Setting hospital infection control policy : a decision-making framework incorporating health economics and healthcare epidemiology

Background: Reducing rates of healthcare acquired infection has been identified by the Australian Commission on Safety and Quality in Health Care as a national priority. One of the goals is the prevention of central venous catheter-related bloodstream infection (CR-BSI). At least 3,500 cases of CR-BSI occur annually in Australian hospitals, resulting in unnecessary deaths and costs to the healthcare system between $25.7 and $95.3 million. Two approaches to preventing these infections have been proposed: use of antimicrobial catheters (A-CVCs); or a catheter care and management ‘bundle’. Given finite healthcare budgets, decisions about the optimal infection control policy require consideration of the effectiveness and value for money of each approach. Objectives: The aim of this research is to use a rational economic framework to inform efficient infection control policy relating to the prevention of CR-BSI in the intensive care unit. It addresses three questions relating to decision-making in this area: 1. Is additional investment in activities aimed at preventing CR-BSI an efficient use of healthcare resources? 2. What is the optimal infection control strategy from amongst the two major approaches that have been proposed to prevent CR-BSI? 3. What uncertainty is there in this decision and can a research agenda to improve decision-making in this area be identified? Methods: A decision analytic model-based economic evaluation was undertaken to identify an efficient approach to preventing CR-BSI in Queensland Health intensive care units. A Markov model was developed in conjunction with a panel of clinical experts which described the epidemiology and prognosis of CR-BSI. The model was parameterised using data systematically identified from the published literature and extracted from routine databases. The quality of data used in the model and its validity to clinical experts and sensitivity to modelling assumptions was assessed. Two separate economic evaluations were conducted. The first evaluation compared all commercially available A-CVCs alongside uncoated catheters to identify which was cost-effective for routine use. The uncertainty in this decision was estimated along with the value of collecting further information to inform the decision. The second evaluation compared the use of A-CVCs to a catheter care bundle. We were unable to estimate the cost of the bundle because it is unclear what the full resource requirements are for its implementation, and what the value of these would be in an Australian context. As such we undertook a threshold analysis to identify the cost and effectiveness thresholds at which a hypothetical bundle would dominate the use of A-CVCs under various clinical scenarios. Results: In the first evaluation of A-CVCs, the findings from the baseline analysis, in which uncertainty is not considered, show that the use of any of the four A-CVCs will result in health gains accompanied by cost-savings. The MR catheters dominate the baseline analysis generating 1.64 QALYs and cost-savings of $130,289 per 1.000 catheters. With uncertainty, and based on current information, the MR catheters remain the optimal decision and return the highest average net monetary benefits ($948 per catheter) relative to all other catheter types. This conclusion was robust to all scenarios tested, however, the probability of error in this conclusion is high, 62% in the baseline scenario. Using a value of $40,000 per QALY, the expected value of perfect information associated with this decision is $7.3 million. An analysis of the expected value of perfect information for individual parameters suggests that it may be worthwhile for future research to focus on providing better estimates of the mortality attributable to CR-BSI and the effectiveness of both SPC and CH/SSD (int/ext) catheters. In the second evaluation of the catheter care bundle relative to A-CVCs, the results which do not consider uncertainty indicate that a bundle must achieve a relative risk of CR-BSI of at least 0.45 to be cost-effective relative to MR catheters. If the bundle can reduce rates of infection from 2.5% to effectively zero, it is cost-effective relative to MR catheters if national implementation costs are less than $2.6 million ($56,610 per ICU). If the bundle can achieve a relative risk of 0.34 (comparable to that reported in the literature) it is cost-effective, relative to MR catheters, if costs over an 18 month period are below $613,795 nationally ($13,343 per ICU). Once uncertainty in the decision is considered, the cost threshold for the bundle increases to $2.2 million. Therefore, if each of the 46 Level III ICUs could implement an 18 month catheter care bundle for less than $47,826 each, this approach would be cost effective relative to A-CVCs. However, the uncertainty is substantial and the probability of error in concluding that the bundle is the cost-effective approach at a cost of $2.2 million is 89%. Conclusions: This work highlights that infection control to prevent CR-BSI is an efficient use of healthcare resources in the Australian context. If there is no further investment in infection control, an opportunity cost is incurred, which is the potential for a more efficient healthcare system. Minocycline/rifampicin catheters are the optimal choice of antimicrobial catheter for routine use in Australian Level III ICUs, however, if a catheter care bundle implemented in Australia was as effective as those used in the large studies in the United States it would be preferred over the catheters if it was able to be implemented for less than $47,826 per Level III ICU. Uncertainty is very high in this decision and arises from multiple sources. There are likely greater costs to this uncertainty for A-CVCs, which may carry hidden costs, than there are for a catheter care bundle, which is more likely to provide indirect benefits to clinical practice and patient safety. Research into the mortality attributable to CR-BSI, the effectiveness of SPC and CH/SSD (int/ext) catheters and the cost and effectiveness of a catheter care bundle in Australia should be prioritised to reduce uncertainty in this decision. This thesis provides the economic evidence to inform one area of infection control, but there are many other infection control decisions for which information about the cost-effectiveness of competing interventions does not exist. This work highlights some of the challenges and benefits to generating and using economic evidence for infection control decision-making and provides support for commissioning more research into the cost-effectiveness of infection control.

Future-proofing : the academic library’s role in e-research support

Purpose – The paper describes a project created to enhance e-research support activities within an Australian university, based on environmental scanning of e-research activities and funding both nationally and internationally. Participation by the university library is also described.----- Design/methodology/approach – The paper uses a case study that describes the stages of a project undertaken to develop an academic library’s capacity to offer e-research support to its institution’s research community.----- Findings – While the outcomes of the project have been successfully achieved, the work needs to be continued and eventually mainstreamed as core business in order to keep pace with developments in e-research. The continual skilling up of the university’s researchers and research support staff in e-research activities is imperative in reaching the goal of becoming a highly competitive research institution.----- Research limitations/implications – Although a single case study, the work has been contextualised within the national research agenda.----- Practical implications – The paper provides a project model that can adapted within an academic library without external or specialist skills. It is also scalable and can be applied at a divisional or broader level.----- Originality/value – The paper highlights the drivers for research investment in Australia and provides a model of how building e-research support activities can leverage this investment and contribute towards successful research activity.

Two voices : the marginalised body as a voice & Imperfect Offerings a novel

This thesis investigates the phenomenon of self-harm as a form of political protest using two different, but complementary, methods of inquiry: a theoretical research project and a novel. Through these two approaches, to the same research problem, I examine how we can re-position the body that self-harms in political protest from weapon to voice; and in doing so find a path towards ethical and equitable dialogue between marginalised and mainstream communities. The theoretical, or academic, portion of the thesis examines self-harm as protest, positing these acts as a form of tactical selfharm, and acknowledge its emergence as a voice for the otherwise silenced in the public sphere. Through the use of phenomenology and feminist theory I examine the body as site for political agency, the circumstances which surround the use of the body for protest, and the reaction to tactical self-harm by the individual and the state. Using Bakhtin’s concept of dialogism, and the dialogic space I propose that by ‘hearing’ the body engaged in tactical selfharm we come closer to entering into an ethical dialogue with the otherwise silenced in our communities (locally, nationally and globally). The novel, Imperfect Offerings, explores these ideas in a fictional world, and allows me to put faces, names and lives to those who are compelled to harm their bodies to be heard. Also using Bakhtin’s framework I encourage a dialogue between the critical and creative parts of the thesis, challenging the traditional paradigm of creative PhD projects as creative work and exegesis.

Preparation of future weather data to study the impact of climate change on buildings

The dynamic interaction between building systems and external climate is extremely complex, involving a large number of difficult-to-predict variables. In order to study the impact of climate change on the built environment, the use of building simulation techniques together with forecast weather data are often necessary. Since most of building simulation programs require hourly meteorological input data for their thermal comfort and energy evaluation, the provision of suitable weather data becomes critical. In this paper, the methods used to prepare future weather data for the study of the impact of climate change are reviewed. The advantages and disadvantages of each method are discussed. The inherent relationship between these methods is also illustrated. Based on these discussions and the analysis of Australian historic climatic data, an effective framework and procedure to generate future hourly weather data is presented. It is shown that this method is not only able to deal with different levels of available information regarding the climate change, but also can retain the key characters of a “typical” year weather data for a desired period.

Future developments in chest pain diagnosis and management

Much of the focus of research on patients with chest pain is directed at technological advances in the diagnosis and management of acute coronary syndrome (ACS), pulmonary embolism (PE), and acute aortic dissection (AAD), despite there being no significant difference at 4 years as regards mortality, ongoing chest pain, and quality of life between patients presenting to the emergency department with noncardiac chest pain and those with cardiac chest pain. This article examines future developments in the diagnosis and management of patients with suspected ACS, PE, AAD, gastrointestinal disease, and musculoskeletal chest pain.

Inventing future schools

A group of Australian researchers and designers have been working on ways to imagine, demonstrate and accelerate the use of ICT that extend learning relationships and environments to include the classroom, home and local community. These learning projects aim to transform how students identify and interact with learning, subject areas, teachers, other students, family, organisations and more broadly how learning tools can create connections that permeate students' life worlds now and in the future.---------- It is our intention that such demonstrators must - Be simple, flexible, scalable and adaptive - Result in increased confidence in the use of ICT for both students and teachers - Offer opportunities for personalized learning - Promote new and effective learning partnerships between students, teachers and families. - Extend the learning experience to include other environments both local and virtual. - Inspire further innovation - Provide solutions to current limitations---------- Presenting Innovation in Practice - Innovative ICT projects currently being used by students in schools, at home and in the community - Stories of use from teacher, student, and other stakeholder perspectives - Lessons learnt so far: a design perspective - Surprising and inspiring opportunities

In search of Chinese jurisprudence : does Chinese legal tradition have a place in China's future?

Questions the extent to which Westerrn commercial laws adopted by China, particularly in its Company Laws of 1993 and 1995, are comptaible with China's different cultural and legal traditions. Suggests that Western concepts of the rule of law and of corporate governance are alient to China. Outlines the development of the Western legal tradition. based on Judaeo-Christian beliefs and legal rationalism. Compares this with the deveopment of the Chinese legal tradtion, based on Confucianism and legalism. Proposes ways in which the two traditions could be reconciled more effectively.

Narrative on the "Compliance and Regulatory Journal" : past, present and future

A conversation over a cup of coffee in late 2005 between Australasian Compliance Institute members Bill Dee and Dr Len Gainsford quickly turned to previously unsuccessful attempts to start a professional journal about compliance. There were two main issue - the difficultly in getting a professional journal off the ground and then sustaining a continuous flow of quality contributions. As practitioners, Bill and Len knew there was a considerable amount of 'thought and practice leadership' compliance material out there but they also knew that such material had not been presented in a relevant and interesting way. A foolish thought arose - could we start a professional journal that practitioners might actually read and use?

Applied theatre : performing the future

Objective: This paper provides an introduction to applied theatre and performance as a body of practice that may enhance the wellbeing of Indigenous communities. Applied theatre forms are conceptualized along a continuum from ‘performance-oriented’ to ‘participant-oriented’. Participant reflections are reported from a pilot workshop in Papua New Guinea, as a contribution to the evolution of theory and practice of applied theatre for health promotion in Indigenous communities. -------- Methods: Twelve Papua New Guinean nationals engaged in health promotion participated in the workshop. Participants were invited to reflect on the potential application of the theatre forms for their own health promotion practice. The workshop was qualitatively evaluated through a focus group at the conclusion of the workshop. --------- Results: Participants identified specific theatre forms which they could use in their own health promotion practice. Several participants articulated a view that participant-oriented forms were more likely to influence health-related behaviour than performance-oriented forms, in their cultural context. --------- Conclusions: The theatre-for-development literature does not yet clearly articulate how specific theatre forms may be more or less efficacious in terms of influencing health-related behaviour across cultural contexts. More extensive research into this question will yield significant benefits in terms of focusing practice culturally.

Behavioural biases and information disclosure laws relating to residential property sales : narrowing the gap between existing laws and calls for future reforms

Market failures involving the sale of complex merchandise, such as residential property, financial products and credit, have principally been attributed to information asymmetries. Existing legislative and regulatory responses were developed having regard to consumer protection policies based on traditional economic theories that focus on the notion of the ‘rational consumer’. Governmental responses therefore seek to impose disclosure obligations on sellers of complex goods or products to ensure that consumers have sufficient information upon which to make a decision. Emergent research, based on behavioural economics, challenges traditional ideas and instead focuses on the actual behaviour of consumers. This approach suggests that consumers as a whole do not necessarily benefit from mandatory disclosure because some, if not most, consumers do not pay attention to the disclosed information before they make a decision to purchase. The need for consumer policies to take consumer characteristics and behaviour into account is being increasingly recognised by governments, and most recently in the policy framework suggested by the Australian Productivity Commission

Current child restraint practice in Queensland, new legislation and future challenges

Correct use of child restraints reduces the risk of death and injury. Use of adult seat belts is better than being unrestrained but can result in injury to children who are too small. New Australian legislation extends the requirement for using child-specific restraints until children are 7 years old and thus requires more appropriate levels of protection for these children. As part of a larger study of injury prevention in Queensland, parents of children 0-9 years old were surveyed regarding their restraint practices before the introduction of the new legislation. The restraint status of 18% of the children would not be compliant with the new legislation, with the problem being more prevalent for 5-9 year olds (22%) than 0-4 year olds (16%). A high proportion of older children used an adult seat belt. Very few children aged 0-4 (1.3%) usually travelled in the front seat in contravention of the new requirement, but around 11% of this age group were reported as ever having done so. Usual travel in the front seat was higher among 5-9 year olds (8.5%), with more than half of the 5-9 year olds reported as ever having done so. Given the widespread use of adult seat belts by older children, there is a need to consider improving protection of children in the ‘gap’ between when the requirement for the child to use a booster ceases (effectively age 7) and when the adult belt is likely to actually fit the child (closer to age 9 or 10).

An evaluation of current and future botnet defenses

Botnets are large networks of compromised machines under the control of a bot master. These botnets constantly evolve their defences to allow the continuation of their malicious activities. The constant development of new botnet mitigation strategies and their subsequent defensive countermeasures has lead to a technological arms race, one which the bot masters have significant incentives to win. This dissertation analyzes the current and future states of the botnet arms race by introducing a taxonomy of botnet defences and a simulation framework for evaluating botnet techniques. The taxonomy covers current botnet techniques and highlights possible future techniques for further analysis under the simulation framework. This framework allows the evaluation of the effect techniques such as reputation systems and proof of work schemes have on the resources required to disable a peer-to-peer botnet. Given the increase in the resources required, our results suggest that the prospects of eliminating the botnet threat are limited.

Non-motorised public transport : the past, the present, the future

Non-motorized public transport (NMPT) involves cycle-powered vehicles that carry several passengers and a small amount of goods; and provide flexible hail-and-ride services. Effectively they are non-motorized taxis. NMPT is widespread in developing countries, where it caters for a wide range of mobility needs. Common forms include cycle-rickshaw (Bangladesh, India), becak (Indonesia), cyclos (Vietnam, Cambodia), bicitaxi (Columbia, Cuba). Over the last 10-15 years there has also been a re-emergence of NMPT in the form of pedicabs in many developed countries because of the operating flexibility of NMPT, its eco-sustainability, and its ability to operate where use of motorized vehicles is restricted. In particular, in cities such as Berlin, London, New York and Vancouver, pedicabs are making the transition from ‘novelty’ to ‘serious’ transport mode. This is creating new transport policy/planning questions about pedicab operation and integration. This paper examines the phenomenon of NMPT and where it is heading. It uses case studies from Asia/Latin America and Europe/North America to examine emerging NMPT issues and possible responses, and how this may affect NMPT in Australia and New Zealand where it is still somewhat a ‘novelty’ but has potential as both an opportunity and a challenge.

A new future for growth factor complexes as wound therapies?

Background: Topical administration of growth factors (GFs) has displayed some potential in wound healing, but variable efficacy, high doses and costs have hampered their implementation. Moreover, this approach ignores the fact that wound repair is driven by interactions between multiple GFs and extracellular matrix (ECM) proteins. The Problem: Deep dermal partial thickness burn (DDPTB) injuries are the most common burn presentation to pediatric hospitals and also represent the most difficult burn injury to manage clinically. DDPTB often repair with a hypertrophic scar. Wounds that close rapidly exhibit reduced scarring. Thus treatments that shorten the time taken to close DDTPB’s may coincidently reduce scarring. Basic/Clinical Science Advances: We have observed that multi-protein complexes comprised of IGF and IGF-binding proteins bound to the ECM protein vitronectin (VN) significantly enhance cellular functions relevant to wound repair in human skin keratinocytes. These responses require activation of both the IGF-1R and the VN-binding αv integrins. We have recently evaluated the wound healing potential of these GF:VN complexes in a porcine model of DDTPB injury. Clinical Care Relevance: This pilot study demonstrates that GF:VN complexes hold promise as a wound healing therapy. Enhanced healing responses were observed after treatment with nanogram doses of the GF:VN complexes in vitro and in vivo. Critically healing was achieved using substantially less GF than studies in which GFs alone have been used. Conclusion: These data suggest that coupling GFs to ECM proteins, such as VN, may ultimately prove to be an improved technique for the delivery of novel GF-based wound therapies.