<Amir's article brings out one point very interesting to me in the sense
that
the ER docs were relying a lot of the report of deep pain rather than
febrile sx as a reliable indicator of mastitis. >
Maybe I'll join in the discussion of my article now!
As Barbara and others point out, there are many limitations of a review of
medical records, and it can't really be used to work out the signs and
symptoms of mastitis - b/c we are limited to relying on what the doctor
wrote. Often, the notes just said "mastitis left breast" or not much more.
Mostly, redness and pain was reported - only "no pain" in 3 and "no redness"
in 12%. So, usually there was redness and pain. I don't think you draw much
more of a conclusion than that.
We did not conduct the audit in order to gain a deeper understanding of
mastitis actually. The reason we did was to find out more practical issues
like: how many women attend the Emerg Department with mastitis, at what time
of day or night, weekdays or weekends, how many are prescribed antibiotics,
how many need an interpreter?
At the time, in 1997, I was trying to recruit women from the community with
symptoms of breast thrush to come into the hospital for a randomised trial
of fluconazole. As recruitment was very slow, I was fantasising about
conducting a trial where women would be attending the hospital anyway and
could be included in a study. I had read a study in cows where the vets gave
an anti-inflammatory as well as an antibiotic to cows with mastitis, and
those cows recovered faster than cows receiving an antibiotic only.
So, I started wondering if we could do the same sort of trial in women in
presenting to the hospital with mastitis. I asked a couple of people who had
worked in Emerg, how many women presented with mastitis - and got different
answers. Heather Harris, the hospital LC, suggested I talk to the director
of Emerg. I saw him the next day and he was happy to ask the computer which
gave an approx number for the previous year - and he said he'd ask medical
records to get out the files. 2 days later he rang to say medical records
had the files out and we could go anytime to med records to go through them!
(ethics approval was not necessary b/c it was considered quality assurance -
not so sure if the same applies now). Of course then Heather and I had to
develop an audit sheet, and trial it together. We tried to collect as much
info as we could from the files, to make it as useful as possible. We were
able to answer our logistics questions - which would have made it possible
to then work out sample size, recruitment and so on.
Anyway, I thought it was interesting enough to write up what we found, and
at first I wrote a 400 word letter and sent it to the Med J Australia. They
weren't interested (perhaps they already had the Kinlay et al article that
Denise mentioned already under review), so I expanded it for an article for
JHL. The reviewers asked for more discussion, and eventually it was accepted
for publication.
I thought it would be interesting for LCs to think about auditing, ie
looking at the practices in their hospital or in their own practice, as it
is easy and would expand our knowledge about many different aspects of
breastfeeding.
eg how many babies are given supplements in hospital and are the reasons
recorded in their files? what time of day or night are they given?
eg how many women are given nipple shields in one month this year, compared
to some time in the past?
eg how many women attending your breastfeeding clinic are smokers? (ha, yes
I've asked this before!).
A review of records obviously raises more questions than it answers, but it
does give some idea of what is happening in the real world. For example, one
of the reviewers of another article on mastitis tried to insist that a milk
culture should be collected on all women with mastitis - but I was able to
say that in a tertiary referral hospital less than 15% of cases had a milk
culture, and therefore it was inappropriate to say that it should be done
routinely in general practice. (BTW this article has been published on
Current Therapeutics website: http://www.ctonline.com.au - complete with
photos!).
Lisa Amir
MBBS, MMed, IBCLC in Melbourne, Australia

             ***********************************************
The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(TM)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html