Bona General Hospital EOPD 2016 E.

C 1st
Quarter clinical Audit report

BY BGH EOPD QIT

BONA, SIDAMA, ETHIOPIA

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Outline
 Team members
 Background
 Aim
 Objective
 Methodology
 Finding
 Discussion
 Conclusion
 Recommendation
 References

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Team members

1. Dr. Mesfin Markos( EOPD coordinator)

2. Mr. Thomas Butisha (EOPD head nurse)
3. Mr. Ashagire Abera (Quality officer)
4. Mr. Tariku Yototta (EOPD triage staff)
5. Mr. Tsegaye Fikiru (EOPD triage staff)

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Background

 Bona Hospital is one of 19 public Hospitals in Sidama

Regional state.
 It located 486 km from south west of Addis Ababa and

112 km from south east of Hawassa in Bona Zuria

woreda.
 Its catchment area is about 1.6 million people including
southern part of Oromia regional state.
 The Hospital was upgraded from health center to district
Hospital in 1999 E.C

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Cont…

 Emergency department is one of best performing

department in BG hospital.
 Department has eight beds and four beds adult and
pediatrics respectively with one exit and entry gate.
 Includes pediatric and adult Emergency attendants
 Department gives curative service coordinating with
other departments like OPD, pharmacy, lab and. etc.
 To improve patient care EOPD sub QIT conducted 1st
quarter clinical audit on emergency triage.

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Aim

 To improve the quality of triage care provided for a

patient presenting to ED.

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Objectives

 To ensure patients’ vital signs are properly measured at

triage
 To ensure patients are asked for chief complaint at the
triage
 To ensure patients are evaluated for differential factors
at triage
 To ensure patient’s triage destination is properly decided

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Methodology

 Department of Audit: BGH EOPD

 Ethiopia hospital clinical audit guide (2022) tool used for
data collection and data is analyzed manually because
the tool has analysis defect.
Sampling: Randomly selected 19 EOPD patient chart
used
Period of audit:1/11/2015 E.C-5/1/2016E.C
Inclusion criteria: All patients who were admitted to the
emergency
Exclusion criteria: Patients who were referred to the
emergency from OPD or other departments.

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 Finding
1. Patient’s bio-data is record upon presentation to ED
S.N 1. Standards/criteria Target Met Remark

1.1 Name 100% 100%

1.2 Age 100% 100%

1.3 Sex 100% 100%

1.4 Date of triage 100% 100%

1.5 Time of triage 100% 100%

1.6 MRN NA NA

1.7 Mode of arrival 100% 95%

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 Finding cont…
2. Patient’s clinical condition assessment upon presentation to ED

S.N 2. Standards/criteria Target Met Remark

2.1 Chief Complaint is 100% 100%
identified
2.2 BP is measured 100% 100%

2.3 PR is counted 100% 100%

2.4 RR is Counted 100% 100%

2.5 Temperature is 100% 100%
measured
2.6 RBS is Measured 100% 32%
2.7 SPO2 is measured 100% 100%

2.8 Triage score is 100% 84%

calculated
2.9 Differential factors are 100% 100%
circled
2.10 Triage color is decided 100% 95%
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 Finding cont…

3. Additional information identification for a patient presenting to the ED

S.N 2. Standards/criteria Target Met Remark

3.1 History of Allergy 100% 79%

(Including
“None”)
3.2 Triage intervention 100% 100%
(Including paper
“None”)
4. Identification of provider is documented for a patient presenting to the ED
S.N 4. Standards/criteria Target Met Remark

4.1 Name and signature of 100% 100%

the triage
personnel is recorded

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Finding cont…

 100% patient’s triage score and/or differential factor

matches with the triage destination the patient is
allocated to.
 99% of Patient’s bio-data is completed properly.
 Patient’s clinical condition assessment upon
presentation to ED is 91%
 For 89.5% of patients Additional information is identified.
 Name and Signature of care giver recorded on 100%
patient triage sheet.

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Finding cont…

 The total percentage of EOPD triage service

according to Ethiopia hospital clinical audit guide
(2022) tool is

90%

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Graphical presentation of triage service

100

96

92

88

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Discussion

 Necessary information like Name, Age, Sex ,Date of

triage, Time of triage, MRN, and Mode of arrival are
recorded properly.
 RBS is measured and recorded for only 32% of patient
and which Is too low.
 Triage score is calculated for 84% of patient and still
needs improvement.
 History of Allergy (Including “None”) asked for 79% of
patients
 Generally, the over all result is good EOPD triage
services needs improvement.

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Conclusion

 Some Standards/criteria are too low e.g. RBS is

measured and recorded for only 32% of patient
 Even though the over all result is good, EOPD triage
services needs improvement

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Recommendation

 For unmet standards, the EOPD case team SUBQIT

have to develop action plan and act accordingly.
 Sustain met standards.
 Do Triage audit regularly and take action.

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References

 Ethiopia hospital clinical audit guide tool (2022)

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