Search results for: audit expectation gap

Authors: Rachael Andrews, Viktoria McMillan, Shuaib Nasser, Christopher M. Roberts

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Background and objective: The National Review of Asthma Deaths (NRAD) found that asthma management and care was inadequate in 26% of cases reviewed. Major shortfalls identified were adherence to national guidelines and standards and, particularly, the organisation of care, including supervision and monitoring in primary care, with 70% of cases reviewed having at least one avoidable factor in this area. 5.4 million people in the UK are diagnosed with and actively treated for asthma, and approximately 60,000 are admitted to hospital with acute exacerbations each year. The majority of people with asthma receive management and treatment solely in primary care. This has therefore created concern that many people within the UK are receiving sub-optimal asthma care resulting in unnecessary morbidity and risk of adverse outcome. NRAD concluded that a national asthma audit programme should be established to measure and improve processes, organisation, and outcomes of asthma care. Objective: To develop a primary care dataset enabling extraction of information from GP practices in Wales and providing robust data by which results and lessons could be drawn and drive service development and improvement. Methods: A multidisciplinary group of experts, including general practitioners, primary care organisation representatives, and asthma patients was formed and used as a source of governance and guidance. A review of asthma literature, guidance, and standards took place and was used to identify areas of asthma care which, if improved, would lead to better patient outcomes. Modified Delphi methodology was used to gain consensus from the expert group on which of the areas identified were to be prioritised, and an asthma patient and carer focus group held to seek views and feedback on areas of asthma care that were important to them. Areas of asthma care identified by both groups were mapped to asthma guidelines and standards to inform and develop primary and secondary care datasets covering both adult and pediatric care. Dataset development consisted of expert review and a targeted consultation process in order to seek broad stakeholder views and feedback. Results: Areas of asthma care identified as requiring prioritisation by the National Asthma Audit were: (i) Prescribing, (ii) Asthma diagnosis (iii) Asthma Reviews (iv) Personalised Asthma Action Plans (PAAPs) (v) Primary care follow-up after discharge from hospital (vi) Methodologies and primary care queries were developed to cover each of the areas of poor and variable asthma care identified and the queries designed to extract information directly from electronic patients’ records. Conclusion: This paper describes the methodological approach followed to develop primary care datasets for a National Asthma Audit. It sets out the principles behind the establishment of a National Asthma Audit programme in response to a national asthma mortality review and describes the development activities undertaken. Key process elements included: (i) mapping identified areas of poor and variable asthma care to national guidelines and standards, (ii) early engagement of experts, including clinicians and patients in the process, and (iii) targeted consultation of the queries to provide further insight into measures that were collectable, reproducible and relevant.

Keywords: asthma, primary care, general practice, dataset development

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Authors: Mahmoud Tarek, Alaa Obeida, Mai Magdy, Khalid Hussein, Aly Shalaby

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Background: More doctors are complaining of burnout than before, Burnout is a state of physical and mental exhaustion caused by the doctor’s lifestyle, unfortunately, Medical errors are also more likely in those suffering from burnout and these may result in malpractice suits. Methodology: It is a retrospective audit of burnout response on all neonatologists over a 9 months period. We gathered data using burnout questionnaire, it was obtained from 23 physicians, the physicians divided into 5 categories according to the final score of the 28 questions in the questionnaire. Category 1 with score from 28-38 with almost no work stress, category 2 with score (38-50) who express a low amount of job related stress, category 3 with score (51-70) with moderate amount of stress, category 4 with score (71-90) those express a high amount of job stress and begun to burnout, category 5 with score (91 and above) who are under a dangerous amount of stress and advanced stage of burnout. Results: 33 neonatologists have received the questionnaire, 23 responses were sent back with a response rate of 69.6%. The results showed that 61% of physicians fall in category 4, 31% of the physician in category 5, while 8% of physicians equally distributed between category 2 and 3 (4% each of them). On the other hand, there is no physician present in category 1. Conclusion: Burnout is prevalent in SNICUs, So interventions to minimize burnout prevalence may be of greater importance as this may be reflected indirectly on medical conditions of the patients and physicians, efforts should be done to decrease this high rate of burnout.

Keywords: Cairo, work overload, exhaustion, surgery, neonatal ICU

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Authors: Shalinawati Ramli, Khairani Omar, Nurul Azmawati Mohamed, Zarini Ismail, Nur Syahrina Rahim, Nurul Hayati Chamhuri

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Medical doctors’ work to prevent, diagnose, treat diseases, disorders, and injuries as well as prescribing medication. Many people are attracted to this profession because it gives them the opportunity to help others. Doctors’ improve quality of life by providing advice, healing physical ailments and performing complex surgeries. Medicine is a profession in which dedication to the wellbeing of others is of paramount importance. Balancing the requirements of work and personal life can be a struggle as the demand of work as a doctors’ is great. Perception and expectation of medical students regarding the lifestyle of doctors’ is important to ensure that they had made the right career choice. Thus, the aim of this study is to assess the perception of pre-clinical students regarding doctors’ lifestyle. This study is a cross-sectional study involving all third-year pre-clinical medical students at University Sains Islam Malaysia. A total of 81 students participated in this study. Participants were given a set of questionnaire consisting of demographic data, open-ended questions on their perception on doctors’ lifestyle of working environment, salary expectation and family life. Thematic analysis were used to analyse the data. The participants comprised 69% female and their age range was between 20-21 years old. Majority of them were from middle-income families. Majority of the students perceived that the doctors’ lifestyle would be busy (72%). Approximately 30% of them expected that the time schedule will be unpredictable, 21% mentioned that sacrifice is required and 16% perceived it as a tiring job. Other themes emerged were ‘requiring high commitment’ (6%), challenging (7%) and risky (4%). With regards to salary expectation, 48% expected reasonable salary, 33% high salary and 12% described it as 'not worth compared to the workload'. Majority of them perceived that their family life will be restricted (62%) and time management is important (33%). Only 15% mentioned that family members have to sacrifice and spousal understanding is important (7%). About 10% of them perceived that their family will not be affected by their profession. Majority of the medical students perceived a busy doctors’ lifestyle, reasonable salary and restricted family life. However, there was a significant proportion of them who required counselling for better preparation of their future lifestyle.

Keywords: doctors lifestyle, pre-clinical students, perception, understanding

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Authors: Prashant Neupane, Sumitra Kafle, Asmi Pandey, Laura Mitchell

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Pain following caesarean section can influence recovery, patient satisfaction, breast feeding success and mother-child bonding. Since the introduction of enhanced recovery protocols, mothers are often discharged 24 hours later. We identified concerns within our hospital with mothers tolerating poorly controlled pain in order to achieve earlier discharge and subsequently suffering significant pain at home with inadequate analgesia. Methods: We conducted a prospective audit of analgesic prescribing and post-operative pain scores after caesarean section. Mothers were seen on post-operative day one, their pain score recorded on a verbal analogue score from 0-10, and their prescription chart reviewed. A follow-up phone call was then made on post-operative day 3-7 to enquire about pain scores and analgesia use at home. Following this, a standardized proforma for prescribing after the caesarean section was introduced, including the addition of dihydrocodeine that patients can take home following discharge. There were educational update sessions for anesthetists and midwifes, and then a re-audit was conducted months later. Results: Data was collected from 50 women before and after the introduction of the change. Initial audit showed that there was considerable variation in prescribing, with four women prescribed no regular analgesia at all and inconsistency in the dose of oral morphine prescribed. Women were not given any form of analgesia to take home after discharge and were advised to take regular paracetamol and ibuprofen. However, 31/50 (62%) reported that they needed additional analgesia and eight women (16%) even sought prescription for additional analgesia from elsewhere. After the introduction of the change, prescribing was more consistent with all patients prescribed regular analgesia. 46/50 patients were given dihydrocodeine on discharge. Mean pain scores on post-operative day one improved from 5.16 to 3.9, and at home improved from 6.18 to 2.58. Use of dihydrocodeine at home significantly improved patients reporting of severe pain at home from 24% to zero. Discussion: Lack of strong analgesia out of the hospital and the increased demands on activity levels means that women are frequently in more pain at home after discharge. Introduction of a standardized prescription proforma, including the use of to-take-out dihydrocodeine, was successful in improving patient pain scores and the requirement for additional analgesia, both in hospital and at home.

Keywords: analgesia, caesarean section, post-operative pain, standardised

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Authors: Kamal Kaushik, Trisha, Dandapni, Sambit Nanda, A. Mukherjee, S. Pradhan

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INTRODUCTION: As complexity in radiotherapy practice and processes are increasing, there is a need to assure quality control to a greater extent. At present, no international literature available with regards to the optimal quality control indicators for radiotherapy; moreover, few clinical audits have been conducted in the field of radiotherapy. The primary aim is to improve the processes that directly impact clinical outcomes for patients in terms of patient safety and quality of care. PROCEDURE: A team of an Oncologist, a Medical Physicist and a Radiation Therapist was formed for weekly clinical audits of patient’s undergoing radiotherapy audits The stages for audits include Pre planning audits, Simulation, Planning, Daily QA, Implementation and Execution (with image guidance). Errors in all the parts of the chain were evaluated and recorded for the development of further departmental protocols for radiotherapy. EVALUATION: The errors at various stages of radiotherapy chain were evaluated and recorded for comparison before starting the clinical audits in the department of radiotherapy and after starting the audits. It was also evaluated to find the stage in which maximum errors were recorded. The clinical audits were used to structure standard protocols (in the form of checklist) in department of Radiotherapy, which may lead to further reduce the occurrences of clinical errors in the chain of radiotherapy. RESULTS: The aim of this study is to perform a comparison between number of errors in different part of RT chain in two groups (A- Before Audit and B-After Audit). Group A: 94 pts. (48 males,46 female), Total no. of errors in RT chain:19 (9 needed Resimulation) Group B: 94 pts. (61 males,33 females), Total no. of errors in RT chain: 8 (4 needed Resimulation) CONCLUSION: After systematic periodic clinical audits percentage of error in radiotherapy process reduced more than 50% within 2 months. There is a great need in improving quality control in radiotherapy, and the role of clinical audits can only grow. Although clinical audits are time-consuming and complex undertakings, the potential benefits in terms of identifying and rectifying errors in quality control procedures are potentially enormous. Radiotherapy being a chain of various process. There is always a probability of occurrence of error in any part of the chain which may further propagate in the chain till execution of treatment. Structuring departmental protocols and policies helps in reducing, if not completely eradicating occurrence of such incidents.

Keywords: audit, clinical, radiotherapy, improving functionality

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Authors: Anton James

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This study explored the contribution of parenting styles in the Maternal Perception of Compliance Model (MPCM). This model explores maternal expectations to illustrate the formation of maternal perception of severity of noncompliance in adolescent children. The methodology consisted of three stages: In the first stage, a focus group was held, and the data was analysed to fine-tune the interview schedule. In the second stage, a single interview was held, and the interview schedule was further modified. The third and the final stage consisted of interviewing six mothers who had adolescent children. They were chosen with ‘maximum variation’ approach to represent three tiered socioeconomic statuses, and Asian, white and black ethnicities. The data was thematically analysed in a hybrid fashion: inductive coding and deductive assignment of codes into discrete parenting styles. The study found: a) parenting styles are not always discrete and sometimes it can be mixed. b) The parenting styles are influenced by culture, socioeconomic status, transgenerational knowledge, academic knowledge, observational knowledge, self-reflective knowledge, and parental anxiety. c) The parenting style functioned a mediating mechanism where it attempted to converge discrepancies between parental expectations of compliance with maternal perception of severity of noncompliance. The findings of parenting styles were discussed in relation to MPCM.

Keywords: compliance, expectation, parenting styles, perception

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Authors: Karolina Wieczorek, Zofia Przypaśniak

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Climate change is a rapidly growing threat to global health, and part of the responsibility to combat it lies within the healthcare sector itself, including adequate education of future medical professionals. To mitigate the consequences, the General Medical Council (GMC) has equipped medical schools with a list of outcomes regarding sustainability teaching. Students are expected to analyze the impact of the healthcare sector’s emissions on climate change. The delivery of the related teaching content is, however, often inadequate and insufficient time is devoted for exploration of the topics. Teaching curricula lack in-depth exploration of the learning objectives. This study aims to assess the extent and characteristics of climate change and sustainability subjects teaching in the curriculum of a chosen UK medical school (Barts and The London School of Medicine and Dentistry). It compares the data to the national average scores from the Climate Change and Sustainability Teaching (C.A.S.T.) in Medical Education Audit to draw conclusions about teaching on a regional level. This is a single-center audit of the timetabled sessions of teaching in the medical course. The study looked at the academic year 2020/2021 which included a review of all non-elective, core curriculum teaching materials including tutorials, lectures, written resources, and assignments in all five years of the undergraduate and graduate degrees, focusing only on mandatory teaching attended by all students (excluding elective modules). The topics covered were crosschecked with GMC Outcomes for graduates: “Educating for Sustainable Healthcare – Priority Learning Outcomes” as gold standard to look for coverage of the outcomes and gaps in teaching. Quantitative data was collected in form of time allocated for teaching as proxy of time spent per individual outcomes. The data was collected independently by two students (KW and ZP) who have received prior training and assessed two separate data sets to increase interrater reliability. In terms of coverage of learning outcomes, 12 out of 13 were taught (with the national average being 9.7). The school ranked sixth in the UK for time spent per topic and second in terms of overall coverage, meaning the school has a broad range of topics taught with some being explored in more detail than others. For the first outcome 4 out of 4 objectives covered (average 3.5) with 47 minutes spent per outcome (average 84 min), for the second objective 5 out of 5 covered (average 3.5) with 46 minutes spent (average 20), for the third 3 out of 4 (average 2.5) with 10 mins pent (average 19 min). A disproportionately large amount of time is spent delivering teaching regarding air pollution (respiratory illnesses), which resulted in the topic of sustainability in other specialties being excluded from teaching (musculoskeletal, ophthalmology, pediatrics, renal). Conclusions: Currently, there is no coherent strategy on national teaching of climate change topics and as a result an unstandardized amount of time spent on teaching and coverage of objectives can be observed.

Keywords: audit, climate change, sustainability, education

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Authors: Shuofen Hsu, Ya-Yi Chao, Chao-Wei Li

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This paper investigates the factors of whether firms’ quarterly consolidated financial statements to be voluntary reviewed by auditor. To promote the information transparency, the Financial Supervisory Commission of Executive Yuan in Taiwan ruled the Taiwanese listed companies should announce the first and third quarterly consolidated financial statements since 2008 to 2012, while the Commission didn’t require the consolidated financial statements should be reviewed by auditors. This is a very special practice in emerging market, especially in Taiwan. The valuable data of this period is suitable for us to research the determinants of firms’ voluntary review decision in emerging markets. We collected the auditors' report of each company and each year of Taiwanese listed companies since 2008 to 2012 for our research samples. We use probit model to test and analyze the determinants of voluntary review decision of the first and third quarterly consolidated financial statements. Our empirical result shows that the firms whose first and third quarterly consolidated financial statements are voluntary to be reviewed by auditors have better ranking of information transparency, higher audit quality, and better corporate governance, suggesting that voluntary review is a good signal to firms’ better information and corporate governance quality.

Keywords: voluntary review, information transparency, audit quality, quarterly consolidated financial statements

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Authors: Nadheer A. Shalash, Abu Zaharin Bin Ahmad

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Technological developments in industrial innovations have currently been related to interconnected system assistance and distribution networks. This important in order to enable an electrical load to continue receive power in the event of disconnection of load from the main power grid. This paper represents a method for reliability assessment of interconnected power systems based. The multi-agent system consists of four agents. The first agent was the generator agent to using as connected the generator to the grid depending on the state of the reserve margin and the load demand. The second was a load agent is that located at the load. Meanwhile, the third is so-called "the reverse margin agent" that to limit the reserve margin between 0-25% depend on the load and the unit size generator. In the end, calculation reliability Agent can be calculate expected energy not supplied (EENS), loss of load expectation (LOLE) and the effecting of tie line capacity to determine the risk levels Roy Billinton Test System (RBTS) can use to evaluated the reliability indices by using the developed JADE package. The results estimated of the reliability interconnection power systems presented in this paper. The overall reliability of power system can be improved. Thus, the market becomes more concentrated against demand increasing and the generation units were operating in relation to reliability indices.

Keywords: reliability indices, load expectation, reserve margin, daily load, probability, multi-agent system

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Authors: Hsin-Yi Lo, Huang-Ju Jiun, Yu-Chiao Chu

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Hemodynamic monitoring is an important in the intensive care unit. Advances in medical technology in recent years, more diversification of intensive care equipment, there are many kinds of instruments available for monitoring of hemodynamics, Edwards Lifesciences Hemodynamic Monitoring (FloTrac) is one of them. The recent medical safety incidents in parameters were changed, nurses have not to notify doctor in time, therefore, it is hoped to analyze the current problems and find effective improvement strategies. In August 2021, the survey found that only 74.0% of FloTrac correctness of operation, reasons include lack of education, the operation manual is difficulty read, lack of audit mechanism, nurse doesn't know those numerical changes need to notify doctor, work busy omission, unfamiliar with operation and have many nursing records then omissions. Improvement methods include planning professional nurse education, formulate the secret arts of FloTrac, enacting an audit mechanism, establish FloTrac action learning, make「follow the sun」care map, hold simulated training and establish monitoring data automatically upload nursing records. After improvement, FloTrac correctness of operation increased to 98.8%. The results are good, implement to the ICU of the hospital.

Keywords: hemodynamic monitoring, edwards lifesciences hemodynamic monitoring, multiple strategies, intensive care

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Authors: Dimitrios J. Dimitriou, Maria F. Sartzetaki

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Transport infrastructure assets are key components of the national asset portfolio. The decision to invest in a new infrastructure in transports could take from a few years to some decades. This is mainly because of the need to reserve and spent many capitals, the long payback period, the number of the stakeholders involved in decision process and –many times- the investment and business risks are high. Therefore, the decision assessment framework is an essential challenge linked with the key decision factors meet the stakeholder expectations highlighting project trade-offs, financial risks, business uncertainties and market limitations. This paper examines the decision process for new transport infrastructure projects in cross border regions, where a wide range of stakeholders with different expectation is involved. According to a consequences analysis systemic approach, the relationship of transport infrastructure development, economic system development and stakeholder expectation is analyzed. Adopting the on system of system methodological approach, the decision making framework, variables, inputs and outputs are defined, highlighting the key shareholder’s role and expectations. The application provides the methodology outputs presenting the proposed decision framework for a strategic railway project in north Greece deals with the upgrade of the existing railway corridor connecting Greece, Turkey and Bulgaria.

Keywords: decision making, system of system, cross-border, infrastructure project

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Authors: Ayami Umemura

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The purpose of this paper is to examine the meaning of verbalization in clinical practice using the keywords silence and singularity. A patient's experience of illness and treatment is singular, irreplaceable, and irreproducible and ultimately cannot be compared with that of others. In his book Difference and Repetition, Gilles Deleuze positioned irreplaceable singularity as the opposite concept of particularity as a generalizable and substitutable property and matched the former with universality. He also said that singularity could not be represented because of its irreplaceable nature. Representation or verbalization is a procedure that converts an irreplaceable, idiosyncratic reality into something that can be substituted. Considering the act of verbalizing medical diagnosis based on this, it can be said that diagnosis is the practice of decontextualizing and generalizing the suffering embedded in the patient's irreplaceable life history as a disease. This paper examines the above with the key concept of the practice of "non-verbalization" in traditional medical practices in Sri Lanka. In the practice of Sri Lankan traditional medicine and the inheritance of medical knowledge and care techniques, there is a tendency to avoid verbalizing specific matters or stating them aloud. Specifically, the following should be avoided. The healer informs the patient of the name of the disease, mentions the name of the herb used in front of the patient, explains the patient's condition to the healer, and referring the names of poisonous animals, such as poisonous snakes that have been damaged. And so on. Furthermore, when passing on medical knowledge and skills, it is also possible to avoid verbalizing knowledge of medicinal herbs and medical treatment methods and explaining them verbally. In addition to the local belief that the soul of language in Sri Lanka is deeply involved in this background, Sri Lankan traditional medicine has a unique view of the human body and personality that is rooted in the singularity that appears in the relationship with the movement of celestial bodies and the supernatural realm. It can be pointed out that it is premised on the view. In other words, the “silence” in Sri Lankan indigenous medicine is the reason for emphasizing specificity. Furthermore, we can say that "non-verbalization" is a practice aimed at healing. Based on these discussions, this paper will focus on the unique relationships between practitioners and patients that become invisible due to verbalization, which is overlooked by clinical medicine, where informed consent, ensuring transparency, and audit culture is dominant. We will examine the experience of treatment and aim to relativize clinical medicine, which is based on audit cultures.

Keywords: audit cultures, indigenous medicine, singularity, verbalization

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Authors: Shreya Saxena

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Background: Choledocholithiasis is a common complication of gallstone disease. Risk scoring systems exist to guide the need for further imaging or endoscopy in managing choledocholithiasis. We completed an audit to review the American Society for Gastrointestinal Endoscopy (ASGE) scoring system for prediction and management of choledocholithiasis against the current practice at a tertiary hospital to assess its utility in resource optimisation. We have now conducted a cost focused sub-analysis on patients categorized high-risk for choledocholithiasis according to the guidelines to determine any associated cost benefits. Method: Data collection from our prior audit was used to retrospectively identify thirteen patients considered high-risk for choledocholithiasis. Their ongoing management was mapped against the guidelines. Individual costs for the key investigations were obtained from our hospital financial data. Total cost for the different management pathways identified in clinical practice were calculated and compared against predicted costs associated with recommendations in the guidelines. We excluded the cost of laparoscopic cholecystectomy and considered a set figure for per day hospital admission related expenses. Results: Based on our previous audit data, we identified a77% positive predictive value for the ASGE risk stratification tool to determine patients at high-risk of choledocholithiasis. 47% (6/13) had an magnetic resonance cholangiopancreatography (MRCP) prior to endoscopic retrograde cholangiopancreatography (ERCP), whilst 53% (7/13) went straight for ERCP. The average length of stay in the hospital was 7 days, with an additional day and cost of £328.00 (£117 for ERCP) for patients awaiting an MRCP prior to ERCP. Per day hospital admission was valued at £838.69. When calculating total cost, we assumed all patients had admission bloods and ultrasound done as the gold standard. In doing an MRCP prior to ERCP, there was a 130% increase in cost incurred (£580.04 vs £252.04) per patient. When also considering hospital admission and the average length of stay, it was an additional £1166.69 per patient. We then calculated the exact costs incurred by the department, over a three-month period, for all patients, for key investigations or procedures done in the management of choledocholithiasis. This was compared to an estimate cost derived from the recommended pathways in the ASGE guidelines. Overall, 81% (£2048.45) saving was associated with following the guidelines compared to clinical practice. Conclusion: MRCP is the most expensive test associated with the diagnosis and management of choledocholithiasis. The ASGE guidelines recommend endoscopy without an MRCP in patients stratified as high-risk for choledocholithiasis. Our audit that focused on assessing the utility of the ASGE risk scoring system showed it to be relatively reliable for identifying high-risk patients. Our cost analysis has shown significant cost savings per patient and when considering the average length of stay associated with direct endoscopy rather than an additional MRCP. Part of this is also because of an increased average length of stay associated with waiting for an MRCP. The above data supports the ASGE guidelines for the management of high-risk for choledocholithiasis patients from a cost perspective. The only caveat is our small data set that may impact the validity of our average length of hospital stay figures and hence total cost calculations.

Keywords: cost-analysis, choledocholithiasis, risk stratification tool, general surgery

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Authors: Ramya P, Lino Abraham Varghese, S. Bose

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By cloud storage services, the data can be stored in the cloud, and can be shared across multiple users. Due to the unexpected hardware/software failures and human errors, which make the data stored in the cloud be lost or corrupted easily it affected the integrity of data in cloud. Some mechanisms have been designed to allow both data owners and public verifiers to efficiently audit cloud data integrity without retrieving the entire data from the cloud server. But public auditing on the integrity of shared data with the existing mechanisms will unavoidably reveal confidential information such as identity of the person, to public verifiers. Here a privacy-preserving mechanism is proposed to support public auditing on shared data stored in the cloud. It uses group signatures to compute verification metadata needed to audit the correctness of shared data. The identity of the signer on each block in shared data is kept confidential from public verifiers, who are easily verifying shared data integrity without retrieving the entire file. But on demand, the signer of the each block is reveal to the owner alone. Group private key is generated once by the owner in the static group, where as in the dynamic group, the group private key is change when the users revoke from the group. When the users leave from the group the already signed blocks are resigned by cloud service provider instead of owner is efficiently handled by efficient proxy re-signature scheme.

Keywords: data integrity, dynamic group, group signature, public auditing

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Authors: Adrian Craig, Jonathan Easaw, Rose Jordan, Ben Hall

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The prescription of intravenous fluids is a fundamental component of inpatient management, but it is one which usually lacks thought. Fluids are a drug, which like any other can cause harm when prescribed inappropriately or wrongly. However, it is well recognised that it is poorly done, especially in the acute portals. The National Institute for Health and Care Excellence (NICE) recommends 1mmol/kg of potassium, sodium, and chloride per day. With various options of fluids, clinicians tend to face difficulty in choosing the most appropriate maintenance fluid, and there is a reluctance to prescribe potassium as part of an intravenous maintenance fluid regime. The aim was to prospectively audit the prescription of the first bag of intravenous maintenance fluids, the use of urea and electrolytes results to guide the choice of fluid and the use of fluid prescription charts, in a busy emergency department of a major trauma centre in Stoke-on-Trent, United Kingdom. This was undertaken over a week in early November 2016. Of those prescribed maintenance fluid only 8.9% were prescribed a fluid which was most appropriate for their daily electrolyte requirements. This audit has helped to highlight further the issues that are faced in busy Emergency Departments within hospitals that are stretched and lack capacity for prompt transfer to a ward. It has supported the findings of NICE, that emergency admission portals such as Emergency Departments poorly prescribed intravenous fluid therapy. The findings have enabled simple steps to be taken to educate clinicians about their fluid of choice. This has included: posters to remind clinicians to consider the urea and electrolyte values before prescription, suggesting the inclusion of a suggested intravenous fluid of choice in the prescription chart of the trust and the inclusion of a session within the introduction programme revising intravenous fluid therapy and daily electrolyte requirements. Moving forward, once the interventions have been implemented then, the data will be reaudited in six months to note any improvement in maintenance fluid choice. Alongside this, an audit of the rate of intravenous maintenance fluid therapy would be proposed to further increase patient safety by avoiding unintentional fluid overload which may cause unnecessary harm to patients within the hospital. In conclusion, prescription of maintenance fluid therapy was poor within the Emergency Department, and there is a great deal of opportunity for improvement. Therefore, the measures listed above will be implemented and the data reaudited.

Keywords: chloride, electrolyte, emergency department, emergency medicine, fluid, fluid therapy, intravenous, maintenance, major trauma, potassium, sodium, trauma

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Authors: Nureni O. Adeboye, Dawud A. Agunbiade

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This research attempts to investigate the effects of heteroscedasticity and periodicity in a Panel Data Regression Model (PDRM) by extending previous works on balanced panel data estimation within the context of fitting PDRM for Banks audit fee. The estimation of such model was achieved through the derivation of Joint Lagrange Multiplier (LM) test for homoscedasticity and zero-serial correlation, a conditional LM test for zero serial correlation given heteroscedasticity of varying degrees as well as conditional LM test for homoscedasticity given first order positive serial correlation via a two-way error component model. Monte Carlo simulations were carried out for 81 different variations, of which its design assumed a uniform distribution under a linear heteroscedasticity function. Each of the variation was iterated 1000 times and the assessment of the three estimators considered are based on Variance, Absolute bias (ABIAS), Mean square error (MSE) and the Root Mean Square (RMSE) of parameters estimates. Eighteen different models at different specified conditions were fitted, and the best-fitted model is that of within estimator when heteroscedasticity is severe at either zero or positive serial correlation value. LM test results showed that the tests have good size and power as all the three tests are significant at 5% for the specified linear form of heteroscedasticity function which established the facts that Banks operations are severely heteroscedastic in nature with little or no periodicity effects.

Keywords: audit fee lagrange multiplier test, heteroscedasticity, lagrange multiplier test, Monte-Carlo scheme, periodicity

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Authors: Waqas Ahmad, Eisha Tahir, Shahper Aqeel, Imran Khalid Niazi, Amjad Iqbal

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Background: Breast conservation surgery applies a number of techniques for accurate localization of lesions. Wire localization remains the method of choice in non-palpable breast cancers post-neoadjuvant chemotherapy. Objective: The aim of our study was to determine the accuracy of wire localization procedures in our department and compare it with internationally set protocols as per the Royal College of Radiologists. Post wire mammography, as well as the margin status of the postoperative specimen, assessed the accuracy of the procedure. Methods: We retrospectively reviewed the data of 225 patients who presented to our department from May 2014 to June 2015 post neoadjuvant chemotherapy with non-palpable cancers. These patients are candidates for wire localized lumpectomies either under ultrasound or stereotactic guidance. Metallic marker was placed in all the patients at the time of biopsy. Post wire mammogram was performed in all the patients and the distance of the wire tip from the marker was calculated. The presence or absence of the metallic clip in the postoperative specimen, as well as the marginal status of the postoperative specimen, was noted. Results: 157 sonographic and 68 stereotactic wire localization procedures were performed. 95% of the wire tips were within 1 cm of the metallic marker. Marginal status was negative in 94% of the patients in histopathological specimen. Conclusion: Our audit report declares more than 95% accuracy of image guided wire localization in successful excision of non-palpable breast lesions.

Keywords: breast, cancer, non-palpable, wire localization

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Authors: Jack R. McKenzie, Peter A. Appleby, Thomas House, Neil Walton

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Cold-start is a notoriously difficult problem which can occur in recommendation systems, and arises when there is insufficient information to draw inferences for users or items. To address this challenge, a contextual bandit algorithm – the Fast Approximate Bayesian Contextual Cold Start Learning algorithm (FAB-COST) – is proposed, which is designed to provide improved accuracy compared to the traditionally used Laplace approximation in the logistic contextual bandit, while controlling both algorithmic complexity and computational cost. To this end, FAB-COST uses a combination of two moment projection variational methods: Expectation Propagation (EP), which performs well at the cold start, but becomes slow as the amount of data increases; and Assumed Density Filtering (ADF), which has slower growth of computational cost with data size but requires more data to obtain an acceptable level of accuracy. By switching from EP to ADF when the dataset becomes large, it is able to exploit their complementary strengths. The empirical justification for FAB-COST is presented, and systematically compared to other approaches on simulated data. In a benchmark against the Laplace approximation on real data consisting of over 670, 000 impressions from autotrader.co.uk, FAB-COST demonstrates at one point increase of over 16% in user clicks. On the basis of these results, it is argued that FAB-COST is likely to be an attractive approach to cold-start recommendation systems in a variety of contexts.

Keywords: cold-start learning, expectation propagation, multi-armed bandits, Thompson Sampling, variational inference

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Authors: Wanhyun Cho, Soonja Kang, Sangkyoon Kim, Soonyoung Park

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In this paper, we propose a novel inference algorithm for the multi-class Gaussian process classification model that can be used in the field of human behavior recognition. This algorithm can drive simultaneously both a posterior distribution of a latent function and estimators of hyper-parameters in a Gaussian process classification model with multi-class. Our algorithm is based on the Laplace approximation (LA) technique and variational EM framework. This is performed in two steps: called expectation and maximization steps. First, in the expectation step, using the Bayesian formula and LA technique, we derive approximately the posterior distribution of the latent function indicating the possibility that each observation belongs to a certain class in the Gaussian process classification model. Second, in the maximization step, using a derived posterior distribution of latent function, we compute the maximum likelihood estimator for hyper-parameters of a covariance matrix necessary to define prior distribution for latent function. These two steps iteratively repeat until a convergence condition satisfies. Moreover, we apply the proposed algorithm with human action classification problem using a public database, namely, the KTH human action data set. Experimental results reveal that the proposed algorithm shows good performance on this data set.

Keywords: bayesian rule, gaussian process classification model with multiclass, gaussian process prior, human action classification, laplace approximation, variational EM algorithm

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Authors: B. Kenny, M. Dixon, A. Boshell

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The use of alcoholic surgical prep was recently introduced into the Royal Newcastle Center for elective procedures. In the past 3 months there have been a significant number of burns believed to be related to ‘pooling’ of this surgical prep in patients undergoing procedures where they are placed in the lateral position with hip bolsters. The aim of the audit was to determine the reason for the burns, analyze what pre-existing factors may contribute to the development of the burns and what can be changed to prevent further burns occurring. All patients undergoing a procedure performed on the hip who were placed in the lateral position with sacral and anterior, superior iliac spine (ASIS) support with ‘bolsters’ were included in the audit. Patients who developed a ‘burn’ were recorded, details of the surgery, demographics, surgical prep used and length of surgery were obtained as well as photographs taken to document the burn. Measures were then taken to prevent further burns and the efficacy was documented. Overall 14 patients developed burns over the ipsilateral ASIS. Of these, 13 were Total Hip Arthroplasty (THA) and 1 was a removal of femoral nail. All patients had Chlorhexidine 0.5% in Alcohol 70% Tinted Red surgical preparation or Betadine Alcoholic Skin Prep (70% etoh). Patients were set up in the standard lateral decubitus position with sacral and bilateral ASIS bolsters with a valband covering. 86% of patients were found to have pre-existing hypersensitivities to various substances. There is very little literature besides a few case reports on surgical prep-related burns. The case reports that do exist are related to the use of tourniquet-related burns and there is no mention in the literature examining ‘bolster’ related burns. The burns are hypothesized to be caused by pooling of the alcoholic solution which is amplified by the use of Valband.

Keywords: arthroplasty, chemical burns, wounds, rehabilitation

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Authors: Adeyinka Adesanya, Isaac Bamgboye

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There is a growing need to develop the processes to produce renewable fuels and chemicals due to the economic, political, and environmental concerns associated with fossil fuels. Lignocellulosic biomass is an excellent renewable feedstock because it is both abundant and inexpensive. This project aims at producing bioethanol from lignocellulosic plants (Sorghum Arundinacieum and Heteropogon Contortus) by biochemical means, computing the energy audit of the process and determining the fuel properties of the produced ethanol. Acid pretreatment (0.5% H2SO4 solution) and enzymatic hydrolysis (using malted barley as enzyme source) were employed. The ethanol yield of wild sorghum was found to be 20% while that of spear grass was 15%. The fuel properties of the bioethanol from wild sorghum are 1.227 centipoise for viscosity, 1.10 g/cm3 for density, 0.90 for specific gravity, 78 °C for boiling point and the cloud point was found to be below -30 °C. That of spear grass was 1.206 centipoise for viscosity, 0.93 g/cm3 for density 1.08 specific gravity, 78 °C for boiling point and the cloud point was also found to be below -30 °C. The energy audit shows that about 64 % of the total energy was used up during pretreatment, while product recovery which was done manually demanded about 31 % of the total energy. Enzymatic hydrolysis, fermentation, and distillation total energy input were 1.95 %, 1.49 % and 1.04 % respectively, the alcoholometric strength of bioethanol from wild sorghum was found to be 47 % and the alcoholometric strength of bioethanol from spear grass was 72 %. Also, the energy efficiency of the bioethanol production for both grasses was 3.85 %.

Keywords: lignocellulosic biomass, wild sorghum, spear grass, biochemical conversion

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Authors: Raja Ezman Raja Shariff

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Acute kidney injury (AKI) is commonly seen in inpatients, and places a great cost on the NHS and patients. Timely and appropriate management is both nephron sparing and potentially life-saving. Ultrasound scanning (USS) is a well-recognised method for stratifying patients. Subsequently, the NICE AKI guidance has defined groups in whom scanning is recommended within 6 hours of request (pyonephrosis), within 24 hours (obstruction/cause unknown), and in whom routine scanning isn't recommended (cause for AKI identified). The audit looks into whether Stockport NHS Trust USS practice was in line with such recommendations. The audit evaluated 92 patients with AKI who had USS, between 01/01/14 to 30/04/14. Data collection was divided into 2 parts. Firstly, radiology request cards and the online imaging software (PACS) were evaluated. Then, the electronic case notes (ADVANTIS) was evaluated further. Based on request cards, 10% of requests were for pyonephrosis. Only 33% were scanned within 6hours and a further 33% within 24hours. 75% were requested for possible obstructions and unknown cause collectively. Of those due to possible obstruction, 71% of patients were scanned within 24 hours. Of those with unknown cause, 50% were scanned within 24 hours. 15% of requests had a cause declared and so potentially did not require scanning. Evaluation of the patients’ notes suggested further interesting findings. Firstly, potentially 39% of patients had a known cause for AKI, therefore, did not need USS. Subsequently, the cohort of unknown cause and possible obstruction was collectively reduced to 45%. Alarmingly the patient cohort with possible pyonephrosis went up to 16%, suggesting an under-recognition of this life-threatening condition. We plan to highlight these findings within our institution and make changes to encourage more appropriate requesting and timely scanning. Time will tell if we manage to save or increase our costs in this cost-conscious NHS. Patient benefits, though, seem to be guaranteed.

Keywords: AKI, ARF, kidney, renal

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Authors: Emma Carr, Bilal Aslam-Pervez, David Laraway

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Litigation against surgeons and hospitals continues to increase in Western countries. While verbal consent is all that is required legally, it has for a long time been considered that written consent offers proof of discussion and interaction between the surgeon and the patient. Inadequate consenting of patients continues in the United Kingdom leaving surgeons and Health Trusts open to litigation. We present a standardised consent form which improves patient autonomy and engagement. The General Medical Council recommends that all material risks relevant to the patient are discussed and recorded prior to undergoing surgery, regardless of how likely they are to occur. Current literature was reviewed to evaluate complications associated with surgical management of mandible fractures. Analysis of risks on 52 consent forms were analysed within the Glasgow OMFS department, leading to a procedure-specific form being designed and implemented. This audit showed that the documentation of risks on consent forms was extremely variable- with uncommon risks not being recorded. Interestingly, not a single consent form was found which highlighted all the risks associated with mandible fractures. Our re-audit data confirms 100% of risks being discussed when a procedure specific form is utilised. Our hope, is to introduce further forms for inclusion on the BAOMS website and peripheral distribution. The forms are quick and easy to print and leave more time for consultation with the patient. Whilst we are under no illusion that the forms may not decrease the incidence of intended litigation, we feel confident that they will decrease the chances of it being successful.

Keywords: consent, litigation, mandible fracture, surgery

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Authors: Fan Wei, Tang Yipeng

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Knowledge sharing is of great value to organizational performance and innovation ability. However, the mainstream research has focused largely on the impact of knowledge sharing at the team level on individuals and teams. There is a lack of empirical studies on how employees interact in the exchange of knowledge and its effect on employees’ own creative performance. Based on communication accommodation theory and social exchange theory, this article explores the construction of an employee knowledge interaction mechanism under the moderating of social status and introduces the leader's creativity expectation as a moderating variable to explore its cross-level moderating effect on employee knowledge sharing and their own creative performance. An empirical test was conducted on 36 teaching and research teams in the two primary schools, and the results showed that: (1) Explicit/tacit knowledge of employees is positively correlated with acquisition of explicit/tacit knowledge; (2) Colleagues’ evaluations of employees’ social status play a moderating role between the employees’ explicit/tacit knowledge and the acquisition of explicit/tacit knowledge. (3) The leadership creativity expectation positively regulates the relationship between the employees' explicit knowledge acquisition and creative performance. This research helps to open the "black box" of the interpersonal interaction mechanism of knowledge sharing and also provides an important theoretical basis and practical guidance for organizational managers to effectively stimulate employee knowledge sharing and creative performance.

Keywords: knowledge sharing, knowledge interaction, social status, leadership creativity expectations, creative performance

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Authors: jihen ayadi sellami

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The rapid evolution of the global financial landscape has led to increased attention to corporate tax policies and the need to understand the factors that influence their tax behavior. In order to mitigate any residual loss for shareholders resulting from tax aggressiveness and resolve the agency problem, appropriate systems that separate the function of management from that of controlling are needed. In this context of growing concerns to limit aggressive corporate taxation practices through governance, this study discusses. Its aims is to examine the influence of six key characteristics of the board of directors (board size, diligence, CEO duality, presence of audit committees, gender diversity and independence of directors), given a governance mechanism, on the tax decisions of non-financial corporations in the United State. In fact, using a sample of 90 non-financial US firms from S&P 500 over a period of 4 years going from 2014 to 2017, the results based on a multivariate linear regression highlight significant associations between these characteristics and corporate tax policy. Notably, larger board, gender diversity, diligence and increased director independence appear to play an important role in reducing aggressive taxation. While duality has a positive and significant correlation with tax aggressiveness, that can be explained by the fact that the manager did properly exploit his specific position within the company. These findings contribute to a deeper understanding of how board characteristics can influence corporate tax management, providing avenues for more effective corporate governance and more responsible tax decision-making

Keywords: tax aggressiveness, board of directors, board size, CEO duality, audit committees, gender diversity, director independence, diligence, corporate governance, united states

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Authors: Aarati Susan Mathew, Radhika Narendra Patel, Jiji Mathew

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A retrospective study conducted at Christian Medical College (CMC) Teaching Hospital, Vellore, India on 14th August 2014 to assess the accuracy of clinically estimated foetal weight upon labour admission. Estimating foetal weight is a crucial factor in assessing maternal and foetal complications during and after labour. Medical notes of ninety-eight postnatal women who fulfilled the inclusion criteria were studied to evaluate the correlation between their recorded Estimated Foetal Weight (EFW) on admission and actual birth weight (ABW) of the newborn after delivery. Data concerning maternal and foetal demographics was also noted. Accuracy was determined by absolute percentage error and proportion of estimates within 10% of ABW. Actual birth weights ranged from 950-4080g. A strong positive correlation between EFW and ABW (r=0.904) was noted. Term deliveries (≥40 weeks) in the normal weight range (2500-4000g) had a 59.5% estimation accuracy (n=74) compared to pre-term (<40 weeks) with an estimation accuracy of 0% (n=2). Out of the term deliveries, macrosomic babies (>4000g) were underestimated by 25% (n=3) and low birthweight (LBW) babies were overestimated by 12.7% (n=9). Registrars who estimated foetal weight were accurate in babies within normal weight ranges. However, there needs to be an improvement in predicting weight of macrosomic and LBW foetuses. We have suggested the use of an amended version of the Johnson’s formula for the Indian population for improvement and a need to re-audit once implemented.

Keywords: clinical palpation, estimated foetal weight, pregnancy, India, Johnson’s formula

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Authors: Rizwan Iqbal

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Introduction: Re-TURBT has been recommended by international guidelines for patients with non-muscle invasive bladder cancer (NMIBC) who are deemed high-risk. Indications for re-TURBTs remain controversial and studies show mixed outcomes. It should be performed when the initial TURBT specimen lacks detrusor muscle, has tumor stage pT1 or G3/high-grade, or where resection is deemed incomplete. This ensures complete resection of tumors that have a high risk of recurrence as well as accurately identifying any tumors which have been upstaged. The aim of this audit was to evaluate the quality of re-TURBTs in a district general hospital. Method: Data were retrospectively collected from 31 patients who had re-TURBTs between April 2021 and September 2022. Data included baseline demographics, time from initial to re-TURBT, quality of operation note, presence of residual tumor, complications, and administration of chemotherapy within 24 hours of the initial TURBT. Data collection remains ongoing at the time of writing. Results: The mean age was 76 years old and 71.0% of patients were male. 32.3% of patients had their re-TURBT within six weeks and 32.3% had intravesical chemotherapy administered within 24 hours of the initial TURBT. 74.2% of initial TURBTs had detrusor muscle present in the specimen. 48.4% of patients had residual disease following re-TURBT. Just one patient had their pathology upstaged at re-TURBT. The use of the TURBT proforma on the operation note was variable, with 51.6% and 38.7% of surgeons using the proforma after the initial and re-TURBT. Conclusion: Re-TURBT improves bladder cancer staging and is necessary in patients who are deemed high-risk in order to identify any upstaging or recurrence of the disease.

Keywords: urology, bladder cancer, turbt, cancer

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Authors: Dimitrios J. Dimitriou, Maria F. Sartzetaki, Anastasia Kalamakidou

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Transport infrastructure assets are key components of the national asset portfolio. The decision to invest in a new infrastructure in transports could take from a few years to some decades. This is mainly because of the need to reserve and spent many capitals, the long payback period, the number of the stakeholders involved in the decision process and –many times- the investment and business risks are high. Decision makers and stakeholders need to define the framework and the outputs of the decision process taking into account the project characteristics, the business uncertainties, and the different expectations. Therefore, the decision assessment framework is an essential challenge linked with the key decision factors meet the stakeholder expectations highlighting project trade-offs, financial risks, business uncertainties and market limitations. This paper examines the decision process for new transport infrastructure projects in cross-border regions, where a wide range of stakeholders with different expectation is involved. According to a consequences analysis systemic approach, the relationship of transport infrastructure development, economic system development and stakeholder expectation is analysed. Adopting the on system of system methodological approach, the decision making the framework, variables, inputs and outputs are defined, highlighting the key shareholder’s role and expectations. The application provides the methodology outputs presenting the proposed decision framework for a strategic railway project in north Greece deals with the upgrade of the existing railway corridor connecting Greece, Turkey, and Bulgaria.

Keywords: system of system decision making, managing decisions for transport projects, decision support framework, defining decision process

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Authors: Obiakor Casmir Uchenna, Ikegbunam Peter Chierike, Ezeja Perpetual Chisom

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Irregularities have been a major feature of the Nigerian political activities since 1999. The rate at which such impunities thrive in the country has made elections grossly unacceptable among the people because the outcomes have never reflected the wish of the masses. Conscious of this, citizens have subscribed to the use of social media in exposing the ugly faces of the country’s elections which have always been against the less privileged. This study is an exploration of the relationship between exposure to social media shared video-clips and the respondents’ perception of the 2023 presidential election in Nigeria. The general objective of the study is to find out what the respondents make of the election as a result of the video-clips shared on different social media platforms showing electoral irregularities. The study adopted survey research method in studying 378 university undergraduates from NAU, COOU and Paul University selected through purposive sampling technique. The study was premised on the theoretical provision of violation of expectation theory. Findings revealed that the respondents are well exposed to different video-clips showing irregularities on the election. It was also found that the respondents have negative perception of the election. It was concluded that electoral umpire, the government in power and the security apparatus violated the respondents’ expectation from the election based on the pre-election promises made to the citizens. It was recommended among others, that Nigeria must strengthen the various institutions responsible for the conduct of elections if violence will not be made the best option for the poor masses.

Keywords: social media shared video-clips, exposure, irregularities, elections, audience perception, outcome

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Authors: Prashant Neupane, Asmi Pandey, Mumna Ehsan, Katie Davies, Richard Lowsby

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Introduction/Background & aims: Safe and effective prescribing in hospitals, directly and indirectly, impacts the health of the patients. Even though digital prescribing in the National Health Service (NHS), UK has been used in lots of tertiary centers along with district general hospitals, a significant number of NHS trusts are still using paper prescribing. We came across lots of irregularities in our daily clinical practice when we are doing paper prescribing. The main aim of the study was to assess how safely and effectively are we prescribing at our hospital where there is no access to digital prescribing. Method/Summary of work: We conducted a prospective audit in the critical care department at Mid Cheshire Hopsitals NHS Foundation Trust in which 20 prescription charts from different patients were randomly selected over a period of 1 month. We assessed 16 multiple categories from each prescription chart and compared them to the standard trust guidelines on prescription. Results/Discussion: We collected data from 20 different prescription charts. 16 categories were evaluated within each prescription chart. The results showed there was an urgent need for improvement in 8 different sections. In 85% of the prescription chart, all the prescribers who prescribed the medications were not identified. Name, GMC number and signature were absent in the required prescriber identification section of the prescription chart. In 70% of prescription charts, either indication or review date of the antimicrobials was absent. Units of medication were not documented correctly in 65% and the allergic status of the patient was absent in 30% of the charts. The start date of medications was missing and alternations of the medications were not done properly in 35%of charts. The patient's name was not recorded in all desired sections of the chart in 50% of cases and cancellations of the medication were not done properly in 45% of the prescription charts. Conclusion(s): From the audit and data analysis, we assessed the areas in which we needed improvement in prescription writing in the Critical care department. However, during the meetings and conversations with the experts from the pharmacy department, we realized this audit is just a representation of the specialized department of the hospital where access to prescribing is limited to a certain number of prescribers. But if we consider bigger departments of the hospital where patient turnover is much more, the results could be much worse. The findings were discussed in the Critical care MDT meeting where suggestions regarding digital/electronic prescribing were discussed. A poster and presentation regarding safe and effective prescribing were done, awareness poster was prepared and attached alongside every bedside in critical care where it is visible to prescribers. We consider this as a temporary measure to improve the quality of prescribing, however, we strongly believe digital prescribing will help to a greater extent to control weak areas which are seen in paper prescribing.

Keywords: safe prescribing, NHS, digital prescribing, prescription chart

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