The relationship between patient blood pathology values and patient falls in an acute-care setting : a retrospective analysis

Few studies have investigated the relationship between patient falls and patient blood pathology values, which can reveal objective information about the health and nutritional status of a patient. It could be that some abnormal values are associated with patients that fall. The objectives of the current study were to determine whether blood pathology values were different in patients who fell compared to patients who did not fall, and whether there was a difference in the type and number of currently documented risk factors for falls found for patients who fell compared to patients who did not fall. A retrospective audit of patient incident reports and medical records was conducted in an acute-care hospital for 220 patients who fell and who did not fall. Faller and non-faller patients were matched by casemix type and length of stay. Findings revealed a significant relationship between patients who fell and the variables of age, confusion status and alkaline phosphatase blood values.

Is chemotherapy dose intensity adequate in breast cancer management in the Australian healthcare setting: a retrospective analysis

Aim
To determine the adequacy of chemotherapy received dose intensity (RDI) in breast cancer treatment in a general population and to identify factors that influence RDI.

Methods
A retrospective analysis of breast cancer patients who commenced a course of i.v. chemotherapy in 2008 was undertaken. Data were collected on patient and tumor characteristics, chemotherapy regimen, dose (including delays, reductions and the reasons for these), granulocyte colony-stimulating factor (G-CSF) use and febrile neutropenia incidence. RDI was calculated using the planned and actual dose received and time taken. A level of ≥85% RDI was considered acceptable for treatment given with curative intent.

Results
In all, 131 patients (aged 28 to 77 years) received chemotherapy in adjuvant (n = 76, 58%), neoadjuvant (n = 11, 8%) and metastatic settings (n = 44, 34%). RDI did not reach 85% for 12% adjuvant, 36% neoadjuvant and 34% metastatic cases (χ2 = 10.55, P = 0.005). Overall, 43% of patients received G-CSF.

Conclusion
Acceptable chemotherapy RDI was delivered for most patients in the adjuvant setting but not in the neoadjuvant setting. G-CSF treatment contributed to the optimization of dose intensity in the adjuvant setting only. Dose intensity in the metastatic setting was considered satisfactory where quality of life is the primary focus. Other factors can be modified to improve RDI.

Retrospective analysis of cancer survival across South-Western Victoria in Australia

OBJECTIVE: This paper aims to describe cancer survival and examine association between survival and socio-demographic characteristics across Barwon South-Western region (BSWR) in Victoria, Australia. DESIGN: This study is based on the retrospective cohort database of patients accessing oncology services across BSWR. SETTING: Six rural and three urban hospital settings across the BSWR. PARTICIPANTS: The participants were patients who were diagnosed with cancer in 2009. MAIN OUTCOME MEASURES: Overall survival (OS) of participants was the main outcome measure. RESULTS: Total of 1778 eligible patients had four-year OS for all cancers combined of 59.7% (95% CI, 57.4-62.0). Improved OS was observed for patients in the upper socio-economic tertile (64.2%; 95% CI, 60.9-67.5) compared to the middle (59.3%; 95% CI, 55.5-63.1) and lowest tertiles (49.6%; 95% CI, 44.2-54.9) (P < 0.01). On multivariate analyses, higher socio-economic status remained a significant predictor of OS adjusting for gender, remoteness and age (HR [hazard ratio] 0.81; 95% CI 0.74-0.89; P < 0.01). Remoteness was significantly associated with improved OS after adjusting for age, gender and socio-economic status (HR 0.86; 95% CI, 0.77-0.97; P = 0.01). Older age ≥70 years compared to <70 years conferred inferior OS (HR 3.08; 95% CI, 2.64-3.59; P < 0.01). CONCLUSIONS: Our study confirmed improved survival outcomes for patients of higher socio-economic status and younger age. Future research to explain the unexpected survival benefit in patients who lived in more remote areas should examine factors including the correlation between geographical residence and eventual treatment facility as well as compare the BSWR care model to other regions' approaches.

Ambulance call triage outcomes for patients reporting pain : a retrospective cross-sectional analysis of pain score versus traige level

Objective: To identify any association between the response priority code generated during calls to the ambulance communication centre and patient reports of pain severity.

Methods: A retrospective analysis of patient care records was undertaken for all patients transported by paramedics over a 7-day period. The primary research interest was the association between the response code allocated at the time of telephone triage and the initial pain severity score recorded using a numeric rating scale (NRS). Univariate and multivariate logistic regression methods were used to analyse the association between the response priority variable and explanatory variables.

Results: There were 1246 cases in which both an initial pain score using the NRS and a response code were recorded. Of these cases, 716/1246 (57.5%) were associated with a code 1 ("time-critical") response. After adjusting for gender, age, cause of pain and duration of pain, a multivariate logistic regression analysis found no significant change in the odds of a patient in pain receiving a time-critical response compared with patients who had no pain, regardless of their initial pain score (NRS 1–3, odds ratio (OR) 1.11, 95% CI 0.7 to 1.8; NRS 4–7, OR 1.12, 95% CI 0.7 to 1.8; NRS 8–10, OR 0.84, 95% CI 0.5 to 1.4).

Conclusion: The severity of pain experienced by the patient appeared to have no influence on the priority (urgency) of the dispatch response. Triage systems used to prioritise ambulance calls and decide the urgency of response or type of referral options should consider pain severity to facilitate timely and humane care.

Bystander resuscitation attempts at heroin overdose: does it improve outcomes?

Study objective: To document the characteristics and effectiveness of cardiopulmonary resuscitation (CPR) at non-fatal heroin overdose events in Melbourne, Australia. Methods: A retrospective analysis of a computerised database of ambulance attendance records at non-fatal heroin overdose cases for the period 1/12/1998 to 31/7/2000 was undertaken.

Main outcome measures: The main outcome measure was the rate of patient hospitalisation. The rate of CPR administration at heroin overdose cases was also examined, along with characteristics of the attendance, such as the age and sex of the overdose case, the relationship of person providing CPR to the overdose case as well as the location, time and date of the event.

Results: CPR was administered prior to ambulance arrival in 579 heroin overdose cases (9.4% of total heroin overdose cases attended) between 1/12/98 and 31/7/2000. A greater proportion of female overdose cases were administered CPR than males and CPR administrations were evenly distributed across attendances occurring in private and public locations. Bystander administration of CPR prior to ambulance attendance resulted in a significantly lower rate of heroin user hospitalisation (14.5%) compared to cases where bystander CPR was not administered (18.8%).

Conclusions: While CPR administration prior to ambulance attendance at heroin overdose events is relatively uncommon (especially compared to out-of-hospital cardiac arrest), such administration was associated with a statistically significant improvement in clinical outcomes in cases of non-fatal heroin overdose. These findings suggest that the provision of CPR training to people likely to come into contact with heroin overdose events may be an effective strategy at minimising consequent overdose-related harm.

Effects of a walking program in the psychiatric in-patient treatment setting: a cohort study.

Issue addressed: To assess the effectiveness of a walking program in a psychiatric in-patient unit. Method: In-patients at a private psychiatric unit were offered the opportunity to participate in a daily morning 40 minute walk led by an activity supervisor. After discharge, outcomes for patients who had regularly participated in the walking group (n=35) and patients who had not participated (n=49) were compared for length of stay during their period of admission and Clinical Global Impression - Severity (CGI-S) and  Depression Anxiety Stress Scales (DASS) scores measured at admission and discharge. This was a retrospective analysis of data collected routinely. Results: There were no significant differences between the two cohorts on most primary outcome measures, including length of stay, DASS scores at admission and at discharge and CGI-S scores at admission. Patients who had not participated in the walking group had a significantly lower score on a single measure, the CGI-S, than patients who had participated (p=0.001). Conclusions: This study showed no evidence that in-patients benefited from participating in the physical activity program. However, this must be  interpreted within the confines of a number of study limitations and, as such, the findings can neither support nor refute the effectiveness of physical activities.

Consumer participation in designing community based consumer-directed disability care : lessons from a participatory action research-inspired project

User participation has been embraced worldwide as a means to provide better consumer outcomes in health and community care. However, methodologies to achieve effective consumer engagement at the programme design level have remained under-explored. The purpose of this study was to evaluate the impact of a Participatory Action Research (PAR)-inspired methodology used to develop a consumer-directed community care/individualised funding service model for people with disabilities. A retrospective analysis of case notes and internal reports for the first 6 years of an ongoing project were examined. The findings suggest that PAR methodologies need to take into account community development, group support, and capacity building as well as succession planning and risk management issues in order to facilitate the often lengthy policy and project development process. Drawing on these findings, this article discusses five lessons and their methodological implications for PAR in a health or social policy/programme design context.

Can the ABCD Score be dichotomised to identify high−risk patients with trainsient ischaemic attack in the emergency department?

Background: Recent evidence shows a substantial short-term risk of ischaemic stroke after transient ischaemic attack (TIA). Identification of patients with TIA with a high short-term risk of stroke is now possible through the use of the “ABCD Score”, which considers age, blood pressure, clinical features and duration of symptoms predictive of stroke.

Aim: To evaluate the ability of dichotomising the ABCD Score to predict stroke at 7 and 90 days in a population with TIA presenting to an emergency department.

Methods: A retrospective audit was conducted on all probable or definite TIAs presenting to the emergency department of a metropolitan hospital from July to December 2004. The ABCD Score was applied to 98 consecutive patients with TIA who were reviewed for subsequent strokes within 90 days. Patients obtaining an ABCD Score ≥5 were considered to be at high risk for stroke.

Results: Dichotomising the ABCD Score categorised 48 (49%) patients with TIA at high risk for stroke (ABCD Score ≥5). This high-risk group contained all four strokes that occurred within 7 days (sensitivity 100% (95% confidence interval (CI) 40% to 100%), specificity 53% (95% CI 43% to 63%), positive predictive value 8% (95% CI 3% to 21%) and negative predictive value 100% (95% CI 91% to 100%)), and six of seven occurring within 90 days (sensitivity 86% (95% CI 42% to 99%), specificity 54% (95% CI 43% to 64%), positive predictive value 12.5% (95% CI 5% to 26%) and negative predictive value 98% (95% CI 88% to 100%)). Removal of the “age” item from the ABCD Score halved the number of false-positive cases without changing its predictive value for stroke.

Conclusion: In this retrospective analysis, dichotomising the ABCD Score was overinclusive but highly predictive in identifying patients with TIA at a high short-term risk of stroke. Use of the ABCD Score in the emergency care of patients with TIA is simple, efficient and provides a unique opportunity to prevent stroke in this population of patients.

Students' perceptions of the value of the elements of an online learning environment : looking back in moving forward

In 2003, Deakin University implemented a centralised learning management system (LMS) under the banner of Deakin Studies Online (DSO), as well as implementing policies requiring all its units of study to have at least a basic online presence from 2004. Given the scope of the university's commitment to online education, it was considered essential to evaluate the effectiveness of this investment. Based on more than 5400 responses obtained from students in 2004 and 2005 as part of the DSO evaluation survey, the analysis presented here identifies those elements of the online learning environment (OLE) that are most used and valued by students, those elements of the OLE that students most want to see improved, and, those factors that most contribute to students' perceptions that use of the OLE enhanced their learning experience. The most used and valued elements were core LMS functions, including accessing unit information, accessing lecture/tute/lab notes, interacting with unit learning resources, reading online discussions, contacting lecturers/tutors and submitting assignments online. The OLE elements identified as most needing attention were receiving feedback on assignments; viewing my marks; and reviewing unit progress. Students felt that using DSO enhanced their learning experience when they were adequately supported by unit teachers and technical support services; when they were able to find and use unit information; and when they were able to read the online contributions of other unit members. The retrospective analysis of data collected in the period 2004-2005 has been shaped by a forward-looking agenda. The array of elements available within, and in association with, traditional LMSs which has emerged since that time raises the future challenge of how to maximise and evidence educational value through the optimal combination of elements from the portfolio of e-learning technologies increasingly available to educators.

The role of contexts and teacher's questioning to enhance students' thinking

This paper discusses results from a design research in line with Realistic Mathematics Education (RME). Daily cycles of design, classroom experiments, and retrospective analysis are enacted in five days of working about division by fractions. Data consists of episodes of video classroom discussions, and samples of students’ work. The focus of discussion and analysis centres on the role of contexts and the role of teachers’ probing questions to elicit students’ thinking. Our findings suggest that contexts that are meaningful for and understandable by students bring out rich mathematical thinking and discussion amongst students. Meaningful contexts combined with teacher’s probing questions - highlighting big mathematical ideas - allow students to attain various approaches at different levels of formal mathematics.

Activating teacher critical moments of learning through reflection

Mathematical modelling is one of the current focuses in the Singapore Mathematics Curriculum Framework. A multi-tiered teaching experiment using design research methodology was conducted to build teachers’ capacity in designing, facilitating, and evaluating learning during mathematical modelling tasks for Primary 5 students (aged 10-11). This paper illustrates the use of the retrospective analysis phase within design research cycles to activate a critical moment of teacher learning involving the interplay between questioning and listening during her first attempt at facilitating a mathematical modelling task. The teacher affirmed her deliberate focuses in the use of questions to (a) refine students’ models, (b) encourage articulation of student ideas in self-evaluation of the models, and (c) clarify and understand student reasoning. However, she also discovered the importance of interpretative listening in conjunction with questioning to promote more sophisticated mathematisation processes in model development. Implications from the use of the retrospective analysis phase on activating critical moments of learning during teacher education will be discussed.

Reported medication errors after introducing an electronic medication management system

Aims and objectives
To explore the effects of introducing an electronic medication management system on reported medication errors.
Background
Computerised medication management systems have been found to improve medication safety; however, introducing medication management system into healthcare environments can create unanticipated or new problems and opportunities for medication error.
Design
Descriptive analysis of medication error reports.
Methods
This was a retrospective analysis of 359 incident reports drawn from the period of 1 May 2005–30 April 2006 across two hospital sites of a single not-for-profit private health service located in metropolitan Melbourne. Site A used a conventional pen and paper system for medication management, and Site B had introduced a computerised medication management system.
Results
Most medication errors occurred at the nurse administration (71·5%) and prescribing (16·4%) stages of delivery. The most common medication error type reported at Site A was omission (33%), and at Site B was wrong documentation (24·2%). A higher proportion of errors at the prescribing phase, and less nurse administration errors, were detected at Site B where the medication management system was in use. The incidence of other, less frequent errors was similar across the two hospital sites.
Conclusions
This examination of medication error reports suggests there are differences in the types of medication errors that are reported in association with the introduction of electronic medication management system compared to pen and paper system systems. The findings provide a new insight into the effects of introducing an electronic medication management system on the types of medication errors reported.
Relevance to clinical practice
The findings provide a new insight into the types of medication errors that are reported during implementation of an electronic medication management system. Extra support for physicians prescribing practices should be considered.

Fixed-angle locking proximal humerus plate: an evaluation of functional results and implant-related outcomes

Background
Displaced and unstable proximal humeral fractures are challenging injuries to treat. Proximal humeral locking plates are a recent development for the treatment of these complex fractures.

Methods
Retrospective analysis of 23 patients with 23 proximal humeral fractures treated with the Synthes locking proximal humerus plate. These were Neer two-, three- and four-part fractures. Follow-up was at a mean of 22 months and included clinical assessment using the Constant score (CS) and the Short Form-12 health questionnaire. Radiographic assessment was performed to assess implant-related complication in relation to the initial fracture pattern and the presence of adequate medial support.

Results
The mean CS for all patients was 60.4 (range, 29–85). The mean adjusted CS was 82% (range, 30–117), active forward flexion 127 degrees and the active abduction 115 degrees. Initial fracture pattern, the presence or absence of adequate medial support and age did not significantly influence the clinical scores. Complications included one infection, two cases of avascular necrosis, two cases of varus collapse with screw penetration and one non-union. The overall reoperation rate was 26%. There was an increased rate of complications in those with inadequate medial support (P = 0.0183) and a trend to higher complication rates in four-part fractures.

Conclusion
Using the locking proximal humerus plate for the treatment of proximal humeral fractures is an acceptable procedure with comparable outcomes with historical controls, but with a complication rate of 30%. More important than implant selection, however, is the ability to achieve a stable reduction with calcar support.