Improving the performance of nutrition screening through a series of quality improvement initiatives

Background Nutrition screening identifies patients at risk of malnutrition to facilitate early nutritional intervention. Studies have reported incompletion and error rates of 30-90% for a range of commonly used screening tools. This study aims to investigate the incompletion and error rates of 3-Minute Nutrition Screening (3-MinNS) and the effect of quality improvement initiatives in improving the overall performance of the screening tool and the referral process for at risk patients. Methods Annual audits were carried out from 2008-2013 on 4467 patients. Value Stream Mapping, Plan-Do-Check-Act cycle and Root Cause Analysis were used in this study to identify gaps and determine the best intervention. The intervention included 1) implementing a nutrition screening protocol, 2) nutrition screening training, 3) nurse empowerment for online dietetics referral of at-risk cases, 4) closed-loop feedback system and 5) removing a component of 3-MinNS that caused the most error without compromising its sensitivity and specificity. Results Nutrition screening error rates were 33% and 31%, with 5% and 8% blank or missing forms, in 2008 and 2009 respectively. For patients at risk of malnutrition, referral to dietetics took up to 7.5 days, with 10% not referred at all. After intervention, the latter decreased to 7% (2010), 4% (2011) and 3% (2012 and 2013), and the mean turnaround time from screening to referral was reduced significantly from 4.3 ± 1.8 days to 0.3 ± 0.4 days (p < 0.001). Error rates were reduced to 25% (2010), 15% (2011), 7% (2012) and 5% (2013) and percentage of blank or missing forms reduced to and remained at 1%. Conclusion Quality improvement initiatives are effective in reducing the incompletion and error rates of nutrition screening, and led to sustainable improvements in the referral process of patients at nutritional risk.

Psychological symptoms : a review of screening practices for patients with coronary heart disease (CHD)

Background/Aims: Coronary heart disease (CHD) and coronary events have been strongly linked to psychological symptoms in patients during hospitalisation and post-discharge. Within Australia CHD average length of stay is decreasing and symptoms often do not present until discharge. Early screening and treatment of psychological symptoms has been recommended to reduce mortality and identify anxiety and depression. This literature review was undertaken to evaluate and describe current screening practices to identify psychological symptoms in these patients.

Increasing incidence of Clostridium difficile infection, Australia, 2011–2012

Objectives: To report the quarterly incidence of hospital-identified Clostridium difficile infection (HI-CDI) in Australia, and to estimate the burden ascribed to hospital-associated (HA) and community-associated (CA) infections. Design, setting and patients: Prospective surveillance of all cases of CDI diagnosed in hospital patients from 1 January 2011 to 31 December 2012 in 450 public hospitals in all Australian states and the Australian Capital Territory. All patients admitted to inpatient wards or units in acute public hospitals, including psychiatry, rehabilitation and aged care, were included, as well as those attending emergency departments and outpatient clinics. Main outcome measures: Incidence of HI-CDI (primary outcome); proportion and incidence of HA-CDI and CA-CDI (secondary outcomes). Results: The annual incidence of HI-CDI increased from 3.25/10 000 patient-days (PD) in 2011 to 4.03/10 000 PD in 2012. Poisson regression modelling demonstrated a 29% increase (95% CI, 25% to 34%) per quarter between April and December 2011, with a peak of 4.49/10 000 PD in the October–December quarter. The incidence plateaued in January–March 2012 and then declined by 8% (95% CI, − 11% to − 5%) per quarter to 3.76/10 000 PD in July–September 2012, after which the rate rose again by 11% (95% CI, 4% to 19%) per quarter to 4.09/10 000 PD in October–December 2012. Trends were similar for HA-CDI and CA-CDI. A subgroup analysis determined that 26% of cases were CA-CDI. Conclusions: A significant increase in both HA-CDI and CA-CDI identified through hospital surveillance occurred in Australia during 2011–2012. Studies are required to further characterise the epidemiology of CDI in Australia.

Epidemiology of Clostridium difficile infection (CDI) in Queensland, Australia

Background: International epidemic clones (ribotypes 027 and 078) of Clostridium difficile have been associated with death, toxic megacolon and other adverse outcomes in North America and Europe. In 2010, the first local transmission of an epidemic strain (027) of C. difficile was reported in the state of Victoria, Australia, but no cases of infection with this strain were reported in the state of Queensland. In 2012, a prevalence study was undertaken in all public and selected private hospitals to examine the epidemiology of CDI and determine the prevalence of epidemic C. difficile strains in Queensland. Methods: Enhanced surveillance was undertaken on all hospital identified CDI cases aged over 2 years between 10 April and 15 June 2012. Where available, patient samples were cultured and isolates of C. difficile ribotyped. The toxin profile of each isolate was determined by PCR. Results: In total, 168 cases of CDI were identified during the study period. A majority (58.3%) of cases had onset of symptoms in hospital. Of the 62 patients with community onset of symptoms, most (74%) had a hospital admission in the previous 3 months. Only 4 of 168 patients had onset of symptoms within a residential care facility. Thirteen out of the 168 (7.7%) patients included in the study had severe disease (ICU admission and/or death within 30 days of onset). Overall 136/168 (81%) of cases had been prescribed antibiotics in the last month. Of concern was the emergence of a novel ribotype (244) which has recently been described in other parts of Australia and is genetically related to ribotype 027. Seven patients were infected with C. difficile ribotype 244 (8% of 83 samples ribotyped), including one patient requiring ICU admission and one patient who died. Ribotype 244 was tcdA, tcdB and CDT positive and contained a tcdC mutation at position 117. Conclusion: Ongoing surveillance is required to determine the origin and epidemiology of C. difficile ribotype 244 infections in Australia.

Why 'down under' is a cut above: a comparison of rates of and reasons for caesarean section in England and Australia

Background Most studies examining determinants of rising rates of caesarean section have examined patterns in documented reasons for caesarean over time in a single location. Further insights could be gleaned from cross-cultural research that examines practice patterns in locations with disparate rates of caesarean section at a single time point. Methods We compared both rates of and main reason for pre-labour and intrapartum caesarean between England and Queensland, Australia, using data from retrospective cross-sectional surveys of women who had recently given birth in England (n = 5,250) and Queensland (n = 3,467). Results Women in Queensland were more likely to have had a caesarean birth (36.2%) than women in England (25.1% of births; OR = 1.44, 95% CI = 1.28-1.61), after adjustment for obstetric characteristics. Between-country differences were found for rates of pre-labour caesarean (21.2% vs. 12.2%) but not for intrapartum caesarean or assisted vaginal birth. Compared to women in England, women in Queensland with a history of caesarean were more likely to have had a pre-labour caesarean and more likely to have had an intrapartum caesarean, due only to a previous caesarean. Among women with no previous caesarean, Queensland women were more likely than women in England to have had a caesarean due to suspected disproportion and failure to progress in labour. Conclusions The higher rates of caesarean birth in Queensland are largely attributable to higher rates of caesarean for women with a previous caesarean, and for the main reason of having had a previous caesarean. Variation between countries may be accounted for by the absence of a single, comprehensive clinical guideline for caesarean section in Queensland. Keywords: Caesarean section; Childbirth; Pregnancy; Cross-cultural comparison; Vaginal birth after caesarean; Previous caesarean section; Patient-reported data; Quality improvement

The once-and-for-all withdrawal of the Liverpool Care Pathway in the UK : what are the implications for Australia?

This Perspective reflects on the withdrawal of the Liverpool Care Pathway in the UK, and its implications for Australia. Integrated care pathways are documents which outline the essential steps of multidisciplinary care in addressing a specific clinical problem. They can be used to introduce best clinical practice, to ensure that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. By providing clear instructions, decision support and a framework for clinician-patient interactions, care pathways guide the systematic provision of best evidence-based care. The Liverpool Care Pathway (LCP) is an example of an integrated care pathway, designed in the 1990s to guide care for people with cancer who are in their last days of life and are expected to die in hospital. This pathway evolved out of a recognised local need to better support non-specialist palliative care providers’ care for patients dying of cancer within their inpatient units. Historically, despite the large number of people in acute care settings whose treatment intent is palliative, dying patients receiving general hospital acute care tended to lack sufficient attention from senior medical staff and nursing staff. The quality of end-of-life care was considered inadequate, therefore much could be learned from the way patients were cared for by palliative care services. The LCP was a strategy developed to improve end-of-life care in cancer patients and was based on the care received by those dying in the palliative care setting.

Securing medical devices Part A : what’s available for endotracheal tubes?

Oral endotracheal tubes (ETTs) and nasogastric tubes (NGT) are common devices used in adult intensive care and numerous options exist for safe and comfortable securement of these devices. The aim of this project was to identify the available range of ETT and NGT securement devices in Australia as a resource for clinicians seeking to explore options for tube stabilisation. This article reports part A of this project: ETT securement options. Part B will report NGT device fixation options. Securing ETTs to ensure a patent airway with minimal ETT movement, promotion of patient comfort and absence of adverse events such as ETT dislodgement, unplanned extubation and device-related injury1, are essential critical care nursing actions. The ETT requires a fixation method that is robust yet does not traumatise or injure the mucosal tissues of the mouth and soft tissue of the lips.2,3 Choice of a securement apparatus is often determined by product availability in our units or hospitals but is also driven by evidence-based practice and clinician preference. Trying to put this information together can be difficult and time-consuming for the bedside clinician...

Securing medical devices Part B : what’s available for nasogastric tubes?

This article is the second part of a two-part series examining securement options for commonly used therapeutic devices in the adult intensive care unit. Part A focused on endotracheal device securement.1 This article addresses nasogastric tube (NGT) securement options and with the aim of identifying the available range of NGT securement devices in Australia as a resource for clinicians seeking to explore options for tube stabilisation. Nasogastric feeding or gastric decompression tubes are commonly inserted via the nostril/nares. The National Pressure Ulcer Advisory Panel (NPUAP) 2011 position statement on mucosal pressure injuries, highlighted that mucosal tissues are vulnerable to pressure from devices.2 Securing of these devices sometimes leads to pressure-related injury to the internal mucosa due to difficulty visualising the mucosa and failure to reposition the nasogastric tube to relieve the pressure in a particular area.3 The nasal orifice is much smaller than the oral cavity and regular tube position changes are vital to minimise the risk of mucosal damage and ulcer development.

Can the use of quality assurance tools reduce the impact of surgical complications on the well-being of obstetricians and gynaecologists in Australia and New Zealand?

Background While adverse events primarily affect the patient, surgeons involved can also experience considerable distress. Aims The aim of the survey was to assess the impact of complications on the day-to-day life, work and health of Australian and New Zealand obstetricians and gynaecologists and to evaluate existing support systems and coping strategies. Methods A 43-question survey on self-assessment, quality assurance (QA) tools, impact of complications on individuals’ health and relationships, and support available was emailed to fellows, trainees, subspecialists and subspecialty trainees of the Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG). We collected 606 responses from a target population of 2296 (response rate 26.3%). Results When complications occur, sleep was affected of 80%, family and social relationships of 55% and physical health of 48% of respondents. The major sources of support were from colleagues (83%), family (82%) and medical defence organisations (73%), with professional bodies perceived as providing least support. Nearly 80% of respondents felt the need to talk to someone they trust during times of complications. Overall, 100% of respondents used at least one QA tool (62% used two, 26% three and 9% four QA strategies). There were significant differences between respondent groups in use of the QA tools. Conclusions Surgical complications have a significant impact on the well-being of Australian and New Zealand obstetricians and gynaecologists. Existing support comes from colleagues and family, but structured, unbiased support for surgeons from a professional source is urgently warranted.

Assessing capacity in the context of testamentary, enduring power of attorney, and advance care directive documents in Australia

Balancing the competing interests of autonomy and protection of individuals is an escalating challenge confronting an ageing Australian population. Legal and medical professionals are increasingly being asked to determine whether individuals are legally capable to make their own testamentary, financial and/or personal/health care decisions. Diseases such as dementia impact upon cognition which necessitates collaboration between the legal and medical professions to satisfactorily assess the effect of such mentally disabling conditions upon legal competency. Terminological and methodological differences exist between the two professions when assessing capacity in this context which subsequently create miscommunication and misunderstanding. Consequently, it is not necessarily a simple solution for a legal professional to seek the opinion of a medical practitioner. Exacerbating the situation is the fact that no consistent and transparent capacity assessment paradigm currently exists in Australia. Assessments are instead being undertaken on an ad hoc basis dependent upon the skill set of the legal and/or medical professionals involved. A qualitative study seeking the views of legal and medical professionals who practise in this area has been conducted. This incorporated a review of the relevant literature and surveys which informed the semi-structured interviews conducted with 10 legal and 20 medical practitioners. Practitioners were asked whether there is a standard approach to assessment and whether national guidelines would assist. The general consensus was that uniform guidelines would be advantageous. The research also canvassed practitioner views as to the state of the relationship between the professions when assessing capacity. Three promising practices have emerged from this research: first, is the need for the development of national guidelines and supporting principles to satisfactorily assess capacity; second, is the possibility of strengthening the relationship between legal and medical professionals to assist in the satisfactory assessment of legal capacity; and third, the need for increased community education.

LexisNexis Questions and Answers : Medical Law

LexisNexis Questions and Answers: Medical Law is designed to facilitate both continuous review and preparation for assignments and examinations. This book provides a clear and concise revision guide for each of the major topics covered in the typical health law course. It provides an understanding of medical law in each Australian jurisdiction and gives a clear and systematic approach to analysing and answering problem and essay questions. Each chapter commences with an identification of the key issues, including a summary of the relevant cases and legislation. Each question is followed by a suggested answer plan, a sample answer and comments on how the answer might be assessed by an examiner. The author also offers advice on common errors to avoid and practical hints and tips on how to achieve higher marks.

Livable housing design : the voluntary provision of inclusive housing in Australia

This paper reports on a study of the voluntary provision of inclusive housing. The impetus for the study is the Livable Housing Design initiative, an agreement among Australian housing industry and community leaders in 2010 to a national guideline and voluntary strategy with a target to provide minimum access features in all new housing by 2020. Situated in and around Brisbane, Australia, the study problematises the assumption that the housing industry will respond voluntarily; an assumption which this study concludes is unfounded. The Livable Housing Design initiative asks individual agents to consider the needs of people beyond the initial contract, to proceed with objective reasoning and to do the right thing voluntarily. Instead, the study found that interviewees focused on their immediate contractual obligations, were reluctant to change established practices and saw little reason to do more than was legally required of them. This paper argues that the highly-competitive and risk-averse nature of the industry works against a voluntary approach for inclusive housing and, if the 2020 target of the Livable Housing Design initiative is to be reached, a mandated approach through legislation will be necessary. The Livable Housing Design initiative, however, has an important role to play in preparing the Australian housing industry to accept further regulation.

A QUM partnership approach to regulating biosimilars in Australia

Despite the realisation of the potential implications from biosimilars is relatively recent, much has already been written about raising the awareness of differences between biosimilars and originating/ reference listed (innovator) pharmaceuticals. The European Medicines Agency has led the global charge in regulating biosimilars. Regardless of sufficient similarities across international regulations, differences do exist across jurisdictions. The consideration of regulating biosimilars demands a congruent approach across all stages: pre-registration (Australian copyright protection, patent, international obligations), registration (confidential information, international regulators, safety and efficacy), post-registration (Pharmaceutical Benefit Scheme, prescriber and dispenser awareness). Our National Medicines Policy could provide the necessary congruent framework and function for national and international regulation of biosimilars. The Policy concedes that pharmaceuticals will be affected by financial policies and trade considerations, international treaty obligations, industrial policies, education policies and the need for public-private partnerships.

Health Law in Australia [Second Edition]

Health Law in Australia is the country’s leading text in this area and was the first book to deal with health law on a comprehensive national basis. In this important field that continues to give rise to challenges for society Health Law in Australia takes a logical, structured approach to explain the breadth of this area of law across all Australian jurisdictions. By covering all the major areas in this diverse field, Health Law in Australia enhances the understanding of the discipline as a whole. Beginning with an exploration of the general principles of health law, including chapters on “Negligence”, “Children and Consent to Medical Treatment”, and “Medical Confidentiality and Patient Privacy”, the book goes on to consider beginning-of-life and end-of-life issues before concluding with chapters on emerging areas in health law, such as biotechnology, genetic technologies and medical research. The contributing authors are national leaders who are specialists in these areas of health law and who can share with readers the results of their research. Health Law in Australia has been written for both legal and health audiences and is essential reading for undergraduate and postgraduate students, researchers and scholars in the disciplines of law, health and medicine, as well as health and legal practitioners, government departments and bodies in the health area, and private health providers.

Withholding and withdrawing life-sustaining medical treatment

• At common law, a competent adult can refuse life-sustaining medical treatment, either contemporaneously or through an advance directive which will operate at a later time when the adult’s capacity is lost. • Legislation in most Australian jurisdictions also provides for a competent adult to complete an advance directive that refuses life-sustaining medical treatment. • At common law, a court exercising its parens patriae jurisdiction can consent to, or authorise, the withdrawal or withholding of life-sustaining medical treatment from an adult or child who lacks capacity if that is in the best interests of the person. A court may also declare that the withholding or withdrawal of treatment is lawful. • Guardianship legislation in all jurisdictions allows a substitute decision-maker, in an appropriate case, to refuse life-sustaining medical treatment for an adult who lacks capacity. • In terms of children, a parent may refuse life-sustaining medical treatment for his or her child if it is in the child’s best interests. • While a refusal of life-sustaining medical treatment by a competent child may be valid, this decision can be overturned by a court. • At common law and generally under guardianship statutes, demand for futile treatment need not be complied with by doctors.