Intern underperformance is detected more frequently in emergency medicine rotations

Objective: To determine the frequency and nature of intern underperformance as documented on in-training assessment forms. Methods: A retrospective review of intern assessment forms from a 2 year period (2009–2010) was conducted at a tertiary referral hospital in Brisbane, Queensland. The frequency of interns assessed as ‘requiring substantial assistance’ and/or ‘requires further development’ on mid- or end-of-term assessment forms was determined. Forms were analysed by the clinical rotation, time of year and domain(s) of clinical practice in which underperformance was documented. Results: During 2009 and 2010 the overall documented incidence of intern underperformance was 2.4% (95% CI 1.5–3.9%). Clinical rotation in emergency medicine detected significantly more underperformance compared with other rotations (P < 0.01). Interns predominantly had difficulty with ‘clinical judgment and decision-making skills’, ‘time management skills’ and ‘teamwork and colleagues’ (62.5%, 55% and 32.5% of underperforming assessments, respectively). Time of the year did not affect frequency of underperformance. A proportion of 13.4% (95% CI 9.2–19.0%) of interns working at the institution over the study period received at least one assessment in which underperformance was documented. Seventy-six per cent of those interns who had underperformance identified by mid-term assessment successfully completed the term following remediation. Conclusion: The prevalence of underperformance among interns is low, although higher than previously suggested. Emergency medicine detects relatively more interns in difficulty than other rotations.

Qualitative analysis and eating disorders : Discourse analytic research on anorexia nervosa

The absence of qualitative analysis in mainstream research on eating disorders is discussed in the following article as being a weakness in developing theory and clinical practice. This article includes an analysis of interviews with British healthcare workers who manage anorexic patients. This analysis presents an example of qualitative methodology in the form of discourse analysis, which is argued to provide a systematic, yet flexible approach to research on eating disorders. The overwhelming prevalence of anorexia nervosa in women is specifically examined within the context of the identification of the "discourse of femininity. " The research findings are discussed in relation to the use of discursive practices that contribute to the maintenance and reproduction of clinical processes and their relative efficacy.

Aliens, borders and social citizens : Health and community services for trafficked women

Australian policy makers recognise women who are trafficked to Australia (and these are largely for the purposes of sexual exploitation) primarily as victims of crime. The main public mechanism by which the "problem" of trafficked people in Australia is managed is the criminal law. At the same time, however, as a signatory to the UN Protocol on Trafficking and the Declaration of Human Rights, the Australian Government also recognises the rights of women trafficked to Australia to access health and community services in the wake of the health damage and trauma they often incur as a consequence of their experience. Current evidence suggests that trafficked women in Australia face considerable barriers in being able to avail themselves of such a right and of the services that accompany it. This paper explores the tensions posed by Australian policy and service approaches to trafficked women in light of the concept of social citizenship and the ways in which it is mediated in the Australian context by national border protection policy.

The potential contributions of traditional Chinese medicine to emergency medicine

BACKGROUND: Despite the fact that traditional Chinese medicine (TCM) has been developed and used to treat acute and urgent illness for many thousands of years. TCM has been widely perceived in western societies that TCM may only be effective to treat chronic diseases. The aim of this article is to provide some scientific evidence regarding the application of TCM in emergency medicine and its future potential. METHODS: Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) were searched using the terms: Traditional Chinese Medicine/ Chinese Medicine, Emergency Medicine, China. In addition, three leading TCM Journals in China were searched via Oriprobe Information Services for relevant articles (published from 1990—2012). Particular attention was paid to those articles that are related to TCM treatments or combined medicine in dealing with intensive and critical care. RESULTS: TCM is a systematic traditional macro medicine. The clinical practice of TCM is guided by the TCM theoretical framework – a methodology founded thousands of years ago. As the methodologies between TCM and Biomedicine are significantly different, it provides an opportunity to combine two medicines, in order to achieve clinical efficacy. Nowadays, combined medicine has become a common clinical model particular in TCM hospitals in China. CONCLUSIONS: It is evident that TCM can provide some assistance in emergency although to combine them in practice is stillits infant form and is mainly at TCM hospitals in China. The future effort could be put into TCM research, both in laboratories and clinics, with high quality designs, so that TCM could be better understood and then applied in emergency medicine.

Most relevant strategies for preventing surgical site infection after total hip arthroplasty : guideline recommendations and expert opinion

BACKGROUND: Numerous strategies are available to prevent surgical site infections in hip arthroplasty, but there is no consensus on which might be the best. This study examined infection prevention strategies currently recommended for patients undergoing hip arthroplasty. METHODS: Four clinical guidelines on infection prevention/orthopedics were reviewed. Infection control practitioners, infectious disease physicians, and orthopedic surgeons were consulted through structured interviews and an online survey. Strategies were classified as "highly important" if they were recommended by at least one guideline and ranked as significantly or critically important by >/=75% of the experts. RESULTS: The guideline review yielded 28 infection prevention measures, with 7 identified by experts as being highly important in this context: antibiotic prophylaxis, antiseptic skin preparation of patients, hand/forearm antisepsis by surgical staff, sterile gowns/surgical attire, ultraclean/laminar air operating theatres, antibiotic-impregnated cement, and surveillance. Controversial measures included antibiotic-impregnated cement and, considering recent literature, laminar air operating theatres. CONCLUSIONS: Some of these measures may already be accepted as routine clinical practice, whereas others are controversial. Whether these practices should be continued for this patient group will be informed by modeling the cost-effectiveness of infection prevention strategies. This will allow predictions of long-term health and cost outcomes and thus inform decisions on how to best use scarce health care resources for infection control.

Crisis response planning in tunnel and road networks

Critical road infrastructure (such as tunnels and overpasses) is of major significance to society and constitutes major components of interdependent, ‘systems and networks’. Failure in critical components of these wide area infrastructure systems can often result in cascading disturbances with secondary and tertiary impacts - some of which may become initiating sources of failure in their own right, triggering further systems failures across wider networks. Perrow1) considered the impact of our increasing use of technology in high-risk fields, analysing the implications on everyday life and argued that designers of these types of infrastructure systems cannot predict every possible failure scenario nor create perfect contingency plans for operators. Challenges exist for transport system operators in the conceptualisation and implementation of response and subsequent recovery planning for significant events. Disturbances can vary from reduced traffic flow causing traffic congestion throughout the local road network(s) and subsequent possible loss of income to businesses and industry to a major incident causing loss of life or complete loss of an asset. Many organisations and institutions, despite increasing recognition of the effects of crisis events, are not adequately prepared to manage crises2). It is argued that operators of land transport infrastructure are in a similar category of readiness given the recent instances of failures in road tunnels. These unexpected infrastructure failures, and their ultimately identified causes, suggest there is significant room for improvement. As a result, risk profiles for road transport systems are often complex due to the human behaviours and the inter-mix of technical and organisational components and the managerial coverage needed for the socio-technical components and the physical infrastructure. In this sense, the span of managerial oversight may require new approaches to asset management that combines the notion of risk and continuity management. This paper examines challenges in the planning of response and recovery practices of owner/operators of transport systems (above and below ground) in Australia covering: • Ageing or established infrastructure; and • New-build infrastructure. With reference to relevant international contexts this paper seeks to suggest options for enhancing the planning and practice for crisis response in these transport networks and as a result support the resilience of Critical Infrastructure.

Community response to disasters in Indonesia : Gotong Royong; a double edged-sword

Indonesia is a country spread across wide-ranging archipelago, located in South East Asia between two oceans, the Indian and the Pacific. Indonesia is well known as an active tectonic region because it lies on top of three major active tectonic plates: the Eurasian in the North, the Indian Ocean-Australian in the South, and the Pacific plate in the East. The southern and eastern part of the country features a range of volcanic arcs, volcanic mountains, and lowlands with 500 young volcanoes, of which 128 are active and thus representing 15% of the world’s active volcanoes. In the period 2002-2007, approximately 1782 disasters occurred, with hundreds of thousands of lives lost and billions of rupiah in losses incurred: (Floods - 1183 instances, cyclones - 272 instances, and landslides - 252 instances). Of these, the 2004 Aceh tsunami and the 2006 central Java earthquake (impacting predominantly city and suburbs of Yogyakarta) were the most significant. Even so, disaster management experts believe lessons learnt from the two major natural disasters needs to be formalised into laws and institutions before another disaster occurs, regardless of the type of natural disaster – i.e. Volcano eruption or landslide; as opposed to tsunami or earthquake. Following in the wake of disasters occurring in Yogyakarta, many of its community members responded by banding together as one, with the determination of rebuilding its villages and cities through the spirit of ‘gotong royong’. The idea of social interaction; in particular as a collective, consensual, and cooperative nation; has predominantly formed the ideological basis of Indonesia’s societal nature. Many Indonesian terms cohere to this ideology, such as: ‘koperasi” (cooperatives as the basis of economic interactions), ‘musyawarah’ (consensual nature in decision making), and ‘gotong royong’ (mutual assistance). ‘Gotong royong’ has become a key cultural operator in Indonesia, in particular In Jogjakarta. Appropriately so as ‘gotong royong’ is depicted from the traditional Javanese village, where labour is accomplished through reciprocal exchange and the villagers are motivated by a general ethos of selfishness and concern for the common good. The culture of ‘gotong royong’ promotes positive values such as social harmony and mutual reciprocation in disaster-affected areas provides the necessary spirit needed to endure the hardships and for all involved. While gotong royong emphasises the positive notions of mutual family support and deep community level activity there is a potential for contrast against government lead disaster response and recovery management activities especially in settings where sporadic governance mechanisms exist and transparency and accountability in the recovery process of public infrastructure assets have been questioned. This paper thus questions whether Gotong Royong is a double-edged sword, and explores the potential marriage of community values and governance mechanisms for future disaster management planning and practice.

Young people, public space and new urbanism

The first of three articles in this issue addressing the public space topic considers public space and young people in the light of a range of papers delivered at the 27th International Conference on 'Making Cities Livable', held in Vienna, Austria, in July 2000. Under the overarching concept of the "liveable city" the conference themes of 'Rediscovery of public space' and 'Cities for the wellbeing of children' attracted a broad mix of those interested in the planning, design and management of urban space. A number of themes percolated through the conference which stimulated the writers to examine the nexus between urban development, young people and public space. There is an ongoing need to examine the meaning of public space in the face of powerful urban development trends. A model of public space practice is required which incorporates a vision of inclusive public spaces, fosters the interactivity of design, planning, social policy and management, and resources for greater communication and strategic action between stake holders from the most local of levels to those at state and international levels. The speed and magnitude of contemporary urban development makes community input and influence difficult, particularly for those impacted on by the exclusionary tendencies of much urban development. It is critical that a range of meaningful and sustainable mechanisms are developed which allow young people’s conceptions of what constitutes youth-friendly space to be directly made and taken account of.

Young people and the social exclusion of their public and private space

This paper explores the concept of social exclusion as it impacts on young people within their local communities and the wider British, European and Australian context in terms of surveillance and other control measures.

Young people, children and their social and spatial citizenship rights

The use of public space by young people and children is a major issue in a number of countries and a range of measures are deployed to to control public space which restrict their social and spatial citizenship rights.

Beyond the accolades : a postcolonial critique of the foundations of the Ottawa Charter

Introduction: The Ottawa Charter is undeniably of pivotal importance in the history of ideas associated with the establishment of health promotion. There is much to applaud in a charter which responds to the need to take action on the social and economic determinants of health and which seeks to empower communities to be at the centre of this. Such accolades tend to position the Ottawa Charter as ‘beyond critique’; a taken-for-granted ‘given’ in the history of health promotion. In contrast, we argue it is imperative to critically reflect on its ‘manufacture’ and assess the possibility that certain voices have been privileged, and others marginalized. Methods: This paper re-examines the 1986 Ottawa Conference including its background papers from a postcolonial standpoint. We use critical discourse analysis as a tool to identify the enactment of power within the production of the Ottawa health promotion discourse. This exercise draws attention to both the power to ensure the dominant presence of privileged voices at the conference as well as the discursive strategies deployed to ‘naturalize’ the social order of inequality. Results: Our analysis shows that the discourse informing the development of the Ottawa Charter strongly reflected Western/colonizer centric worldviews, and actively silenced the possibility of countervailing Indigenous and developing country voices. Conclusion: The Ottawa Charter espouses principles of participation, empowerment and social justice. We question then whether the genesis of the Ottawa Charter lives up to its own principles of practice. We conclude that reflexive practice is crucial to health promotion, which ought to include a preparedness for health promotion to more critically acknowledge its own history.

Integrated multi-professional teams in primary care : rhetoric or reality?

Integrated multi-professional teams are crucial to ongoing health system development and need to be responsive to the increasing demands of health care such as the burgeoning rate of chronic diseases. Integrated multi-professional teams also constitute a fundamental pillar of health service delivery in primary care worldwide. The aim of these teams is to deliver care beyond simple co-location of healthcare providers, through implementing integrated practice together, rather than as a group of independent disciplines. The challenges of developing and implementing integrated multi-professional teams in busy primary care clinical environments is addressed in this paper through a conceptual framework specifically designed for primary care and a case study analysis of examples of teamwork in Australian primary care.