Pandemic (H1N1) Influenza 2009 and Australian emergency departments : implications for policy, practice and pandemic preparedness

Objective: To describe the reported impact of Pandemic (H1N1) 2009 on EDs, so as to inform future pandemic policy, planning and response management. Methods: This study comprised an issue and theme analysis of publicly accessible literature, data from jurisdictional health departments, and data obtained from two electronic surveys of ED directors and ED staff. The issues identified formed the basis of policy analysis and evaluation. Results: Pandemic (H1N1) 2009 had a significant impact on EDs with presentation for patients with ‘influenza-like illness’ up to three times that of the same time in previous years. Staff reported a range of issues, including poor awareness of pandemic plans, patient and family aggression, chaotic information flow to themselves and the public, heightened stress related to increased workloads and lower levels of staffing due to illness, family care duties and redeployment of staff to flu clinics. Staff identified considerable discomfort associated with prolonged times wearing personal protective equipment. Staff believed that the care of non-flu patients was compromised during the pandemic as a result of overwork, distraction from core business and the difficulties associated with accommodating infectious patients in an environment that was not conducive. Conclusions: This paper describes the breadth of the impact of pandemics on ED operations. It identifies a need to address a range of industrial, management and procedural issues. In particular, there is a need for a single authoritative source of information, the re-engineering of EDs to accommodate infectious patients and organizational changes to enable rapid deployment of alternative sources of care.

Telephone support to rural and remote patients with heart failure : the Chronic Heart failure Assessment by Telephone (CHAT) study

Background Heart failure (HF) remains a condition with high morbidity and mortality. We tested a telephone support strategy to reduce major events in rural and remote Australians with HF, who have limited healthcare access. Telephone support comprised an interactive telecommunication software tool (TeleWatch) with follow-up by trained cardiac nurses. Methods Patients with a general practice (GP) diagnosis of HF were randomised to usual care (UC) or UC and telephone support intervention (UC+I) using a cluster design involving 143 GPs throughout Australia. Patients were followed for 12 months. The primary end-point was the Packer clinical composite score. Secondary end-points included hospitalisation for any cause, death or hospitalisation, as well as HF hospitalisation. Results Four hundred and five patients were randomised into CHAT. Patients were well matched at baseline for key demographic variables. The primary end-point of the Packer Score was not different between the two groups (P=0.98), although more patients improved with UC+I. There were fewer patients hospitalised for any cause (74 versus 114, adjusted HR 0.67 [95% CI 0.50-0.89], p=0.006) and who died or were hospitalised (89 versus 124, adjusted HR 0.70 [95% CI 0.53 – 0.92], p=0.011), in the UC+I vs UC group. HF hospitalisations were reduced with UC+I (23 versus 35, adjusted HR 0.81 [95% CI 0.44 – 1.38]), although this was not significant (p=0.43). There were 16 deaths in the UC group and 17 in the UC+I group (p=0.43). Conclusions Although no difference was observed in the primary end-point of CHAT (Packer composite score), UC+I significantly reduced the number of HF patients hospitalised amongst a rural and remote cohort. These data suggest that telephone support may be an efficacious approach to improve clinical outcomes in rural and remote HF patients.

How do allied health professionals evaluate new models of care? What are we measuring and why?

The aim of this study was to identify what outcome measures or quality indicators are being used to evaluate advanced and new roles in nine allied health professions and whether the measures are evaluating outcomes of interest to the patient, the clinician, or the healthcare provider. A systematic search strategy was used. Medical and allied health databases were searched and relevant articles extracted. Relevant studies with at least 1 outcome measure were evaluated. A total of 106 articles were identified that described advanced roles, however, only 23 of these described an outcome measure in sufficient detail to be included for review. The majority of the reported measures fit into the economic and process categories. The most reported outcome related to patients was satisfaction surveys. Measures of patient health outcomes were infrequently reported. It is unclear from the studies evaluated whether new models of allied healthcare can be shown to be as safe and effective as traditional care for a given procedure. Outcome measures chosen to evaluate these services often reflect organizational need and not patient outcomes. Organizations need to ensure that high-quality performance measures are chosen to evaluate the success of new health service innovations. There needs to be a move away from in-house type surveys that add little or no valid evidence as to the effect of a new innovation. More importance needs to be placed on patient outcomes as a measure of the quality of allied health interventions.

Development and testing of an iPad application for teaching self-management to heart failure patients. (Nursing/Allied Health Professional Investigator Award)- Abstract

Purpose: Heart failure (HF) is the leading cause of hospitalization and significant burden to the health care system in Australia. To reduce hospitalizations, multidisciplinary approaches and enhance self-management programs have been strongly advocated for HF patients globally. HF patients who can effectively manage their symptoms and adhere to complex medicine regimes will experience fewer hospitalizations. Research indicates that information technologies (IT) have a significant role in providing support to promote patients' self-management skills. The iPad utilizes user-friendly interfaces and to date an application for HF patient education has not been developed. This project aimed to develop the HF iPad teaching application in the way that would be engaging, interactive and simple to follow and usable for patients' carers and health care workers within both the hospital and community setting. Methods: The design for the development and evaluation of the application consisted of two action research cycles. Each cycle included 3 phases of testing and feedback from three groups comprising IT team, HF experts and patients. All patient education materials of the application were derived from national and international evidence based practice guidelines and patient self-care recommendations. Results: The iPad application has animated anatomy and physiology that simply and clearly teaches the concepts of the normal heart and the heart in failure. Patient Avatars throughout the application can be changed to reflect the sex and culture of the patient. There is voice-over presenting a script developed by the heart failure expert panel. Additional engagement processes included points of interaction throughout the application with touch screen responses and the ability of the patient to enter their weight and this data is secured and transferred to the clinic nurse and/or research data set. The application has been used independently, for instance, at home or using headphones in a clinic waiting room or most commonly to aid a nurse-led HF consultation. Conclusion: This project utilized iPad as an educational tool to standardize HF education from nurses who are not always heart failure specialists. Furthermore, study is currently ongoing to evaluate of the effectiveness of this tool on patient outcomes and to develop several specifically designed cultural adaptations [Hispanic (USA), Aboriginal (Australia), and Maori (New Zealand)].

Paradoxes of participation : non-union workplace partnerships in John Lewis

The extent to which workplace partnership delivers mutual gains is subject to considerable debate amongst practitioners and scholars. One of the oldest and largest examples of workplace partnership is the John Lewis Partnership that began using forms of non-union employee representation in 1929. Despite ongoing interest from researchers in employee representation, and specifically non-union forms of employee voice, there have been few in-depth studies of the Partnership's organisational structure and practices since the 1980s. This paper explores in detail the operation of representation structures in the John Lewis Partnership, which is a significant case of non-union workplace partnership with the potential for mutual gains. A key finding of the paper was that the decision-making structures that characterise the Partnership, and that are protected by a constitution, are under constant threat from the discursive struggle to define partnership in a way that privileges managerial interests. The paper argues, therefore, that mutual gains need to be secured both structurally and discursively to address the tensions and paradoxes at the heart of debates about the meaning and aims of employee representation.

The social construction of prostitution in Californian 'John' Schools

The existence of prostitution in society continues to be a highly contested issue in both political and social arenas. With traditional criminal justice methods to address prostitution focussing predominantly on sex workers, newly formed initiatives have been created to target the demand side of prostitution. ‘John Schools’ – diversionary programs for clients, or ‘johns’ who have been arrested for prostitution offences – aim to educate participants on the various harms and risks associated with such behaviour and claim to provide an innovative means to reduce prostitution by decreasing demand for sexual services. It is evident however, that these programs perpetuate traditional social constructions of prostitution, characterising the act, and the actors, as sexually deviant. This paper examines the curriculum of these programs in order to identify how prostitution is constructed, firstly through the depiction of the victims in the program, and secondly through the characterisation of prostitution offenders. This paper argues that such initiatives merely extend the charge of sexual deviance from the sellers of sex to the buyers, and fail to acknowledge autonomy and choice for sex workers and clients.

Californian 'John Schools' and the social construction of prostitution

Within political and social arenas, prostitution continues to be a highly contested and debated issue. Generally conceptualised as a ‘problem’ in need of eradication, prostitution is strongly linked to immorality and deviance. The methods of addressing this phenomenon have experienced a shift from focusing predominantly on the sex worker, to directly targeting the clients of commercial sex. Such practices have resulted in the creation of policy initiatives such as ‘John Schools’—diversionary programs for clients, or ‘Johns’ who have been arrested for prostitution offences. The programs aim to educate participants on the various harms and risks associated with such behaviour and claim to offer a means to reduce prostitution by targeting the demand for sexual services. It is evident however, that these programs perpetuate traditional social constructions of prostitution, characterising the act, and the actors, as sexually deviant. This paper examines the curriculum of these programs in order to identify how prostitution is constructed—firstly through the depiction of the victims in the program and secondly through the characterisation of prostitution offenders—and argues that such initiatives merely extend the charge of sexual deviance from the sellers of sex to the buyers,whilst failing to acknowledge autonomy and choice for sex workers and clients.

Not all systematic reviews are systematic : a meta-review of the quality of systematic reviews for non-invasive remote monitoring in heart failure

Remote monitoring for heart failure has been evaluated in numerous systematic reviews. The aim of this meta-review was to appraise their quality and synthesise results. We electronically searched online databases, performed a forward citation search and hand-searched bibliographies. Systematic reviews of remote monitoring interventions that were used for surveillance of heart failure patients were included. Seven (41%) systematic reviews pooled results for meta-analysis. Eight (47%) considered all non-invasive remote monitoring strategies. Five (29%) focused on telemonitoring. Four (24%) included both non-invasive and invasive technologies. According to AMSTAR criteria, ten (58%) systematic reviews were of poor methodological quality. In high quality reviews, the relative risk of mortality in patients who received remote monitoring ranged from 0.53 (95% CI=0.29-0.96) to 0.88 (95% CI=0.76-1.01). High quality reviews also reported that remote monitoring reduced the relative risk of all-cause (0.52; 95% CI=0.28-0.96 to 0.96; 95% CI=0.90–1.03) and heart failure-related hospitalizations (0.72; 95% CI=0.64–0.81 to RR 0.79; 95% CI=0.67-0.94) and, as a consequence, healthcare costs. As the high quality reviews reported that remote monitoring reduced hospitalizations, mortality and healthcare costs, research efforts should now be directed towards optimising these interventions in preparation for more widespread implementation.

Issues and challenges associated with nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : a qualitative study

Aims and objectives To explore issues and challenges associated with nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory from the perspectives of senior nurses. Background Nurses play an important part in managing sedation because the prescription is usually given verbally directly from the cardiologist who is performing the procedure and typically, an anaesthetist is not present. Design A qualitative exploratory design was employed. Methods Semi-structured interviews with 23 nurses from 16 cardiac catheterisation laboratories across four states in Australia and also New Zealand were conducted. Data analysis followed the guide developed by Braun and Clark to identify the main themes. Results Major themes emerged from analysis regarding the lack of access to anaesthetists, the limitations of sedative medications, the barriers to effective patient monitoring and the impact that the increasing complexity of procedures has on patients' sedation requirements. Conclusions The most critical issue identified in this study is that current guidelines, which are meant to apply regardless of the clinical setting, are not practical for the cardiac catheterisation laboratory due to a lack of access to anaesthetists. Furthermore, this study has demonstrated that nurses hold concerns about the legitimacy of their practice in situations when they are required to perform tasks outside of clinical practice guidelines. To address nurses' concerns, it is proposed that new guidelines could be developed, which address the unique circumstances in which sedation is used in the cardiac catheterisation laboratory. Relevance to clinical practice Nurses need to possess advanced knowledge and skills in monitoring for the adverse effects of sedation. Several challenges impact on nurses' ability to monitor patients during procedural sedation and analgesia. Preprocedural patient education about what to expect from sedation is essential.

Directing democracy : competing interests and contested terrain in the John Lewis Partnership

The John Lewis Partnership is one of Europe’s largest models of employee ownership and has been operating a form of employee involvement and participation since its formation in 1929. It is frequently held up as a model of best practice (Cathcart, 2013) and has been described as a ‘workers’ paradise’ (Stummer and Lacey, 2001). At the beginning of 2012, the Deputy Prime Minister of the UK unveiled plans to create a ‘John Lewis Economy’ (Wintour, 2012). As John Lewis is being positioned at the heart of political and media discussions in the UK about alternatives to the corporate capitalist model of enterprise, it is vital that more is known about the experience of employee involvement and participation within the organisation. This article explores the ways in which the practice of employee involvement and participation has changed in John Lewis as a result of competing employee and managerial interests. Its contribution is a contemporary exploration of participation in the John Lewis Partnership and an examination of the ways in which management and employees contested the meaning and practice of employee involvement and participation as part of a ‘democracy project’, which culminated in significant changes and degeneration of the democratic structures.

The John Lewis model reveals the tensions and paradoxes at the heart of workplace democracy

Politicians of all parties have been keen to promote the ‘John Lewis model’ of industrial organisation, emphasising its features of employee ownership and workplace democracy. Dr Abby Cathcart’s research into the company shows that management and workers have different visions of what ‘partnership’ means, with ongoing struggle taking place via the organisation’s democratic structures. This, she argues, has stark implications for other organisations with partnership models that are less robust.

Review : "Ghosts...of the Civil Dead" -- John Hillcoat

Synopsis and review of the Australian prison film Ghosts...of the Civil Dead (John Hillcoat, 1988). Drawing heavily from the book In the Belly of the Beast by American author and long-term prisoner Jack Henry Abbott, as well as from the historical and philosophical work of Michel Foucault (the credits include ‘Foucault Authority – Simon During’), Ghosts… Of the Civil Dead is a searing critique of the so-called ‘new generation’ prison system developed in the United States and recently introduced in Australia. Director John Hillcoat and producer Evan English conducted extensive research for the film, including spending time at the National Institute of Corrections, a think tank in Colorado, and visiting numerous institutions like the ‘new Alcatraz’ at Marion Illinois and other maximum security prisons across the United States. Using a mix of professionals and non-actors, including former prisoners and prison guards, the ‘story’ was workshopped during a lengthy rehearsal period with many actual events and experiences of participants incorporated into the film. The end result deliberately blurs the line between American and Australian prison experience to make the political point that what had happened in the US – from where many events and characters, and much of the architecture and design of the prison are drawn – was beginning to happen in Australia. The film emphasises the vicious cycle of institutionalisation, and highlights the role state authorities play in manufacturing, provoking and manipulating violence and fear both in prisons and in wider society as a means to augment policing and surveillance of the population, to oppress the working classes, and to maintain the political status quo...

Using participatory action research for heart self care amongst indigenous patients

This paper describes the initial phases of the Fluid Watchers Pacific Rim project: a participatory action research project that involves developing and trialling an iPad app to provide monitoring and self-care for Indigenous Australians with heart failure. The development phase involved working with health experts, an IT team and Indigenous heart-failure patients through three cycles of development and critical reflection. This was followed by a small pilot study to examine the app’s effectiveness. In this paper, the researchers explain why IT-supported health education can be successful in decreasing re-hospitalisation and improving self-management skills. They describe the steps they took to ensure community participation and ownership of the project and present the findings of their pilot study. This pilot project suggests that an iPad app may be a practical and successful way to provide health-care support for Indigenous Australian heart-failure patients.