying the method of documentation of the emergency physician. Adequacy of randomization to the 2 documentation groups was assessed by comparing ED triage classification, patient disposition, level of training of the evaluating physician, and whether ED consultation with other services occurred. Outcome measurements included emergency physician total evaluation and treatment time, professional bill, and satisfaction, as evaluated by a questionnaire completed after the study period. The 2 documentation groups were compared by an intention-to-treat analysis and by Student's t test and the median test as appropriate.

RESULTS

A total of 1,228 patient encounters were included. Emergency physician total evaluation and treatment time with template-directed documentation was 4.6 minutes less than with undirected recording, a difference that was not significant (95% confidence interval [CI], -9.2 to 18.3). Gross billing was $29. 60 more per patient (95% CI, $22.20 to $37.00) with the T-System, as assessed by our hospital coders. This difference was caused by a mean.50 (95% CI,.39 to.60) higher level of evaluation and management coding. Physicians preferred the T-System (P <.0005).

CONCLUSION

Use of template-assisted documentation in the ED was associated with higher gross billing and physician satisfaction but no significant decrease in emergency physician total evaluation time.

A general practice records audit of the process of care for people with epilepsy

BACKGROUND

The appropriateness of epilepsy as a topic for general practice audit activity has been emphasized, but few audits have been undertaken to data and those that have are small scale. Historically, management of epilepsy has been a neglected area, and services for people with epilepsy remain generally poor.

AIM

The study was designed to examine the process of care for people with epilepsy through a region-wide audit of general practitioner records.

METHOD

General practitioners in 31 randomly selected general practices in one UK health region undertook a notes audit for all patients identified as having active epilepsy (patients who had had seizures in the last 2 years, or were currently seizure-free but on antiepileptic medication). A standard pro forma was used to collect information relating to diagnosis, drug treatment, and primary and secondary care contacts.

RESULTS

Recording of information in the notes was generally good, but poor for some key items essential to the effective management of the condition; results suggest that a number of recommendations about provision of care for epilepsy are not being met: in particular, EEG and CT investigations often appear poorly directed; prescribed antiepileptic therapy is not always optimal; significant numbers of patients are being treated in hospital by non-neurologists; there is little evidence of any regular review being undertaken by general practitioners of their patients with epilepsy; and counselling about the non-clinical aspects of epilepsy often appears inadequate.

CONCLUSIONS

Despite recommendations in a number of recent reports, gaps and inconsistencies in epilepsy care persist, both at the primary and secondary level. The means by which such shortcomings can be reduced (e.g. by specialist epilepsy nurses working across the primary-secondary care interface) should now be systematically examined. The study has highlighted a need for evidence-based guidelines which span the primary-secondary care interface and clarify the contribution of the various practitioners involved in the provision of care for people with epilepsy.

Antenatal 'booking' interviews at midwifery clinics in Sweden: a qualitative analysis of five video-recorded interviews

OBJECTIVE

To describe antenatal 'booking' interviews as regards content and illuminate the meaning of the ways midwives and expectant parents relate to each other.

DESIGN

Content analysis and phenomenological hermeneutic analysis of transcribed texts from five video-recorded antenatal booking interviews.

SETTING

Midwifery clinics at five health centres in the context of Swedish primary care.

PARTICIPANTS

Five midwives, five pregnant women (less than 14 weeks pregnant) and two expectant fathers.

FINDINGS

A variety of content themes and ways of relating were found. Combined themes of biomedical and obstetric content occurred as frequently as the sum of social, emotional, antenatal care and life-style themes. The midwives' ways of relating formed two main themes; considering and disregarding the uniqueness of the expectant parents. The midwives directed the interview through their choice of content themes and the way they related to the expectant parents. The expectant parents mainly shadowed the midwives' content themes and ways of relating. The expectant fathers seemed like strange visitors in the women's world. Two perspectives of antenatal midwifery care, obstetric and parental, operated alternately and in competition within the interviews.

KEY CONCLUSIONS

The content and the ways of relating within the interviews seem to be connected and could be understood in the light of Buber's writings on dialogue.

IMPLICATIONS FOR PRACTICE

The findings provide a basis for reflection on the education of midwives and the planning, training and implementation of midwifery care at antenatal 'booking' interviews.

Incidence of previously undetected disease in routine paediatric otolaryngology admissions

The process of clerking routine pre-operative admissions involves the house officer taking a full medical history and performing a full physical examination. The diagnostic yield is thought to be low, and the educational value to the house officer is also small. This study addresses the question as to whether routine physical examination is always indicated. One hundred and nine children admitted for routine Otolaryngology procedures were prospectively studied to identify the importance of examination in the pre-operative assessment of patients. The results showed that 51 per cent of the children admitted had risk factors. The medical history was sufficient to identify these risk factors in all patients with the exception of one cardiac condition. This study concludes that a suitable alternative to the current process of clerking such as a standardized nurse history could be safely and efficiently undertaken. Eliminating the tiny percentage of previously unrecognized disease would be a prerequisite for such a change.

Content of prenatal care during the initial workup

OBJECTIVE

In its landmark document Caring for Our Future: The Content of Prenatal Care, the Public Health Service Expert Panel on the Content of Prenatal Care presented a framework for refocusing prenatal care in the 1990s. The purpose of this study was to examine the extent to which the panel's recommendations for preconceptional care and for the content of the initial prenatal workup were followed 3 years after they were issued.

STUDY DESIGN

A retrospective review of the prenatal records of 147 patients in Durham and Chatham counties, North Carolina, was conducted. Providers were selected at random, and their first 10 new prenatal patients were enrolled in the study. Data were analyzed descriptively to characterize patterns in content of care and, with multiple logistic regression analysis, to determine whether there were relationships between selected maternal characteristics and receipt of selected components of care.

RESULTS

Only 11% of the patients had one or more preconceptional visits. During the initial prenatal workup risk assessment through history taking and physical examination was virtually complete, whereas documentation of laboratory tests varied. Only about half the population received routine counseling on pregnancy and health behaviors. Multiple logistic regression analysis revealed a consistent association between initiating prenatal care early in pregnancy and receipt of most laboratory tests. No other consistent relationships were found.

CONCLUSIONS

This study suggests that adherence to such long-standing prenatal care practices as physical examination, history taking, and some laboratory tests was high. But the components of prenatal care recommended by the expert panel to ensure behavioral risk assessments and health promotion and education early in pregnancy were provided at lower and more variable rates. Use of preconceptional care was also low. Further research into the use and content of care before and during pregnancy is required to understand variations in practice patterns and levels of adherence to recommendations on the content of care.

Validity of a patient-administered questionnaire for routine otolaryngology admissions

In this study the accuracy of a questionnaire filled in by 109 parents of children admitted for routine ENT surgery was compared with the well recognized verbal clerking. A major problem in communication between doctors and parents was highlighted, as just 44% of the parents were able to state the operation their children were admitted for. The study also showed that it is impossible to rely on parents to give the information required in the form of replies to questionnaires as the sensitivity of the questions designed to recognize risk factors was poor.

Risk identification for HIV infection in an inner London antenatal population

This study was carried out to ascertain whether routine antenatal history taking is an effective means of identifying risk factors for HIV infection. Information about risk obtained at routine booking was compared with answers to selected questions obtained at a research interview. The study was conducted at St. Bartholomew's Hospital Homerton, and ran from February 1991 to March 1992. Of the 3729 women interviewed, 1671 had been hand booked (unstructured questionnaire) and 2058 had been computer booked (structured questionnaire). Hand booking failed to identify 77% of risk factors compared with 7% for computer booking. The findings highlight the underdetection of risk activity and confirm the need for intermittent, anonymous sampling to obtain background information against which a decision to implement universal testing may be made.

Use of a pro forma for head injuries in the accident and emergency department--the way forward

The aim of this study was to assess the quality of documentation of head-injured patients seen in three accident and emergency (A&E) departments using a specially designed head injury pro forma. A 4-week prospective study of a single head injury pro forma was followed by a second similar study with an improved version (two head injury pro formas, one for young children and babies, the other for older children and adults). The main outcome measures were the degree of completion of the pro forma and questionnaire responses from receptionists, nurses and doctors. A total of 1260 patients had their details completed on the pro forma in both studies. Compared with standard hand written A&E notes, the degree of completion of clinical details specific to the head injury were high, eg. over 95% for symptoms. The pro forma was generally well received by A&E staff, particularly after recommended improvements were made, and the majority of staff felt it should be introduced permanently into the A&E department. Concern about its use in cases of very minor head injury and multiple injuries were raised. As well as improved documentation, the pro forma facilitates the process of audit and may have an important role to play in information technology and computers in the future.

Clinical protocols are key to quality health care delivery

The use of clinical protocols allows health care providers to offer appropriate diagnostic treatment and care services to patients, variance reports to purchasers and quality training to clinical staff. Such protocols provide a locally agreed standard to which clinicians and the organization can work and against which they can be audited. By embedding protocols into patients' records and reporting by exception, the use of protocols may help to tackle a raft of other issues successfully such as the reduction in junior doctors' hours, and the facilitation of shared care. It may also bolster the medico-legal robustness of the health care delivered. If the protocols are sufficiently detailed, costing, coding and other resource usage information can flow directly from the clinical records. Such benefits may be maximized by using protocols within the framework of an electronic patient record system.

Do clinical guidelines improve general practice management and referral of infertile couples?

OBJECTIVE

To evaluate guidelines for general practice management and referral of infertile couples. Guidelines were implemented with a disease specific reminder at the time of consultation (the guidelines were embedded within a structured infertility management sheet for each couple).

DESIGN

Pragmatic randomised controlled trial. Participating practices were randomised to a group that received the guidelines and a control group.

SETTING

82 general practices in Grampian region.

SUBJECTS

100 couples referred by general practitioners receiving the guideline and 100 couples referred by control general practitioners.

MAIN OUTCOME MEASURES

Whether the general practitioner had taken a full sexual history and examined and investigated both partners appropriately.

RESULTS

Characteristics of patients referred by study and control general practitioners did not differ significantly at baseline. Compliance with the guidelines increased for all targeted activities. General practitioners in the study group were more likely to take a sexual history (for example, couples' use of fertile period, 85% v 69%, p < 0.01); examine both partners (female partner, 68% v 52%, p < 0.05; male partner 39% v 13%, p < 0.01); and investigate both partners (day 21 progesterone, 72% v 41%, p < 0.001; semen analysis, 51% v 41%, p > 0.05). Improvements were greater when general practitioners used the disease specific reminder.

CONCLUSION

Receiving guidelines led to improvements in the process of care of infertile couples within general practice. This effect was enhanced when the guidelines were embedded in a structured infertility management sheet for each couple.