Antimicrobial stewardship activities : a survey of Queensland hospitals

Objective: In 2011, the Australian Commission on Safety and Quality in Health Care (ACSQHC) recommended that all hospitals in Australia must have an Antimicrobial Stewardship (AMS) program by 2013. Nevertheless, little is known about current AMS activities. This study aimed to determine the AMS activities currently undertaken, and to identify gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. Methods: The AMS activities of 26 facilities from 15 hospital and health services in Queensland were surveyed during June 2012 to address strategies for effective AMS: implementing clinical guidelines, formulary restriction, reviewing antimicrobial prescribing, auditing antimicrobial use and selective reporting of susceptibility results. Results: The response rate was 62%. Nineteen percent had an AMS team (a dedicated multidisciplinary team consisting of a medically trained staff member and a pharmacist). All facilities had access to an electronic version of Therapeutic Guidelines: Antibiotic, with a further 50% developing local guidelines for antimicrobials. One-third of facilities had additional restrictions. Eighty-eight percent had advice for restricted antimicrobials from in-house infectious disease physicians or clinical microbiologists. Antimicrobials were monitored with feedback given to prescribers at point of care by 76% of facilities. Deficiencies reported as barriers to establishing AMS programs included: pharmacy resources, financial support by hospital management, and training and education in antimicrobial use. Conclusions: Several areas for improvement were identified: reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use. There also appears to be a lack of resources to support AMS programs in some facilities. What is known about the topic? The ACSQHC has recommended that all hospitals implement an AMS program by 2013 as a requirement of Standard 3 (Preventing and Controlling Healthcare-Associated Infections) of the National Safety and Quality Health Service Standards. The intent of AMS is to ensure appropriate prescribing of antimicrobials as part of the broader systems within a health service organisation to prevent and manage healthcare-associated infections, and improve patient safety and quality of care. This criterion also aligns closely with Standard 4: Medication Safety. Despite this recommendation, little is known about what AMS activities are undertaken in these facilities and what additional resources would be required in order to meet these national standards. What does the paper add? This is the first survey that has been conducted of public hospital and health services in Queensland, a large decentralised state in Australia. This paper describes what AMS activities are currently being undertaken, identifies practice gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. What are the implications for practitioners? Several areas for improvement such as reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use have been identified. In addition, there appears to be a lack of resources to support AMS programs in some facilities.

Government grants - an abrogation or management of risks?

New public management (NPFM), with its hands-on, private sector-style performance measurement, output control, parsimonious use of resources, disaggreation of public sector units and greater competition in the public sector, has significantly affected charitable and nonprofit organisations delivering community services (Hood, 1991; Dunleavy, 1994; George & Wilding, 2002). The literature indicates that nonprofit organisations under NPM believe they are doing more for less: while administration is increasing, core costs are not being met; their dependence on government funding comes at the expense of other funding strategies; and there are concerns about proportionality and power asymmetries in the relationship (Kerr & Savelsberg, 2001; Powell & Dalton, 2011; Smith, 2002, p. 175; Morris, 1999, 2000a). Government agencies are under increased pressure to do more with less, demonstrate value for money, measure social outcomes, not merely outputs and minimise political risk (Grant, 2008; McGreogor-Lowndes, 2008). Government-community service organisation relationships are often viewed as 'uneasy alliances' characterised by the pressures that come with the parties' differing roles and expectations and the pressures that come with the parties' differing roles and expectations and the pressurs of funding and security (Productivity Commission, 2010, p. 308; McGregor-Lowndes, 2008, p. 45; Morris, 200a). Significant community services are now delivered to citizens through such relationships, often to the most disadvantaged in the community, and it is important for this to be achieved with equity, efficiently and effectively. On one level, the welfare state was seen as a 'risk management system' for the poor, with the state mitigating the risks of sickness, job loss and old age (Giddens, 1999) with the subsequent neoliberalist outlook shifting this risk back to households (Hacker, 2006). At the core of this risk shift are written contracts. Vincent-Jones (1999,2006) has mapped how NPM is characterised by the use of written contracts for all manner of relations; e.g., relgulation of dealings between government agencies, between individual citizens and the state, and the creation of quais-markets of service providers and infrastructure partners. We take this lens of contracts to examine where risk falls in relation to the outsourcing of community services. First we examine the concept of risk. We consider how risk might be managed and apportioned between governments and community serivce organisations (CSOs) in grant agreements, which are quasiy-market transactions at best. This is informed by insights from the law and economics literature. Then, standard grant agreements covering several years in two jurisdictions - Australia and the United Kingdom - are analysed, to establish the risk allocation between government and CSOs. This is placed in the context of the reform agenda in both jurisdictions. In Australia this context is th enonprofit reforms built around the creation of a national charities regulator, and red tape reduction. In the United Kingdom, the backdrop is the THird Way agenda with its compacts, succeed by Big Society in a climate of austerity. These 'case studies' inform a discussion about who is best placed to bear and manage the risks of community service provision on behalf of government. We conclude by identifying the lessons to be learned from our analysis and possible pathways for further scholarship.

Energy Efficiency Resources for Undergraduate Engineering Education: Final Report

This report presents the findings of an investigation of energy efficiency resources for undergraduate engineering education, undertaken by web-based research, conversations with educators, and a university survey. The investigation draws on the results of a number of previous investigations undertaken by the research team for NFEE related to energy efficiency education and presents the following findings and recommendations, as explained in greater detail in the body of the report. The findings suggest that even though certain EE concepts and principles have been identified by lecturers as being important there is little to no coverage of a number of these concepts in some programs/courses. Similarly, many topics relating to the most important EE workforce skills and significant shortages as identified in industry research, do not rate highly in terms of both perceived importance by lecturers, or coverage within existing courses. Overall, these findings suggest that despite growing awareness of the importance of EE in both industry and academia, the current depth and breadth of EE content in courses does not reflect this. It confirms that efforts in these areas can be better supported.

Parents’ perception of their children’s participation in physical activity

This paper describes parents' survey and interview responses about their children's participation in physical activity which were collected for the second part of a three phase project funded by the Commonwealth Department of Health and Family Services: Health Advancement Project through the auspices of ACHPER. In the first phase of the project, an extensive data base was compiled on children's participation in physical activity; the second phase investigated parents' and teachers' perceptions of their children's and students' participation in physical activity. The third phase, which is now underway, will use the first two phases to develop a set of resources with which to advocate for policy, programs and educational strategies to serve the needs of young people in Australia most effectively in relation to physical activity.

Spatial governance: The metalanguage of spatiotemporal information and its infrastructure

‘Spatial governance’ involves a large number of situations where knowledge of place and time is important in achieving acceptable organisational outcomes. This paper argues that spatial governance calls for information-intensive activity in three main areas. The first establishes ‘authority’ in a legal entity to decide issues regarding resources within a territorial jurisdiction. The second involves planning the future use of resources. It engages a language of design, purpose, modeling, visualization, expectations and risk. The third involves monitoring of outcomes to see if expectations are met; and whether changes to authority and planning regimes need to be made in the light of experience. This engages a language of observing, recording, accounting, auditing, statistical indicators and accountability. ‘Authority’, ‘planning’ and ‘monitoring’ regimes can be constructed using a relatively small number of elements, in much the same way that a large number of words with recognisable meanings can be created using a relatively few standardised letters of the alphabet. Words can combine in a similar process of combinatorial explosion to create any message that can be imagined. Similarly, combining authority, planning and monitoring regimes can create a metalanguage of ‘spatial governance’ to give purpose, meaning and value to any spatiotemporal information system that can be imagined, described, interpreted and understood.

The practical potential of self-advocacy for improving safety outcomes for school-aged workers

Young workers are over-represented in workplace injury statistics and there is growing interest in addressing their vulnerability and safety exposure. Such concerns have been raised within a broader discursive framework of responsibilisation which has seen a transfer of responsibility for workplace safety from employer to worker. This article examines the potential for self-advocacy as a strategy for improving the safety of young workers through the provision of resources to articulate and act on workplace rights. The study utilises data derived from 48 group interviews involving 216 high school students (13–16 years of age) at 19 high schools in Queensland, Australia, who were asked to discuss their knowledge and experience of workplace rights and responsibilities. The limitations of the safety self-advocacy approach are explored, including the social, developmental and organisational issues that might affect the ability or willingness of school-aged workers to self-advocate. The findings reveal that the notion of self-advocacy is internalised by young people before they even enter the formal labour market but that in practice, attempts by young people to enact rights to safety are often dismissed or undermined.

Re-theorizing the “digital divide”: Identifying dimensions of social exclusion in contemporary media technologies

The digital divide is the disparancy in access to information, in the ability to communicate, and in the capacity to make information and communication serve full participation in the information society. Indeed, the conversation about the digital divide has developed over the last decade from a focus on connectivity and access to information and communication technologies, to a conversation that encompasses the ability to use them and to the utility that usage provides (Wei et al., 2011). However, this conversation, while transitioning from technology to the skills of the people that use them and to the fruits of their use is limited in its ability to take into account the social role of information and communication technologies (ICTs). One successful attempt in conceptualizing the social impact of the differences in access to and utilization of digital communication technologies, was developed by van Dijk (2005) whose sequential model for analyzing the divide states that: 1. Categorical inequalities in society produce an unequal distribution of resources; 2. An unequal distribution of resources causes unequal access to digital technologies; 3. Unequal access to digital technologies also depends on the characteristics of these technologies; 4. Unequal access to digital technologies brings about unequal participation in society; 5. Unequal participation in society reinforces categorical inequalities and unequal distributions of resources.” (p. 15) As van Dijk’s model demonstrates, the divide’s impact is the exclusion of individuals from participation. Still left to be defined are the “categorical inequalities,” the “resources,” the “characteristics of digital technologies,” and the different levels of “access” that result in differentiated levels of participation, as these change over time due to the evolving nature of technology and the dynamics of society. And most importantly, the meaning of “participation” in contemporary society needs to be determined as it is differentiated levels of participation that are the result of the divide and the engine of the ever-growing disparities. Our argument is structured in the following manner: We first claim that contemporary digital media differ from the previous generation of ICTs along four dimensions: They offer an abundance of information resources and communication channels when compared to the relative paucity of both in the past; they offer mobility as opposed to the stationary nature of their predecessors; they are interactive in that they provide users with the capability to design their own media environments in contrast to the dictated environs of previous architectures; and, they allow users to communicate utilizing multi forms of mediation, unlike the uniformity of sound or word that limited users in the past. We then submit that involvement in the information society calls for egalitarian access to all four dimensions of the user experience that make contemporary media different from their predecessors and that the ability to experience all four affects the levels in which humans partake in the shaping of society. The model being cyclical, we then discuss how lower levels of participation contribute to the enhancement of social inequalities. Finally, we discuss why participation is needed in order to achieve full membership in the information society and what political philosophy should govern policy solutions targeting the re-inclusion of those digitally excluded.

Development and validation of a multilevel model for predicting workload under routine and nonroutine conditions in an air traffic management center

Objective: The aim of this study was to develop a model capable of predicting variability in the mental workload experienced by frontline operators under routine and nonroutine conditions. Background: Excess workload is a risk that needs to be managed in safety-critical industries. Predictive models are needed to manage this risk effectively yet are difficult to develop. Much of the difficulty stems from the fact that workload prediction is a multilevel problem. Method: A multilevel workload model was developed in Study 1 with data collected from an en route air traffic management center. Dynamic density metrics were used to predict variability in workload within and between work units while controlling for variability among raters. The model was cross-validated in Studies 2 and 3 with the use of a high-fidelity simulator. Results: Reported workload generally remained within the bounds of the 90% prediction interval in Studies 2 and 3. Workload crossed the upper bound of the prediction interval only under nonroutine conditions. Qualitative analyses suggest that nonroutine events caused workload to cross the upper bound of the prediction interval because the controllers could not manage their workload strategically. Conclusion: The model performed well under both routine and nonroutine conditions and over different patterns of workload variation. Application: Workload prediction models can be used to support both strategic and tactical workload management. Strategic uses include the analysis of historical and projected workflows and the assessment of staffing needs. Tactical uses include the dynamic reallocation of resources to meet changes in demand.

Simulating the dissipation of two herbicides using micro paddy lysimeters

A set of packed micro paddy lysimeters, placed in a greenhouse, was used to simulate the dissipation of two herbicides, simetryn and thiobencarb, in a controlled environment. Data from a field monitoring study in 2003, including the soil condition and water balances, were used in the simulation. The herbicides were applied and monitored over a period of 21 d. The water balances under two water management scenarios, intermittent irrigation management (AI) and continuous irrigation management (CI), were simulated. In the AI scenario, the pattern of herbicide dissipation in the surface water of the field were simulated, following the first-order kinetics. In the CI scenario, similarity was observed in most lysimeter and field concentrations, but there were differences in some data points. Dissipation curves of both herbicides in the surface water of the two simulated scenarios were not significantly different (P > 0.05) from the field data except for intercept of the thiobencarb curve in the CI scenario. The distribution of simetryn and thiobencarb in the soil profile after simulation were also similar to the field data. The highest concentrations of both herbicides were found on the topsoil layer at 0-2.5 cm depth. Only a small amount of herbicides moved down to the deeper soil layers. Micro paddy lysimeters are thus a good alternative for the dissipation study of pesticides in the paddy environment.

Support services for higher degree research students: A survey of three Australian universities

A survey was conducted across three Australian universities to identify the types and format of support services available for higher degree research (HDR, or MA and Ph.D.) students. The services were classified with regards to availability, location and accessibility. A comparative tool was developed to help institutions categorise their services in terms of academic, administrative, social and settlement, language and miscellaneous (other) supports. All three universities showed similarities in the type of academic support services offered, while differing in social and settlement and language support services in terms of the location and the level of accessibility of these services. The study also examined the specific support services available for culturally and linguistically diverse (CALD) students. The three universities differed in their emphases in catering to CALD needs, with their allocation of resources reflecting these differences. The organisation of these services within the universities was further assessed to determine possible factors that may influence the effective delivery of these services, by considering HDR and CALD student specific issues. The findings and tools developed by this study may be useful to HDR supervisors and university administrators in identifying key support services to better improve outcomes for the HDR students and universities.

Are we there yet? Advancing women in Canada and Australia: Similar goals, different policies

Differences in opportunities and outcomes in the workplace are inherent in a free and competitive market. However when differences between individuals and groups are identified as resulting from particular policies, behaviours or attitudes, any resulting inequality may be identified as unfair. Increasingly, unfair disparities in societies and their workplaces are regularly challenged. Many of the unfair disparities are recognised as caused through unfair discrimination (Anker 1997). When defining discrimination, the International Labour Organization Convention (ILO) No. 111 defines it as “any distinction, exclusion or preference made on the basis of race, colour, sex, religion, political opinion, national extraction, or social origin, which has the effect of nullifying or impairing equality of opportunity or treatment in employment or occupation” (ILO, 1958). Yet, the argument for addressing this ideal of ‘equality of opportunity’ is complex. Ekmekci (2013) identifies the difficulties as the determination of whether any process should be based on equality of opportunity or equality of outcome. In addition, there is the difficulty of determining what exactly constitutes a process for addressing unfair disparity due to the haziness of what constitutes discrimination and controversy in the meaning as well as policy implications of equality (Tomei, 2003).

Evaluation of an intervention for patients with alcohol-related injuries: results of a mixed methods study

Objective: To explore the effect of education and training on the delivery of alcohol screening and brief intervention and referral to high-risk patients in a hospital setting. Main outcome measures included; delivery of training; practice change in relation to staff performing alcohol screening, brief intervention and referrals. Methods: Observational study design using mixed methods set in a tertiary referral hospital. Pre-post assessment of medical records and semi-structured interviews with key informants. Results: Routine screening for substance misuse (9% pre / 71.4% post) and wellbeing concerns (6.6% pre / 15 % post) was more frequent following the introduction of resources and staff participation in educational workshops. There was no evidence of a concomitant increase in delivery of brief intervention or referrals to services. Implementation challenges, including time constraints and staff attitudes, and enablers such as collaboration and visible pathways, were identified. Conclusion: Rates of patient screening increased, however barriers to delivery of brief intervention and referrals remained. Implementation strategies targeting specific barriers and enablers to introducing interventions are both required to improve the application of secondary prevention for patients in acute settings. Implications: Educational training, formalised liaison between services, systematised early intervention protocols, and continuous quality improvement processes will progress service delivery in this area.

The buffering effect of selection, optimization, and compensation strategy use on the relationship between problem solving demands and occupational well-being: A daily diary study

This study investigated within-person relationships between daily problem solving demands, selection, optimization, and compensation (SOC) strategy use, job satisfaction, and fatigue at work. Based on conservation of resources theory, it was hypothesized that high SOC strategy use boosts the positive relationship between problem solving demands and job satisfaction, and buffers the positive relationship between problem solving demands and fatigue. Using a daily diary study design, data were collected from 64 administrative employees who completed a general questionnaire and two daily online questionnaires over four work days. Multilevel analyses showed that problem solving demands were positively related to fatigue, but unrelated to job satisfaction. SOC strategy use was positively related to job satisfaction, but unrelated to fatigue. A buffering effect of high SOC strategy use on the demands-fatigue relationship was found, but no booster effect on the demands-satisfaction relationship. The results suggest that high SOC strategy use is a resource that protects employees from the negative effects of high problem solving demands.

Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: Systematic review and meta-analysis

Objective To assess the impact of exercise referral schemes on physical activity and health outcomes. Design Systematic review and meta-analysis. Data sources Medline, Embase, PsycINFO, Cochrane Library, ISI Web of Science, SPORTDiscus, and ongoing trial registries up to October 2009. We also checked study references. Study selection - Design: randomised controlled trials or non-randomised controlled (cluster or individual) studies published in peer review journals. - Population: sedentary individuals with or without medical diagnosis. - Exercise referral schemes defined as: clear referrals by primary care professionals to third party service providers to increase physical activity or exercise, physical activity or exercise programmes tailored to individuals, and initial assessment and monitoring throughout programmes. - Comparators: usual care, no intervention, or alternative exercise referral schemes. Results Eight randomised controlled trials met the inclusion criteria, comparing exercise referral schemes with usual care (six trials), alternative physical activity intervention (two), and an exercise referral scheme plus a self determination theory intervention (one). Compared with usual care, follow-up data for exercise referral schemes showed an increased number of participants who achieved 90-150 minutes of physical activity of at least moderate intensity per week (pooled relative risk 1.16, 95% confidence intervals 1.03 to 1.30) and a reduced level of depression (pooled standardised mean difference −0.82, −1.28 to −0.35). Evidence of a between group difference in physical activity of moderate or vigorous intensity or in other health outcomes was inconsistent at follow-up. We did not find any difference in outcomes between exercise referral schemes and the other two comparator groups. None of the included trials separately reported outcomes in individuals with specific medical diagnoses. Substantial heterogeneity in the quality and nature of the exercise referral schemes across studies might have contributed to the inconsistency in outcome findings. Conclusions Considerable uncertainty remains as to the effectiveness of exercise referral schemes for increasing physical activity, fitness, or health indicators, or whether they are an efficient use of resources for sedentary people with or without a medical diagnosis.

The clinical effectiveness and cost-effectiveness of exercise referral schemes: A systematic review and economic evaluation

- Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then refers the patient to a third-party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the individual. - Objective To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. - Data sources MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. - Methods Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. - Results Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. - Limitations We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. - Conclusions There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. - Funding The National Institute for Health Research Health Technology Assessment programme.