Quality issues for the National Bowel Cancer Screening Program (NBCSP)

Purpose: This two-part research project was undertaken as part of the planning process by Queensland Health (QH), Cancer Screening Services Unit (CSSU), Queensland Bowel Cancer Screening Program (QBCSP), in partnership with the National Bowel Cancer Screening Program (NBCSP), to prepare for the implementation of the NBCSP in public sector colonoscopy services in QLD in late 2006. There was no prior information available on the quality of colonoscopy services in Queensland (QLD) and no prior studies that assessed the quality of colonoscopy training in Australia. Furthermore, the NBCSP was introduced without extra funding for colonoscopy service improvement or provision for increases in colonoscopic capacity resulting from the introduction of the NBCSP. The main purpose of the research was to record baseline data on colonoscopy referral and practice in QLD and current training in colonoscopy Australia-wide. It was undertaken from a quality improvement perspective. Implementation of the NBCSP requires that all aspects of the screening pathway, in particular colonoscopy services for the assessment of positive Faecal Occult Blood Tests (FOBTs), will be effective, efficient, equitable and evidence-based. This study examined two important aspects of the continuous quality improvement framework for the NBCSP as they relate to colonoscopy services: (1) evidence-based practice, and (2) quality of colonoscopy training. The Principal Investigator was employed as Senior Project Officer (Training) in the QBCSP during the conduct of this research project. Recommendations from this research have been used to inform the development and implementation of quality improvement initiatives for provision of colonoscopy in the NBCSP, its QLD counterpart the QBCSP and colonoscopy services in QLD, in general. Methods – Part 1 Chart audit of evidence-based practice: The research was undertaken in two parts from 2005-2007. The first part of this research comprised a retrospective chart audit of 1484 colonoscopy records (some 13% of all colonoscopies conducted in public sector facilities in the year 2005) in three QLD colonoscopy services. Whilst some 70% of colonoscopies are currently conducted in the private sector, only public sector colonoscopy facilities provided colonoscopies under the NBCSP. The aim of this study was to compare colonoscopy referral and practice with explicit criteria derived from the National Health & Medical Research Council (NHMRC) (1999) Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer, and describe the nature of variance with the guidelines. Symptomatic presentations were the most common indication for colonoscopy (60.9%). These comprised per rectal bleeding (31.0%), change of bowel habit (22.1%), abdominal pain (19.6%), iron deficiency anaemia (16.2%), inflammatory bowel disease (8.9%) and other symptoms (11.4%). Surveillance and follow-up colonoscopies accounted for approximately one-third of the remaining colonoscopy workload across sites. Gastroenterologists (GEs) performed relatively more colonoscopies per annum (59.9%) compared to general surgeons (GS) (24.1%), colorectal surgeons (CRS) (9.4%) and general physicians (GPs) (6.5%). Guideline compliance varied with the designation of the colonoscopist. Compliance was lower for CRS (62.9%) compared to GPs (76.0%), GEs (75.0%), GSs (70.9%, p<0.05). Compliance with guideline recommendations for colonoscopic surveillance for family history of colorectal cancer (23.9%), polyps (37.0%) and a past history of bowel cancer (42.7%), was by comparison significantly lower than for symptomatic presentations (94.4%), (p<0.001). Variation with guideline recommendations occurred more frequently for polyp surveillance (earlier than guidelines recommend, 47.9%) and follow-up for past history of bowel cancer (later than recommended, 61.7%, p<0.001). Bowel cancer cases detected at colonoscopy comprised 3.6% of all audited colonoscopies. Incomplete colonoscopies occurred in 4.3% of audited colonoscopies and were more common among women (76.6%). For all colonoscopies audited, the rate of incomplete colonoscopies for GEs was 1.6% (CI 0.9-2.6), GPs 2.0% (CI 0.6-7.2), GS 7.0% (CI 4.8-10.1) and CRS 16.4% (CI 11.2-23.5). 18.6% (n=55) of patients with a documented family history of bowel cancer had colonoscopy performed against guidelines recommendations (for general (category 1) population risk, for reasons of patient request or family history of polyps, rather than for high risk status for colorectal cancer). In general, family history was inadequately documented and subsequently applied to colonoscopy referral and practice. Methods - Part 2 Surveys of quality of colonoscopy training: The second part of the research consisted of Australia-wide anonymous, self-completed surveys of colonoscopy trainers and their trainees to ascertain their opinions on the current apprenticeship model of colonoscopy in Australia and to identify any training needs. Overall, 127 surveys were received from colonoscopy trainers (estimated response rate 30.2%). Approximately 50% of trainers agreed and 27% disagreed that current numbers of training places were adequate to maintain a skilled colonoscopy workforce in preparation for the NBCSP. Approximately 70% of trainers also supported UK-style colonoscopy training within dedicated accredited training centres using a variety of training approaches including simulation. A collaborative approach with the private sector was seen as beneficial by 65% of trainers. Non-gastroenterologists (non-GEs) were more likely than GEs to be of the opinion that simulators are beneficial for colonoscopy training (χ2-test = 5.55, P = 0.026). Approximately 60% of trainers considered that the current requirements for recognition of training in colonoscopy could be insufficient for trainees to gain competence and 80% of those indicated that ≥ 200 colonoscopies were needed. GEs (73.4%) were more likely than non-GEs (36.2%) to be of the opinion that the Conjoint Committee standard is insufficient to gain competence in colonoscopy (χ2-test = 16.97, P = 0.0001). The majority of trainers did not support training either nurses (73%) or GPs in colonoscopy (71%). Only 81 (estimated response rate 17.9%) surveys were received from GS trainees (72.1%), GE trainees (26.3%) and GP trainees (1.2%). The majority were males (75.9%), with a median age 32 years and who had trained in New South Wales (41.0%) or Victoria (30%). Overall, two-thirds (60.8%) of trainees indicated that they deemed the Conjoint Committee standard sufficient to gain competency in colonoscopy. Between specialties, 75.4% of GS trainees indicated that the Conjoint Committee standard for recognition of colonoscopy was sufficient to gain competence in colonoscopy compared to only 38.5% of GE trainees. Measures of competency assessed and recorded by trainees in logbooks centred mainly on caecal intubation (94.7-100%), complications (78.9-100%) and withdrawal time (51-76.2%). Trainees described limited access to colonoscopy training lists due to the time inefficiency of the apprenticeship model and perceived monopolisation of these by GEs and their trainees. Improvements to the current training model suggested by trainees included: more use of simulation, training tools, a United Kingdom (UK)-style training course, concentration on quality indicators, increased access to training lists, accreditation of trainers and interdisciplinary colonoscopy training. Implications for the NBCSP/QBCSP: The introduction of the NBCSP/QBCSP necessitates higher quality colonoscopy services if it is to achieve its ultimate goal of decreasing the incidence of morbidity and mortality associated with bowel cancer in Australia. This will be achieved under a new paradigm for colonoscopy training and implementation of evidence-based practice across the screening pathway and specifically targeting areas highlighted in this thesis. Recommendations for improvement of NBCSP/QBCSP effectiveness and efficiency include the following: 1. Implementation of NBCSP and QBCSP health promotion activities that target men, in particular, to increase FOBT screening uptake. 2. Improved colonoscopy training for trainees and refresher courses or retraining for existing proceduralists to improve completion rates (especially for female NBCSP/QBCSP participants), and polyp and adenoma detection and removal, including newer techniques to detect flat and depressed lesions. 3. Introduction of colonoscopy training initiatives for trainees that are aligned with NBCSP/QBCSP colonoscopy quality indicators, including measurement of training outcomes using objective quality indicators such as caecal intubation, withdrawal time, and adenoma detection rate. 4. Introduction of standardised, interdisciplinary colonoscopy training to reduce apparent differences between specialties with regard to compliance with guideline recommendations, completion rates, and quality of polypectomy. 5. Improved quality of colonoscopy training by adoption of a UK-style training program with centres of excellence, incorporating newer, more objective assessment methods, use of a variety of training tools such as simulation and rotations of trainees between metropolitan, rural, and public and private sector training facilities. 6. Incorporation of NHMRC guidelines into colonoscopy information systems to improve documentation, provide guideline recommendations at the point of care, use of gastroenterology nurse coordinators to facilitate compliance with guidelines and provision of guideline-based colonoscopy referral letters for GPs. 7. Provision of information and education about the NBCSP/QBCSP, bowel cancer risk factors, including family history and polyp surveillance guidelines, for participants, GPs and proceduralists. 8. Improved referral of NBCSP/QBCSP participants found to have a high-risk family history of bowel cancer to appropriate genetics services.

Solar powered UAV for fire prevention and planning

This project aims to develop a methodology for designing and conducting a systems engineering analysis to build and fly continuously, day and night, propelled uniquely by solar energy for one week with a 0.25Kg payload consuming 0.5 watt without fuel or pollution. An airplane able to fly autonomously for many days could find many applications. Including coastal or border surveillance, atmospherical and weather research and prediction, environmental, forestry, agricultural, and oceanic monitoring, imaging for the media and real-estate industries, etc. Additional advantages of solar airplanes are their low cost and the simplicity with which they can be launched. For example, in the case of potential forest fire risks during a warm and dry period, swarms of solar airplanes, easily launched with the hand, could efficiently monitor a large surface, reporting rapidly any fire starts. This would allow a fast intervention and thus reduce the cost of such disaster, in terms of human and material losses. At higher dimension, solar HALE platforms are expected to play a major role as communication relays and could replace advantageously satellites in a near future.

Enhancing the capacity of oncology nurses to provide supportive care for patients with advanced cancer : evaluation of an educational intervention

Aim: This study aimed to enhance the capacity of oncology nurses to provide supportive care for patients with advanced cancer who have dependent children. ---------- Method: This was a pilot study of an educational intervention comprising a study-developed self-directed learning manual, supported by a day-long communication skills training workshop. Evaluation pre- and post-training included measures of stress and burnout, self-reports of confidence and attitudes, responses to clinical vignettes and video-taped interviews with simulated patients.---------- Results: Nurses found the educational intervention highly acceptable, and reported increased confidence in their ability to provide information and support for parents, and to initiate discussion about emotional issues. There were significant improvements in general communication skills and skills specific to this training, as well as reduced use of blocking.---------- Conclusion: Brief communication skills training supplemented with tailored educational resources can enhance confidence skills and knowledge of oncology nurses regarding their supportive care of parents with advanced cancer.

Research participation of individuals with dementia : decisional capacity, informed consent, and considerations for nurse investigators

Decisional capacity is a precious component of personhood and is progressively diminished in dementia. Conducting research with individuals with dementia demands a commitment to ensure the quest for knowledge does not overwhelm the rights of those it is intended to protect. The purposes of this article are to describe current understandings of the concept of decisional capacity, describe recent regulatory developments related to the consideration of additional protections for decisionally impaired adults, and provide recommendations for nurse investigators working with this vulnerable group.

Emergency department nurses' understanding and experiences of implementing discharge planning

Aim: This paper is a report of a study conducted to describe emergency department nurses' understanding and experiences of implementing discharge planning. ---------- Background: Discharge planning in the emergency department is an important issue because of increased healthcare costs and greater emphasis on continuity of care. When executed as a collaborative process involving a multi-disciplinary team with the patient and family, discharge planning provides continuity of care for patients, less demand on hospitals, improvement in community services and in the services of other healthcare organizations. ---------- Method: The qualitative approach of phenomenography was used in this study. Thirty-two emergency department nurses were recruited between July and September 2005. Semi-structured interviews were conducted. ---------- Findings: From interviewees' descriptions of implementing discharge planning, six categories were established: implementing discharge planning as 'getting rid of my patients', completing routines, being involved in patient education, professionally accountable practice, autonomous practice and demonstrating professional emergency department nursing care. The referential meaning of implementing discharge planning 'in the outcome space' was the professional commitment to emergency department provision of effective discharge services. ---------- Conclusion: The results of this research contribute to knowledge of emergency department nurses' experience in the implementation of the discharge planning process. Key requirements for the provision of manageable discharge services both in Taiwan and worldwide highlighted by this study include adequate workloads, sufficient time, clear policies and standards of discharge planning and enhancement of professional commitment.

Discharge planning in the emergency department : a comprehensive approach

Discharge planning has become increasingly important, with current trends toward shorter hospital stays, increased health care costs, and more community-based health services. Effective discharge planning ensures the safety and ongoing care for patients,1 and it also benefits health care providers and organizations. It results in shorter hospital stays, fewer readmissions, higher access rates to post-hospitalization services, greater patient satisfaction with the discharge, and improved quality of life and continuity of care.[2] and [3] All acute care patients and their caregivers require some degree of preparation for discharge home—education about their health status, risks, and treatment; help setting health goals and maintaining a good level of self-care; information about community resources; and follow-up appointments and referrals to appropriate community health providers. Inadequate preparation exposes the patient to unnecessary risks of recurrence or complications of the acute complaint, neglect of nonacute comorbidities, mismanagement and side effects of medication, disruption of family and social life, emotional distress, and financial loss.[2], [3] and [4] The result may be re-presentation to the emergency department. It is noteworthy that up to 18% of ED presentations are revisits within 72 hours of the original visit5; many of these are considered preventable.6 It is a primary responsibility of nurses to ensure that patients return to the community adequately prepared and with appropriate support in place. Up to 65% of ED patients are discharged home from the emergency department,7 and the characteristics of the emergency department and its patient population make the provision of a high standard of discharge planning uniquely difficult. In addition, discharge planning is neglected in contemporary emergency nursing—there are no monographs devoted to the subject, and there is little published research. In this article 3 issues are explored: the importance of emergency nurses’ participation in the discharge-planning process, impediments to their participation; and strategies to improve discharge planning in the emergency department.

Creating deep and broad change through research and systems approaches in early childhood education for sustainability

The co-authors raise two matters they consider essential for the future development of ECEfS. The first is the need to create deep foundations based in research. At a time of increasing practitioner interest, research in ECEfS is meagre. A robust research community is crucial to support quality in curriculum and pedagogy, and to promote learning and innovation in thinking and practice. The second 'essential' for the expansion and uptake of ECEfS is broad systemic change. All level within the early childhood education system - individual teachers and classrooms, whole centres and schools, professional associations and networks, accreditation and employing authorities, and teacher educators - must work together to create and reinforce the cultural and educational changes required for sustainability. This chapter provides explanations of processes to engender systemic change. It illustrates a systems approach, with reference to a recent study focused on embedding EfS into teacher education. This study emphasises the apparent contradiction that the answer to large-scale reform lies with small-scale reforms that build capacity and make connections.

Beyond the fashionable : strategic planning for critical information literacy education

The challenge for all educators is to fuse the learning of information literacy to an academic education in such a way that the outcome is systematic and sustainable learning for students. This challenge can be answered through long-term commitment to information literacy education bound to organisation-wide, renewable strategic planning and driven through systemic reform. This chapter seeks to explore the two sides of reforming information literacy education in an academic environment. Specifically, it will examine how one Australian university has undertaken the implementation of a rigorous strategic, systemic approach to information literacy learning and teaching.

Towards compatible and integrated airport and regional land use planning in Australia

Over the past decade privatised capital city airports in Australia have planned developed a range of non aviation commercial and retail land uses on airport land. Many surrounding municipalities consider this development in conflict with existing regional land use planning. Conversely airport operators are alarmed at continued urban consolidation and encroachment of incompatible regional development. Land use planning within and surrounding Australian capital city airports does not support compatible and integrated land use. It is currently a fragmented process due to: 1) current legislative and policy frameworks; 2) competing stakeholder priorities and interests; and 3) inadequate coordination and disjointed decision-making. This paper will examine privatised Australian airport development and consider three case studies to detail the context of airport and regional land use planning. A series of stakeholder workshops have served to inform the procedural dynamics and relationships between airport and regional decision-making. This exploratory research will assist in informing the knowledge gaps between aviation, airport development and broader urban land use policy. This paper will provide recommendations to enhance approaches to land use planning for airports and adjacent metropolitan regions in Australia and overseas.

Steering towards pinnacle of success : the NEC tenets in Australian construction contracting

Contractual relationships have become increasingly strained in recent years in the construction industry result in the use of the judicial system for the settlement of contractual disagreements. Why is this so? Evidence from anecdotes suggest that the lack of capacity amongst owners and contractors to carry out a contract using a good practice approach during the construction of a project contribute to the occurrence of conflicts, losses, deficient contractual relationships and poor performance of the construction work. Recognizing that current forms of contract in use today perpetuate a legacy of construction problems, we are conducting explanatory research to examine whether the widely publicized benefits of New Engineering Contract (NEC) could be realized in the Australian construction industry. This paper outlines a research agenda that will help shed light on how contract forms are able to be used as a mechanism to ensure construction projects are delivered successfully whilst also meeting the goals of multiple stakeholders. Understanding the Critical Success Factors (CSFs), commonly used construction contracts and the NEC system can help us address some of these issues. However, there are gaps in the validation of the benefits of NEC and its link with project success. We identify some of these gaps and propose a methodology by which to gain insights into this phenomenon. Keywords: Project Success, Construction Contracting, New Engineering Contract (NEC)

Responding to sustainability challenge and cost implications in highway construction projects

Highway construction often requires a significant capital input; therefore it often causes serious financial implications for developers, owners and operators. The recent industry-wide focus on sustainability has added a new dimension to the evaluation of highway projects, particularly on the economical scale of ‘going green’. Comprehensive analysis of the whole-of-life highway development that responds to sustainability challenges is one of the primary concerns for stakeholders. Principles of engineering economics and life cycle costing have been used to determine the incremental capacity investments for highway projects. However, the consideration of costs and issues associated with sustainability is still very limited in current studies on highway projects. Previous studies have identified that highway project investments are primarily concerned with direct market costs that can be quantified through life cycle costing analysis (LCCA). But they tend to ignore costs that are difficult to calculate, as those related to environmental and social elements. On a more positive note, these studies proved that the inclusion of such costs is an essential part of the overall development investment and a primary concern for decision making by the stakeholders. This paper discusses a research attempt to identify and categorise sustainability cost elements for highway projects. Through questionnaire survey, a set of sustainability cost elements on highway projects has been proposed. These cost elements are incorporated into the extension of some of the existing Life Cycle Costing Analysis (LCCA) models in order to produce a holistic financial picture of the highway project. It is expected that a new LCCA model will be established to serve as a suitable tool for decision making for highway project stakeholders.

Best Practice

The overall theme for the 4th Biennial International Network of Indigenous Health Knowledge and Development (INIHKD)Conference was ‘Knowing Our Roots: Indigenous Medicines, Health Knowledges and Best Practices’. Conference activities were grouped around the following broad themes: •Building of Indigenous research capacity, partnerships and workforce; •Sharing of innovative, traditional and contemporary Indigenous knowledges, especially with respect to culturally-grounded interventions and evidenced-based “best and promising practices”; •Identification of successful Indigenous health policy solutions; and •Sharing of ethical, Indigenous-based research protocols and methodologies. This keynote plenary presentation focused on 'best practice' in research asking the questions: What kind of research will I do? What kind of research will I be? What is the contribution that I will make? what will be my legacy?

Constraints to cost effective land supply

The ready availability of suitably zoned and serviced land is one of the key factors in the timely and cost effective provision of new land for development. Unfortunately, in many high population growth areas, land that may be available does not have ready access to infrastructure, or the appropriate designation/s (zoning) in place. The corresponding lag in supply frequently bears the blame for the resultant disequilibrium in the market and affordability pressures on the end product. Government has the capacity to respond to the issue of land supply in a number of ways. Proactive measures define longer term goals and set the ground rules moving forwards. Reactive policy decisions are made in an often hostile environment where stakeholder interests conflict. With a trend to increased regulation, government risks further constraining the viability of land development in high growth areas, without full consideration of all the supply side variables. This preliminary paper will identify a number of the variables which may be constraining the supply of land for residential development in South East Queensland given the current regulatory environment. It will examine the interrelationship between these supply side constraints, a full understanding of which is required by government in order for its policies to stimulate, rather than restrict the supply of land in this high growth region.

Planning for survival

When the global financial crisis has its own acronym (the “GFC”), you know its going to be around for a while. This article looks at some of the risk/opportunity assessments you should take into consideration if you are planning for your property development business to still be around when the GFC is a thing of the past.

Guided chaos : path planning and control for a UAV-forced landing

In recent years, unmanned aerial vehicles (UAVs) have been widely used in combat, and their potential applications in civil and commercial roles are also receiving considerable attention by industry and the research community. There are numerous published reports of UAVs used in Earth science missions [1], fire-fighting [2], and border security [3] trials, with other speculative deployments, including applications in agriculture, communications, and traffic monitoring. However, none of these UAVs can demonstrate an equivalent level of safety to manned aircraft, particularly in the case of an engine failure, which would require an emergency or forced landing. This may be arguably the main factor that has prevented these UAV trials from becoming full-scale commercial operations, as well as restricted operations of civilian UAVs to only within segregated airspace.