The challenges of meeting the needs of children with Autism Spectrum Disorders (ASD) during out of hospital interactoins with Paramedics

This poster presents the results of a critical review of the literature on the intersection between paramedic practice with Autism Spectrum Disorder (ASD) and previews the clinical and communication challenges likely to be experienced with these patients. Paramedics in Australia provide 24/7 out-of-hospital care to the community. Although their core business is to provide emergency care, paramedics also provide care for vulnerable people as a consequence of the social, economic or domestic milieu. Little is known about the frequency of use of emergency out-of-hospital services by children with ASD and their families. Similarly, little is known about the attitudes and perceptions of paramedics to children with ASD and their emergency health care. However, individuals with ASD are likely to require paramedic services at some point across the life span and may be more frequent users of health services as a consequence of the challenges they face. The high rate of co-morbidities of people diagnosed with ASD is reported and includes seizure disorders, gastro-intestinal disorders, metabolic disorders, hormonal dysfunction, ear, nose and throat infections, hearing impairment, hypertension, allergies/anaphylaxis, immune disorders, migraine and diabetes, gross/fine motor skill dysfunction, premature birth, birth defects, obesity and mental illness. Individuals with ASD may frequently experience concurrent communication, behaviour and sensory challenges. Consequently, Paramedics can encounter difficulties gathering important patient information which may compromise sensitive care. These interactions occur often in high pressure and emotionally challenging environments, which add to the difficulties in communicating the treatment and transport needs of this population.

Using ICD-10-AM codes to characterise hospital-acquired complications

This paper describes the limitations of using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) to characterise patient harm in hospitals. Limitations were identified during a project to use diagnoses flagged by Victorian coders as hospital-acquired to devise a classification of 144 categories of hospital acquired diagnoses (the Classification of Hospital Acquired Diagnoses or CHADx). CHADx is a comprehensive data monitoring system designed to allow hospitals to monitor their complication rates month-to-month using a standard method. Difficulties in identifying a single event from linear sequences of codes due to the absence of code linkage were the major obstacles to developing the classification. Obstetric and perinatal episodes also presented challenges in distinguishing condition onset, that is, whether conditions were present on admission or arose after formal admission to hospital. Used in the appropriate way, the CHADx allows hospitals to identify areas for future patient safety and quality initiatives. The value of timing information and code linkage should be recognised in the planning stages of any future electronic systems.

Marginal costs of hospital-acquired conditions : information for priority-setting for patient safety programmes and research

Objective: To estimate the relative inpatient costs of hospital-acquired conditions. Methods: Patient level costs were estimated using computerized costing systems that log individual utilization of inpatient services and apply sophisticated cost estimates from the hospital's general ledger. Occurrence of hospital-acquired conditions was identified using an Australian ‘condition-onset' flag for diagnoses not present on admission. These were grouped to yield a comprehensive set of 144 categories of hospital-acquired conditions to summarize data coded with ICD-10. Standard linear regression techniques were used to identify the independent contribution of hospital-acquired conditions to costs, taking into account the case-mix of a sample of acute inpatients (n = 1,699,997) treated in Australian public hospitals in Victoria (2005/06) and Queensland (2006/07). Results: The most costly types of complications were post-procedure endocrine/metabolic disorders, adding AU$21,827 to the cost of an episode, followed by MRSA (AU$19,881) and enterocolitis due to Clostridium difficile (AU$19,743). Aggregate costs to the system, however, were highest for septicaemia (AU$41.4 million), complications of cardiac and vascular implants other than septicaemia (AU$28.7 million), acute lower respiratory infections, including influenza and pneumonia (AU$27.8 million) and UTI (AU$24.7 million). Hospital-acquired complications are estimated to add 17.3% to treatment costs in this sample. Conclusions: Patient safety efforts frequently focus on dramatic but rare complications with very serious patient harm. Previous studies of the costs of adverse events have provided information on ‘indicators’ of safety problems rather than the full range of hospital-acquired conditions. Adding a cost dimension to priority-setting could result in changes to the focus of patient safety programmes and research. Financial information should be combined with information on patient outcomes to allow for cost-utility evaluation of future interventions.

Out-of-pocket expenditures for hospital care in Iran : who is at risk of incurring catastrophic payments?

Since the beginning of 1980s, the Iranian health care system has undergone several reforms designed to increase accessibility of health services. Notwithstanding these reforms, out-of-pocket payments which create a barrier to access health services contribute almost half of total health are financing in Iran. This study aimed to provide a greater understanding about the inequality and determinants of the out-of-pocket expenditure (OOPE) and the related catastrophic expenditure (CE) for hospital services in Iran using a nationwide survey data, the 2003 Utilisation of Health Services Survey (UHSS). The concentration index and the Heckman selection model were used to assess inequality and factors associated with these expenditures. Inequality analysis suggests that the CE is concentrated among households in lower socioeconomic levels. The results of the Heckman selection model indicate that factors such as length of stay, admission to a hospital owned by private sector or Ministry of Health and Medical Education, and living in remote areas are positively associated with higher OOPE. Results of the ordered-probit selection model demonstrate that length of stay, lower household wealth index, and admission to a private hospital are major factors contributing to the increase in the probability of CE. Also, we find that households living in East Azarbaijan, Kordestan and Sistan and Balochestan face a higher level of CE. Based on our findings, the current employer-sponsored health insurance system does not offer equal protection against hospital expenditure in Iran. It seems that a single universal health insurance scheme that covers health services for all Iranian—regardless of their employment status—can better protect households from catastrophic health spending.

Hospital care in Iran : an examination of national health system performance

This study examines hospital care system performance in Iran. We first briefly review hospital care delivery system in Iran. Then, the hospital care system in Iran has been investigated from financial, utilization, and quality perspectives. In particular, we examined the extent to which health care system in Iran protects people from the financial consequence of health care expenses and whether inpatient care distributed according to need. We also empirically analyzed the quality of hospital care in Iran using patient satisfaction information collected in a national health service survey. The Iranian health care system consists of unequal access to hospital care; mismatch between the distribution of services and inpatients' need; and high probability of financial catastrophe due to out-of-pocket payments for inpatient services. Our analysis indicates that the quality of hospital care among Iranian provinces favors patients residing in provinces with high numbers of hospital beds per capita such as Esfahan and Yazd. Patients living in provinces with low levels of accessibility to hospital care (e.g. Gilan, Kermanshah, Hamadan, Chahar Mahall and Bakhtiari, Khuzestan, and Sistan and Baluchestan) receive lower-quality services. These findings suggest that policymakers in Iran should work on several fronts including utilization, financing, and service quality to improve hospital care.

Ecosystem management along ephemeral rivers: Trading off socio-economic water supply and vegetation conservation under flood regime uncertainty

In ecosystems driven by water availability, plant community dynamics depend on complex interactions between vegetation, hydrology, and human water resources use. Along ephemeral rivers—where water availability is erratic—vegetation and people are particularly vulnerable to changes in each other's water use. Sensible management requires that water supply be maintained for people, while preserving ecosystem health. Meeting such requirements is challenging because of the unpredictable water availability. We applied information gap decision theory to an ecohydrological system model of the Kuiseb River environment in Namibia. Our aim was to identify the robustness of ecosystem and water management strategies to uncertainties in future flood regimes along ephemeral rivers. We evaluated the trade-offs between alternative performance criteria and their robustness to uncertainty to account for both (i) human demands for water supply and (ii) reducing the risk of species extinction caused by water mining. Increasing uncertainty of flood regime parameters reduced the performance under both objectives. Remarkably, the ecological objective (species coexistence) was more sensitive to uncertainty than the water supply objective. However, within each objective, the relative performance of different management strategies was insensitive to uncertainty. The ‘best’ management strategy was one that is tuned to the competitive species interactions in the Kuiseb environment. It regulates the biomass of the strongest competitor and, thus, at the same time decreases transpiration, thereby increasing groundwater storage and reducing pressure on less dominant species. This robust mutually acceptable strategy enables species persistence without markedly reducing the water supply for humans. This study emphasises the utility of ecohydrological models for resource management of water-controlled ecosystems. Although trade-offs were identified between alternative performance criteria and their robustness to uncertain future flood regimes, management strategies were identified that help to secure an ecologically sustainable water supply.

Design of coreless PCB transformers for power and signal isolation in a modular ADC system for power quality data acquisition

Available industrial energy meters offer high accuracy and reliability, but are typically expensive and low-bandwidth, making them poorly suited to multi-sensor data acquisition schemes and power quality analysis. An alternative measurement system is proposed in this paper that is highly modular, extensible and compact. To minimise cost, the device makes use of planar coreless PCB transformers to provide galvanic isolation for both power and data. Samples from multiple acquisition devices may be concentrated by a central processor before integration with existing host control systems. This paper focusses on the practical design and implementation of planar coreless PCB transformers to facilitate the module's isolated power, clock and data signal transfer. Calculations necessary to design coreless PCB transformers, and circuits designed for the transformer's practical application in the measurement module are presented. The designed transformer and each application circuit have been experimentally verified, with test data and conclusions made applicable to coreless PCB transformers in general.

A call for better care: the impact of postnatal contact services on women’s parenting confidence and experiences of postpartum care in Queensland, Australia

Background Universal postnatal contact services are provided in several Australian states, but their impact on women’s postnatal care experience has not been evaluated. Furthermore, there is lack of evidence or consensus about the optimal type and amount of postpartum care after hospital discharge for maternal outcomes. This study aimed to assess the impact of providing Universal Postnatal Contact Service (UPNCS) funding to public birthing facilities in Queensland, Australia on women’s postnatal care experiences, and associations between amount and type (telephone or home visits) of contact on parenting confidence, and perceived sufficiency and quality of postnatal care. Methods Data collected via retrospective survey of postnatal women (N = 3,724) were used to compare women who birthed in UPNCS-funded and non-UPNCS-funded facilities on parenting confidence, sufficiency of postnatal care, and perceived quality of postnatal care. Associations between receiving telephone and home visits and the same outcomes, regardless of UPNCS funding, were also assessed. Results Women who birthed in an UPNCS-funded facility were more likely to receive postnatal contact, but UPNCS funding was not associated with parenting confidence, or perceived sufficiency or perceived quality of care. Telephone contact was not associated with parenting confidence but had a positive dose–response association with perceived sufficiency and quality. Home visits were negatively associated with parenting confidence when 3 or more were received, had a positive dose–response association with perceived sufficiency and were positively associated with perceived quality when at least 6 were received. Conclusions Funding for UPNCS is unlikely to improve population levels of maternal parenting confidence, perceived sufficiency or quality of postpartum care. Where only minimal contact can be provided, telephone may be more effective than home visits for improving women’s perceived sufficiency and quality of care. Additional service initiatives may be needed to improve women’s parenting confidence.

Valuation of hospital bed-days released by infection control programs: A comparison of methods

We performed a contingent valuation survey to elicit the opportunity cost of bed-days consumed by healthcare-associated infections in 11 European hospitals. The opportunity cost of a bed-day was significantly lower than the accounting cost; median values were i72 and i929, respectively (P ! .001). Accounting methods overestimate the opportunity cost of bed-days...

Sharing of clinical data in a maternity setting: How do paper hand-held records and electronic health records compare for completeness?

Background Historically, the paper hand-held record (PHR) has been used for sharing information between hospital clinicians, general practitioners and pregnant women in a maternity shared-care environment. Recently in alignment with a National e-health agenda, an electronic health record (EHR) was introduced at an Australian tertiary maternity service to replace the PHR for collection and transfer of data. The aim of this study was to examine and compare the completeness of clinical data collected in a PHR and an EHR. Methods We undertook a comparative cohort design study to determine differences in completeness between data collected from maternity records in two phases. Phase 1 data were collected from the PHR and Phase 2 data from the EHR. Records were compared for completeness of best practice variables collected The primary outcome was the presence of best practice variables and the secondary outcomes were the differences in individual variables between the records. Results Ninety-four percent of paper medical charts were available in Phase 1 and 100% of records from an obstetric database in Phase 2. No PHR or EHR had a complete dataset of best practice variables. The variables with significant improvement in completeness of data documented in the EHR, compared with the PHR, were urine culture, glucose tolerance test, nuchal screening, morphology scans, folic acid advice, tobacco smoking, illicit drug assessment and domestic violence assessment (p = 0.001). Additionally the documentation of immunisations (pertussis, hepatitis B, varicella, fluvax) were markedly improved in the EHR (p = 0.001). The variables of blood pressure, proteinuria, blood group, antibody, rubella and syphilis status, showed no significant differences in completeness of recording. Conclusion This is the first paper to report on the comparison of clinical data collected on a PHR and EHR in a maternity shared-care setting. The use of an EHR demonstrated significant improvements to the collection of best practice variables. Additionally, the data in an EHR were more available to relevant clinical staff with the appropriate log-in and more easily retrieved than from the PHR. This study contributes to an under-researched area of determining data quality collected in patient records.

Current pre-hospital traumatic brain injury management in China

BACKGROUND Traumatic brain injury (TBI) is associated with mo st trauma-related deaths. Secondary brain injury is the leading cause of in-hospital deaths after traumatic brain injury. By early prevention and slowing of the initial pathophysiological mechanism of secondary brain injury, pre- hospital service can signifi cantly reduce case-fata lity rates of TBI. In China, the incidence of TBI is increasing and the proportion of severe TBI is much higher than that in other countries. The objective of this paper is to review the pre-hospital management of TBI in China. DATA SOURCES A literature search was conducted in January 2014 using the China National Knowledge Infrastructure (CNKI). Articles on the assessment and treatment of TBI in pre-hospital settings practiced by Chinese doctors were identified. The information on the assessment and treatment of hypoxemia, hypotension, and brain hern iation was extracted from the identifi ed articles. RESULTS Of the 471 articles identified, 65 met the selecti on criteria. The existing literature indicated that current practices of pre-hospital TBI management in China were sub-optimal and varied considerably across different regions. CONCLUSION Since pre-hospital care is the weakest part of Chinese emergency care, appropriate training programs on pre-hospital TBI management are urgently needed in China.

Subjective reasons why immigrant patients attend the emergency department

Background Some patients visit a hospital’s emergency department (ED) for reasons other than an urgent medical condition. There is evidence that this practice may differ among patients from different backgrounds. The objective of this study was to examine the reasons why patients from a non-English speaking background (NESB) and patients with an English speaking background but not born in Australia (ESB-NBA) visit the ED, as compared to patients from English-speaking backgrounds but born in Australia (ESB-BA). Methods A cross-sectional survey was conducted at the ED of a tertiary hospital in metropolitan Brisbane, Queensland, Australia. Over a four-month period patients who were assigned an Australasian Triage Scale score of 3, 4 or 5 were surveyed. Pearson chi-square test and multivariate logistic regression analyses were performed to examine the differences between the ESB and NESB patients’ reported reasons for attending the ED. Results A total of 828 patients participated in this study. Compared to ESB-BA patients NESB patients were less likely to consider contacting a general practitioner (GP) before attending the ED (Odds Ratios (OR) 0.6 (95% Confidence Interval (CI) 0.4–0.8, p < .05) While ESB-NBA were more likely to consider contacting a GP 1.7 (1.1–2.5, p < .05). Both the NESB patients and the ESB-NBA patients were far more likely than ESB-BA patients to report that they had visited the ED either because they do not have a GP (OR 7.9, 95% CI 4.7–13.4, p < .001) and 2.2 (95% CI 1.1–4.4, p < .05) respectively and less likely to think that the ED could deal with their problem better than a GP(OR 0.5 (95% CI 0.3–0.8, p < .05) and 0.7 (0.3–0.9, p < .05) respectively. The NESB patients also thought it would take too long to make an appointment to consult a GP (OR 6.2, 95% CI 3.7–10.4, p < 0.001). Conclusions NESB patients were the least likely to consider contacting a GP before attending hospital EDs. Educational interventions may help direct NESB people to the appropriate health services and therefore reduce the burden on tertiary hospitals ED.

Medication Management of Adult Patients Admitted to Hospital with Epilepsy, Seizure or Convulsion

Background: An inpatient medication chart review at the Gold Coast Hospital identified shortcomings with the prescribing and monitoring of antiepileptic medications. Aim: To evaluate medication management of patients with epilepsy, seizure or convulsion; to map their transition through the health system; and to identify lifestyle behaviours that may lead to overt risks for seizure occurrence. Method: A retrospective observational audit of adult patients (16 years and over) admitted to hospital with a diagnosis of epilepsy, seizure or convulsion from 1 to 31 January 2012. Results: Majority of the 62 episodes of care investigated involved patients who were discharged directly from the ED (68%). Only 30% of all patients discharged from an inpatient unit received a discharge medication record from a pharmacist. Non-adherence with antiepileptic medications, alcohol and/ or recreational drug use and prescription medication misuse were identified as overt risks for seizure occurrence. Conclusion: Valuable insights were gained into the management of seizure patients. The role of the ED pharmacist was reviewed to focus on high-risk seizure patients. An increase in the provision of discharge medication records and patient education on the overt risks for seizure occurrence is needed.

Meta-regulation approach to raise social accountability In global supply firms

This Article proposes a meta-regulation approach to address the gap between the objectives, commitment, practice and outcome in the accountability practice of the global supply chain in the developing countries. The literatures on the accountability practice in the global supply chains typically focuses on the strategies for raising corporate social accountability standards in multinational buying firms and seldom focuses on this strategies in the outsourced firms in the developing countries. This article tries to fill this void by examining the situation in Bangladesh, the third largest RMG supply country in the world. It conceptualizes a meta-regulation approach with the aim of raising social accountability practice in this industry. It shows that this regulation approach is suitable to effectively raise this practice standard in a perspective where the non-legal drivers are meagrely low, global buying firms are highly profit driven and the governmental agencies are either inadequate or highly corrupt.