Change to costs and lengths of stay in the emergency department and the Brisbane protocol: An observational study

- Objective To compare health service cost and length of stay between a traditional and an accelerated diagnostic approach to assess acute coronary syndromes (ACS) among patients who presented to the emergency department (ED) of a large tertiary hospital in Australia. - Design, setting and participants This historically controlled study analysed data collected from two independent patient cohorts presenting to the ED with potential ACS. The first cohort of 938 patients was recruited in 2008–2010, and these patients were assessed using the traditional diagnostic approach detailed in the national guideline. The second cohort of 921 patients was recruited in 2011–2013 and was assessed with the accelerated diagnostic approach named the Brisbane protocol. The Brisbane protocol applied early serial troponin testing for patients at 0 and 2 h after presentation to ED, in comparison with 0 and 6 h testing in traditional assessment process. The Brisbane protocol also defined a low-risk group of patients in whom no objective testing was performed. A decision tree model was used to compare the expected cost and length of stay in hospital between two approaches. Probabilistic sensitivity analysis was used to account for model uncertainty. - Results Compared with the traditional diagnostic approach, the Brisbane protocol was associated with reduced expected cost of $1229 (95% CI −$1266 to $5122) and reduced expected length of stay of 26 h (95% CI −14 to 136 h). The Brisbane protocol allowed physicians to discharge a higher proportion of low-risk and intermediate-risk patients from ED within 4 h (72% vs 51%). Results from sensitivity analysis suggested the Brisbane protocol had a high chance of being cost-saving and time-saving. - Conclusions This study provides some evidence of cost savings from a decision to adopt the Brisbane protocol. Benefits would arise for the hospital and for patients and their families.

Morbid obesity in total hip arthroplasty: Redefining outcomes for operative time, length of stay, and readmission

Background The incidence of obesity amongst patients presenting for elective Total Hip Arthroplasty (THA) has increased in the last decade and the relationship between obesity and the need for joint replacement has been demonstrated. This study evaluates the effects of morbid obesity on outcomes following primary THA by comparing short-term outcomes in THA between a morbidly obese (BMI ≥40) and a normal weight (BMI 18.5 - <25) cohort at our institution between January 2003 and December 2010. Methods Thirty-nine patients included in the morbidly obese group were compared with 186 in the normal weight group. Operative time, length of stay, complications, readmission and length of readmission were compared. Results Operative time was increased in the morbidly obese group at 122 minutes compared with 100 minutes (p=0.002). Post-operatively there was an increased 30-day readmission rate related to surgery of 12.8% associated with BMI ≥40 compared with 2.7% (p= 0.005) as well as a 5.1 fold increase in surgery related readmitted bed days - 0.32 bed days per patient for normal weight compared with 1.64 per patient for the morbidly obese (p=0.026). Conclusion Morbidly obese patients present a technical challenge and likely this and the resultant complications are underestimated. More work needs to be performed in order to enable suitable allocation of resources.

International inter-school competition to encourage children to walk to school: a mixed methods feasibility study.

Background: Active travel to school can be an important contributor to the total physical activity of children but levels have declined and more novel approaches are required to stimulate this as an habitual behaviour. The aim of this mixed methods study was to investigate the feasibility of an international walk to school competition supported by novel swipecard technology to increase children's walking to/from school. Methods: Children aged 9-13 years old participated in an international walk to school competition to win points for themselves, their school and their country over a 4-week period. Walks to and from school were recorded using swipecard technology and a bespoke website. For each point earned by participants, 1 pence (£0.01) was donated to the charity of the school's choice. The primary outcome was number of walks to/from school objectively recorded using the swipecard tracking system over the intervention period. Other measures included attitudes towards walking collected at baseline and week 4 (post-intervention). A qualitative sub-study involving focus groups with children, parents and teachers provided further insight. Results: A total of 3817 children (mean age 11.5±SD 0.7) from 12 schools in three cities (London and Reading, England and Vancouver, Canada) took part in the intervention, representing a 95% intervention participation rate. Results show a gradual decline in the average number of children walking to and from school over the 4-week period (week 1 mean 29%±SD2.5; week 2 mean 18%±SD3.6; week 3 mean 14%±SD4.0; week 4 mean 12%±SD1.1). Post intervention, 97% of children felt that walking to school helped them stay healthy, feel happy (81%) and stay alert in class (76%). These results are supported by qualitative findings from children, parents and teachers. Key areas for improvement include the need to incorporate strategies for maintenance of behaviour change into the intervention and also to adopt novel methods of data collection to increase follow-up rates. Conclusions: This mixed methods study suggests that an international walk to school competition using innovative technology can be feasibly implemented and offers a novel way of engaging schools and motivating children to walk to school.

Implications of aligning full registration of doctors with medical school graduation:a qualitative study of stakeholder perspectives

OBJECTIVES: The Shape of Training report recommended that full registration is aligned with medical school graduation. As part of a General Medical Council-funded study about the preparedness for practice of UK medical graduates, we explored UK stakeholders' views about this proposal using qualitative interviews (30 group and 87 individual interviews) and Framework Analysis.

SETTING: Four UK study sites, one in each country.Save

PARTICIPANTS: 185 individuals from eight stakeholder groups: (1) foundation year 1 (F1) doctors (n=34); (2) fully registered trainee doctors (n=33); (3) clinical educators (n=32); (4) undergraduate/postgraduate Deans, and Foundation Programme Directors (n=30); (5) other healthcare professionals (n=13); (6) employers (n=7); (7) policy and government (n=11); (8) patient and public representatives (n=25).

RESULTS: We identified four main themes: (1) The F1 year as a safety net: patients were protected by close trainee supervision and 'sign off' to prevent errors; trainees were provided with a safe environment for learning on the job; (2) Implications for undergraduate medical education: if the proposal was accepted, a 'radical review' of undergraduate curricula would be needed; undergraduate education might need to be longer; (3) Implications for F1 work practice: steps to protect healthcare team integration and ensure that F1 doctors stay within competency limits would be required; (4) Financial, structural and political implications: there would be cost implications for trainees; clarification of responsibilities between undergraduate and postgraduate medical education would be needed. Typically, each theme comprised arguments for and against the proposal.

CONCLUSIONS: A policy change to align the timing of full registration with graduation would require considerable planning and preliminary work. These findings will inform policymakers' decision-making. Regardless of the decision, medical students should take on greater responsibility for patient care as undergraduates, assessment methods in clinical practice and professionalism domains need development, and good practice in postgraduate supervision and support must be shared.

Should I stay or should I go? Sibling effects in household formation

This paper analyzes peer effects among siblings in the decision to leave parental home. Estimating peer effects is challenging because of problems of refection, endogenous group formation, and correlated unobservables. We overcome these issues using the exogenous variation in siblings' household formation implied by the eligibility rules for a Spanish rental subsidy. Our results show that sibling effects are negative and that these effects can be explained by the presence of old or ill parents. Sibling effects turn positive from older to younger close-in-age siblings, when imitation is more likely to prevail. Our findings indicate that policy makers who aim at fostering household formation should target the household rather than the individual and combine policies for young adults with policies for the elderly.

Mentorships and co-op placements as a means of heightening the need for a secondary school diploma to the education of at-risk students.--

Both educators and politicians appear to be quite concerned about a dropout rate in Ontario's public schools of some 30 percent. With the basic understanding that a high dropout rate is costly both in economic terms and in human terms, something quite obviously needs to be done to reduce the dropout rate in Ontario schools and, in doing so, ensuring Ontario and its graduates an active role in a growing global economy. This study is an exploratory pilot study in that it examined mentoring and the role that mentoring can play in assisting a student in staying in school and graduating from secondary school. Also incorporated in this is co-operative education and the role it can play, through mentoring, in making students aware of lifestyle level of employment, and of the skills necessary to obtain gainful, meaningful employment. In order to gain information on student attitudes, needs and expectations of a mentoring situation, a series of three questionnaires was used. Also, a questionnaire was distributed to the various co-operative education employers. The intent of this questionnaire was to probe the attitudes, needs and expectations of a mentoring situation from the perspective of an employer. The findings of this study indicated that co-operative education and mentoring are a very valuable and useful component in education. There exist certain factors in a co-operative education setting that serve to enhance and to augment the traditional or "theoretical" setting of the classroom. In addition, a mentoring situation tends to add a sense of relevance to education that students seem to require. Also, an opportunity is offered that allows a student to practice and further refine the skills that have been taught over the course of the student's academic life. Results from this study suggested that a mentoring situation, occurring through a co-operative education situation, adds relevance and a sense of "application" to the traditional or classroom schooling situation. The whole idea of mentoring bodes well for the future of education and of the student. Many advantages are identified in a mentoring situation. One of the advantages is that the schools are able to work quite closely with the community and business in order to stay current and informed on the needs and expected needs of the business community. Co-operative education has now gone beyond being an "experimental" mode of education. All students can benefit from being involved in the program. Certainly at-risk students are aided with staying in school. Those students who are said to be not at-risk can also benefit from being enrolled in the program by gaining hands-on work experience and some of the necessary skills to ensure a place in a growing world economy.

The Structure and implications of children's attitudes to school

The paper reports a study of children's attitudes to school based on a questionnaire survey of 845 pupils in their first year of secondary school in England, together with interviews with a sample of the children. A clearly structured set of attitudes emerged from a factor analysis which showed a distinction between instrumental and affective aspects of attitudes but also dimensions within these, including a sense of teacher commitment and school as a difficult environment. Virtually all children had a strong sense of the importance of doing well at school. However, a substantial minority were not sure that they would stay on after 16. There were few differences between boys and girls or between children from different socio-economic backgrounds but children planning to leave at 16 enjoyed school less and were less sure that it had anything to offer them. There was an almost universal commitment to the value of education but, for a minority, an ambivalence about the experience and relevance of schooling for them.

Student experiences of work placement in school-based vocational programs

Using a sample of 446 secondary students who had participated in a vocational education and training in school (VETiS) program, compares the experiences and perceptions of students who had undertaken a work placement with those who had not. Shows that students who had participated in work placement enjoyed the VETiS experience more than those who had not, and that the work placement had assisted them in their decision whether to stay at school or not. A factor analysis of results showed a factor associated with self-confidence about employability, and a factor associated with assistance in achieving specific post-school employment. Students who had completed a work placement were significantly higher on both these factors than students who had not. Results are consistent with other research in the field, and it is argued that the work placement experience plays a considerable part in developing student agency in the decisions and the journey that they make in their transition from school to work.

To stay or to go? 'At risk' young women speak about their influences and experiences in making decisions about post-compulsory schooling

Recent research indicates that young women who leave school early (ie at or before year 10) are the group most 'at risk' of becoming only marginally attached to the labour force or unemployed. Young women from low socio-economic backgrounds are more often those who 'choose' to leave schooling, often for complex reasons, some of which are only marginally connected to their schooling experiences. In order to better understand-and address-the needs of this cohort, it is necessary to examine the multi layered connections between students' lives in and out of school.

This paper reports on the initial stage of a three year ARC-funded study, 'Young women negotiating from the margins of education and work.' In interviews and focus groups, young women identified as 'at risk' of leaving school early speak about the factors that have influenced their decisions. We examine the data with specific reference to the question: what type of social capital do these young women deploy in making their choices? Recent research (Croninger & Lee, 2001) suggest that teachers' support and guidance are a form of social capital that can make a difference, particularly in regards to students from lower socio-economic backgrounds. We discuss the young women's and teachers' interview data in light of recent debates about social capital and education.

Sustainability in online communities of practice : the case study of a group of Secondary School Educators in Victoria

This paper reports on Information Technology (IT) secondary school educators in Victoria and their involvement in an online community of practice. It examined the social effects of the online mailing list technology on their participation and factors that influenced their collaboration with other colleagues. In mapping these elements, the motivations of educators and the effects on online communities of practice can be distilled and then used to build and sustain other architectures of participation. It was found that mailing list subscribers seem to trade a currency of support, thoughts, ideas and answers, which helped them in their day-to-day teaching. Online communities of practice provide a convenient way to keep up professional networks while continuing to stay abreast with subject specific knowledge and skills. The findings of this case study may be generalised to other educational mailing lists to guide designers and managers and inspire educators to join and ultimately benefit from these text based online environments.

The more things change, the more they stay the same : the 2012 alternative film/video festival

The Alternative Film/Video Festival in Belgrade has historically been one of a triumvirate of critical festivals, with Pula’s MAFAF (1965-1990) and Zagreb’s initiating GEFF (1963-70), servicing experimental, exploratory, avant-garde, personal film in the former Yugoslavia, at Belgrade’s Academic Film Center (AFC) within the Student City Cultural Centre (DKSG). Initiated in 1982 it was resurrected in 2003 with a dual regional and international focus after a hiatus due to the collapse of the socialist states of the former Yugoslavia. As well as a series of curated and retrospective programs each competition program is now split into international and regional halves, selected by Greg de Cuir and Zoran Saveski with production support by Milan Milosavljević. Two film workshops were also available. One on scratch film by Ivan Ladislav Galeta, the other on filming and processing led by Vassily Bourakis. Initiated by de Cuir the first Alternative Film/Video Research Forum was part of the festival this year bringing together research on alternative/ experimental/ avant-garde/ underground film and video. Although I participated in this side-bar I will concentrate here more on discussions from the festival roundtable and contextualise a small number of films, a couple from competition but mainly regional work that I would find difficult to encounter without attendance here.

Recommendations for and compliance with social restrictions during implementation of school closures in the early phase of the influenza A (H1N1) 2009 outbreak in Melbourne, Australia

Background Localized reactive school and classroom closures were implemented as part of a suite of pandemic containment measures during the initial response to influenza A (H1N1) 2009 in Melbourne, Australia. Infected individuals, and those who had been in close contact with a case, were asked to stay in voluntary home quarantine and refrain from contact with visitors for seven days from the date of symptom onset or exposure to an infected person. Oseltamivir (Tamiflu®) was available for treatment or prophylaxis. Methods We surveyed affected families through schools involved in the closures. Analyses of responses were descriptive. We characterized recommendations made to case and contact households and quantified adherence to guidelines and antiviral therapy. Results Of the 314 respondent households, 51 contained a confirmed case. The prescribed quarantine period ranged from 1-14 days, reflecting logistic difficulties in reactive implementation relative to the stated guidelines. Household-level compliance with the requirement to stay at home was high (84.5%, 95% CI 79.3,88.5) and contact with children outside the immediate family infrequent. Conclusions Levels of compliance with recommendations in our sample were high compared with other studies, likely due to heightened public awareness of a newly introduced virus of uncertain severity. The variability of reported recommendations highlighted the difficulties inherent in implementing a targeted reactive strategy, such as that employed in Melbourne, on a large scale during a public health emergency. This study emphasizes the need to understand how public health measures are implemented when seeking to evaluate their effectiveness.

"IF YOU BUILD THEM UP, THEY WILL STAY": THE ROLE OF RECOGNITION AND FEEDBACK ON STUDENT RETENTION

While such stratagems are certainly well founded, and have achieved varying degrees of success, it may be that a more fundamentally vital area of examination is being largely overlooked, namely the impact of the high school experience.

Heart rate variability in response to pain stimulus in VLBW infants followed longitudinally during NICU stay.

The objective of this longitudinal study, conducted in a neonatal intensive care unit, was to characterize the response to pain of high-risk very low birth weight infants (<1,500 g) from 23 to 38 weeks post-menstrual age (PMA) by measuring heart rate variability (HRV). Heart period data were recorded before, during, and after a heel lanced or wrist venipunctured blood draw for routine clinical evaluation. Pain response to the blood draw procedure and age-related changes of HRV in low-frequency and high-frequency bands were modeled with linear mixed-effects models. HRV in both bands decreased during pain, followed by a recovery to near-baseline levels. Venipuncture and mechanical ventilation were factors that attenuated the HRV response to pain. HRV at the baseline increased with post-menstrual age but the growth rate of high-frequency power was reduced in mechanically ventilated infants. There was some evidence that low-frequency HRV response to pain improved with advancing PMA.

Let’s Stay Home and Watch TV : The Benefits of Shared Media Use for Close Relationships

Peer reviewed