The recovery concept and crisis intervention : time for a revolution in the realm of acute psychiatric care

“Mental illness is a tough illness to survive, it is incurable but manageable. Living with the illness when at its full potency can disrupt your life at any moment.” Intensive care for patients experiencing acute psychiatric distress is an essential yet complex part of mental health services as a whole system. Psychiatric intensive care units remain a source of controversy; despite promising developments to health services incorporating recovery goals and processes outlined by people with a mental illness themselves. In past decades changes in the provision of mental health services have focused on the restoration of a meaningful and empowered life with choice and hope as a defining attribute of recovery. Yet, what does recovery mean and how are recovery principles accomplished in psychiatric intensive care arrangements for someone experiencing acute psychiatric distress?

Long-term survival after intensive care unit discharge in Thailand : a retrospective study

Introduction Economic evaluations of interventions in the hospital setting often rely on the estimated long-term impact on patient survival. Estimates of mortality rates and long-term outcomes among patients discharged alive from the intensive care unit (ICU) are lacking from lower- and middle-income countries. This study aimed to assess the long-term survival and life expectancy (LE) amongst post-ICU patients in Thailand, a middle-income country. Methods In this retrospective cohort study, data from a regional tertiary hospital in northeast Thailand and the regional death registry were linked and used to assess patient survival time after ICU discharge. Adult ICU patients aged at least 15 years who had been discharged alive from an ICU between 1 January 2004 and 31 December 2005 were included in the study, and the death registry was used to determine deaths occurring in this cohort up to 31st December 2010. These data were used in conjunction with standard mortality life tables to estimate annual mortality and life expectancy. Results This analysis included 10,321 ICU patients. During ICU admission, 3,251 patients (31.5%) died. Of 7,070 patients discharged alive, 2,527 (35.7%) were known to have died within the five-year follow-up period, a mortality rate 2.5 times higher than that in the Thai general population (age and sex matched). The mean LE was estimated as 18.3 years compared with 25.2 years in the general population. Conclusions Post-ICU patients experienced much higher rates of mortality than members of the general population over the five-year follow-up period, particularly in the first year after discharge. Further work assessing Health Related Quality of Life (HRQOL) in both post-ICU patients and in the general population in developing countries is needed.

Do palliative care health professionals settle for low level evidence?

The findings of the recent independent review of the UK Liverpool Care Pathway (LCP)1, following substantial concerns raised by members of the public and health professionals found that the implementation of the LCP is often associated with poor care1. The Neuberger Report highlighted the complexity of various ethical, safety, clinical practice and negligence issues associated with pathway usage and how, despite technological advances, diagnosing dying continues to be challenging. The UK Government’s decision to phase out the LCP as policy following these findings, has generated considerable debate both within and beyond the UK. However, another key issue raised by the Neuberger’s report is the issue of the palliative care community’s perceived willingness to readily adopt new clinical practices in the absence of evidence. It is this translational issue that this editorial explores.

Transition to palliative care for people living with metastatic melanoma : preliminary findings from a grounded theory study

Melanoma is the most aggressive form of skin cancer. Five-year survival rates for patients with metastatic melanoma are less than 10%, with a median survival of 6 to 9 months. Despite a number of clinical trials for metastatic melanoma, the treatment options for patients are limited. Palliation is often the main goal of treatment. This constructivist grounded theory study is seeking to examine how people with metastatic melanoma negotiate the transition to palliative care. The method of sampling is purposive and data have been generated through semi-structured interviews with those with metastatic melanoma and partners. Open, focused and theoretical coding of data from 13 interviews conducted to date has produced analytical concepts that reflect how the transition is negotiated. These concepts depict ways in which individuals interact with a fragmented health care system and how meanings are constructed around the rapid progression of the disease and uncertain treatment decisions. The preliminary findings reported upon here are being further explored with a larger sample. The findings to date highlight the need for improved coordination of services for those living with metastatic melanoma, and improved support for individuals dealing with uncertainty.

An exploration of the roles of nurses working in emergency care services in general hospitals in West Java, Indonesia : a grounded theory study

A review of literature on the role of emergency nurses in Indonesia revealed a dearth of research. Anecdotal evidence suggests a lack of clarity in role definition which has led to uncertainty and role ambiguity. Despite advances in the development of specialist nursing roles in Indonesia, that of the emergency nurse remains unclear. This study explored the role of nurses working in emergency care services in three general hospitals in West Java, Indonesia. The theoretical framework is grounded in Charmaz’s constructivist grounded theory. Data collection methods were observation, in-depth interviews and interrogation of related documents. Phase one of data collection involved 74 h of observation and nterviews with 35 nurses working in the three ED settings. For the purposes of theoretical sampling, a second phase of data collection was conducted. This involved a second nterview with eight participants from the three EDs. nterviews were also undertaken with the three key informants of nursing management of three related hospitals; key informants from the Indonesian Nurses Association; the Directorate of Nursing, Ministry of Health; and from the organization for ED nurses. Data analysis drew on Charmaz’s constructivist approach and the concepts of simultaneous data collection and analysis, constant comparison, coding, and theoretical sampling. The analysis generated four theoretical concepts that characterized the role of the emergency nurse: An arbitrary scope of practice, Struggling for recognition, Learning on the job and Looking to better practice. These concepts provided analytical direction for an exploration of the clinical and political dimensions of the role of the emergency nurse in Indonesia.

Development, implementation and evaluation of a cancer survivor self-management care plan

Aim There is a growing population of people with cancer who experience physiological and psychological effects that persist long after treatment is complete. Interventions that enhance survivors’ self-management abilities might help offset these effects. The aim of this pilot study was to develop, implement and evaluate interventions tailored to assist patients to manage post-treatment health issues effectively. Method In this pre-post intervention cohort study, participants were recruited on completion of cancer treatment. Participants recruited preimplementation, who received usual care, comprised the control group. Participants recruited later formed the intervention group. In the intervention group, the Cancer Care Coordinator developed an individualised, structured Cancer Survivor Self-management Care Plan. Participants were interviewed on completion of treatment (baseline) and at three months. Assessments concerned health needs (CaSUN), self-efficacy in adjusting and coping with cancer and health-related quality of life (FACIT-B or FACT-C). The impact of the intervention was determined by independent t-tests of change scores. Results The intervention (n = 32) and control groups (n = 35) were comparable on demographic and clinical characteristics. Sample mean age was 54 + 10 years. Cancer diagnoses were breast (82%) and colorectal (18%). Statistically significant differences (p < 0.05) indicated improvement in the intervention group for: (a) functional well-being, from the FACIT, (Control: M = −0.69, SE = 0.91; Intervention: M = 3.04, SE = 1.13); and (b) self-efficacy in maintaining social relationships, (Control: M = −0.333, SE = 0.33; Intervention: M = 0.621, SE = 0.27). No significant differences were found in health needs, other subscales of quality of life, the extent and number of strategies used in coping and adjusting to cancer and in other domains of self-efficacy. Conclusions While the results should be interpreted with caution, due to the non-randomised nature of the study and the small sample size, they indicate the potential benefits of tailored self-management interventions warrant further investigation in this context.

Validating a novel, low cost, automated malnutrition screening system as a predictor of nutritional risk in the Oncology Day Care Unit

Background Cancer-related malnutrition is associated with increased morbidity, poorer tolerance of treatment, decreased quality of life, increased hospital admissions, and increased health care costs (Isenring et al., 2013). This study’s aim was to determine whether a novel, automated screening system was a useful tool for nutrition screening when compared against a full nutrition assessment using the Patient-Generated Subjective Global Assessment (PG-SGA) tool. Methods A single site, observational, cross-sectional study was conducted in an outpatient oncology day care unit within a Queensland tertiary facility, with three hundred outpatients (51.7% male, mean age 58.6 ± 13.3 years). Eligibility criteria: ≥18 years, receiving anticancer treatment, able to provide written consent. Patients completed the Malnutrition Screening Tool (MST). Nutritional status was assessed using the PG-SGA. Data for the automated screening system was extracted from the pharmacy software program Charm. This included body mass index (BMI) and weight records dating back up to six months. Results The prevalence of malnutrition was 17%. Any weight loss over three to six weeks prior to the most recent weight record as identified by the automated screening system relative to malnutrition resulted in 56.52% sensitivity, 35.43% specificity, 13.68% positive predictive value, 81.82% negative predictive value. MST score 2 or greater was a stronger predictor of nutritional risk relative to PG-SGA classified malnutrition (70.59% sensitivity, 69.48% specificity, 32.14% positive predictive value, 92.02% negative predictive value). Conclusions Both the automated screening system and the MST fell short of the accepted professional standard for sensitivity (80%) or specificity (60%) when compared to the PG-SGA. However, although the MST remains a better predictor of malnutrition in this setting, uptake of this tool in the Oncology Day Care Unit remains challenging.

The interface of acute and aged care : the role of the nurse in a provincial area

Objective This study was to investigate issues that arose from pre-admission to post-discharge, for people in Toowoomba, Queensland over the age of 65 admitted to an acute facility. This paper concentrates on a significant concern that emerged from the large amount of data collected during this project, that is,the role of the nurse in the continuum of health care involving elderly people. Method The study involved a multi-site, multi-agency and multi-method (qualitative and quantitative) approach. Data was collected from regional service providers, the Department of Health and Aged Care (DHAC), the Australian Bureau of Statistics (ABS), Home and Community Care (HACC), the Aged Care Assessment Team (ACAT), elderly people who had been discharged from regional hospitals and their carers, residents of regional aged care facilities, area health professionals and elderly regional hospital inpatients. Results The data indicated that nurses in this provincial area currently play a limited role in preadmission planning, being mostly concerned with elective surgery, especially joint replacements. While nurses deliver the majority of care during hospitalisation, they do not appear to be cognizant of the needs of the elderly regarding post-acute discharge. Conclusion The recent introduction of the model of nurse case management in the acute sector appears to be a positive development that will streamline and optimise the health care of the elderly across the continuum in the Toowoomba area. The paper recommends some strategies, such as discharge liaison nurses based in Emergency Departments and the expansion of the nurse case management role, which would optimise care for the elderly person at the interface of care.

Young women’s experiences as consumers of maternity care in Queensland

Background: Young motherhood is commonly associated with vulnerabilities, stereotyping of young women’s behaviour and poor outcomes for them and their children. The objective was to understand how maternity care is experienced for this group in the transition to parenthood. Methods: Data from a large-scale 2010 survey of women’s experience of maternity care were analysed using qualitative methods with open text responses. Results: 7,193 women responded to the survey: 237 were aged 20 years or less. Most (83%) of these young women provided open text responses. The main themes were: ‘being a consumer’, ‘the quality of care���, ‘needing support’ and ‘pride in parenthood’ while subthemes included ‘being young’ and ‘how staff made me feel’, ‘testimonials for staff’, ‘not being left’ and ‘it’s all worthwhile’. Conclusion: Many young women responding described a positive experience. For many first time mothers this marked a positive change in their identity. Nevertheless staff perceptions and attitudes affected how they saw themselves and what they took away from their experience of maternity care. A key message for other women supported and reinforced their role as active and involved consumers who, in engaging with services, have to stand up for themselves and make their needs and wishes known.

End-of-life care pathways for improving outcomes in caring for the dying (Review)

Background This is an updated version of a Cochrane review first published in Issue 1, 2010 of The Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. There have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the UK. Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways with a systematic review. Objectives To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community). In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying; those related to the care such as families, carers and health professionals; or a combination of these. Search Methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2013), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles and reference lists of relevant articles.We conducted the original search in September 2009, and the updated search in June 2013. Selection Criteria All randomised controlled trials (RCTs), quasi-randomised trial or high-quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying. Data Collection and Analysis Two review authors assessed the results of the searches against the predetermined criteria for inclusion. Main Results The original review identified 920 titles. The updated search found 2042 potentially relevant titles (including the original 920), but no additional studies met criteria for inclusion in the review update. Authors’ Conclusions With sustained concerns about the safety of the pathway implementation and the lack of available evidence on important patient and relative outcomes, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. Since the last version of this review, no new studies met criteria for inclusion in the review update. With recently documented concerns related to the potential adverse effects associated with Liverpool Care Pathway (the most commonly used end-of-life care pathway), we do not recommend decision making based on indirect or low-quality evidence. All health services using end-of-life care pathways are encouraged to have their use of the pathway, to date, independently audited. Any subsequent use should be based on carefully documented evaluations. Large RCTs or other well-designed controlled studies are urgently required for the evaluation of the use of end-of-life care pathways in caring for dying people in various clinical settings. In future studies, outcome measures should include benefits or harms concerning the outcomes of interest in this review in relation to patients, families, carers and health professionals.

Lung health care for Aboriginal and Torres Strait Islander Queenslanders : breathing easy is not so easy

Objectives In Aboriginal and Torres Strait Islander peoples in Queensland, to (a) determine the disease burden of common chronic lung diseases and (b) identify areas of need with respect to lung health services. Methods Literature reviews and analyses of hospitalisation and mortality data were used to describe disease epidemiology and available programs and services. Key stakeholder interviews and an online survey of health professionals were used to evaluate lung health services across the state and to identify services, needs and gaps. Results Morbidity and mortality from respiratory diseases in the Indigenous population is substantially higher than the non-Indigenous population across all age groups and regions. There are inadequate clinical services and resources to address disease prevention, detection, intervention and management in an evidence-based and culturally acceptable fashion. There is a lack of culturally appropriate educational resources and management programs, insufficient access to appropriately engaged Indigenous health professionals, a lack of multi-disciplinary specialist outreach teams, fragmented information systems and inadequate coordination of care. Conclusions Major initiatives are required at all levels of the healthcare system to adequately address service provision for Indigenous Queenslanders with lung diseases, including high quality research to investigate the causes for poor lung health, which are likely to be multifactorial.

A snapshot of 40 years in early childhood education and care through oral histories

The year 2012 marked 40 years since the introduction of the Child Care Act 1972 and the federal government introduced financial support for the provision of child care services in Australia. Significant changes have occurred in social, political and theoretical contexts of early childhood education and care (ECEC) during this time. Bringing these to life, this paper investigates archival data of key changes in ECEC in association with oral histories of staff, parents and children associated with The Gowrie Qld during the years 1972‒2012. With narrative analysis considered alongside historical information, two dominant issues emerge as integral to ECEC in the past, now and the future. These are: 1) what constitutes effective teaching and learning in the educational program and 2) professional expectations in ECEC. Building an historical picture, this paper provides for critical reflection on the past to inform current and future practices.

Building Healthy Communities : GP Network, Medicare Local and Primary Health Care in the Wheatbelt Region of Western Australia

• Government reports consistently recognise the importance of Primary Health Care to an efficient health system. Barriers identified in Australia’s Primary Health Care include workforce pressures, increase rate of chronic disease, and equitable access to Primary Health Care services. • General Practitioners (GPs) are the key to the successful delivery of Primary Health Care especially in rural and remote regions such as the Wheatbelt region in Western Australia (WA). • The Wheatbelt region of WA is vast: some 72,500 residents spread across 150,000km2 in 43 Local Government Authorities catchments. Majority of the Wheatbelt residents live in small towns. There is a higher reported rates of chronic disease, more at risk of chronic diseases and less utilisation of Primary Health Care services in this region. • General practice patients in the Wheatbelt are among those most in need of Primary Health Care services. • Wheatbelt GP Network (the “Network”) was established in 1998. It is a key health service delivery stakeholder in the Wheatbelt. • The Network has responded to the health needs of the community by creating a mobile Allied Health Team that works closely with GPs and is adaptive to ensure priority needs are met. • The Medicare Local model introduced by the Australian Government in 2011 aimed to improve the delivery of Primary Health Care services by improved health planning and coordinating service delivery. • Little if any recognition has been given to the outstanding work that many Divisions of General Practice have done in improving the delivery of Primary Health Care services such as the Network. • The Network has continued to support GPs and general practices and created a complementary system that integrated general practice with the work of an Allied Health Team. Its program mix is extensive. • The Network has consistently delivered on-required contract outputs and has a fifteen (15) years history of operating successfully in a large geographical area comprising in the main smaller communities that cannot support the traditional health services model. • The complexity of supporting International Medical Graduates in the region requires special attention. • The introduction of the Medicare Local in the South West of WA and their intention to take over the delivery of health services, thus effectively shutting the Network will have catastrophic consequences and cannot be supported economically. • The Network proposes to create a new model, built on its past work that increases the delivery of Primary Health Care services through its current Allied Health Team. • The proposal uses the Wheatbelt GP Super Clinic currently under construction in Northam, part of the Network and funded by the Australian Government is a key to the proposed new model. • Wheatbelt GP Super Clinic is different from existing models of GP Super Clinics around Australia which focus predominately on co-location of services. Wheatbelt GP Super Clinic utilises a hub and spoke model of service outreach to small rural towns to ensure equitable Primary Health Care coverage and continuum of care in a financially responsible and viable manner. In particular, the Wheatbelt GP Super Clinic recognises the importance of Allied Health Professionals and will involve them in a collaborative model with rural general practice. • The proposed model advocated by the Network aims to substitute the South West WA Medicare Local direct service delivery proposed for the Wheatbelt. The Network’s proposed model is to expand on the current hub and spoke model of Primary Health Care delivery to otherwise small unviable Wheatbelt towns. A flexible and adaptive skill mix of Allied Health Professionals, Nurse Practitioners and GPs ensure equitable access to service. Expanded scope of practices are utilised to reduce duplication of service and concentration of services in major towns. This involves a partnership approach. • If the proposed model not funded, the Network and the Wheatbelt region will stand to lose 16 Allied Health Professionals and defeats the purpose of Australian Government current funding for the construction of the Wheatbelt GP Super Clinic. • The Network has considered how its model can best be funded. It proposes a re-allocation of funds made available to the South West WA Medicare Local. • This submission argues that the proposal for the South West WA Medicare Local to take over the service delivery of Primary Health Care services in the Wheatbelt makes no economic sense when an existing agency (the Network) has the infrastructure in place, is experienced in working in this geographical area that has special needs and is capable to expand its programs to meet demand.