Do palliative care health professionals settle for low level evidence?

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

Back to normal: A retrospective, cross-sectional study of the multi-factorial determinants of normal birth in Queensland, Australia

Background Currently, care providers and policy-makers internationally are working to promote normal birth. In Australia, such initiatives are being implemented without any evidence of the prevalence or determinants of normal birth as a multidimensional construct. This study aimed to better understand the determinants of normal birth (defined as without induction of labour, epidural/spinal/general anaesthesia, forceps/vacuum, caesarean birth, or episiotomy) using secondary analyses of data from a population survey of women in Queensland, Australia. Methods Women who birthed in Queensland during a two-week period in 2009 were mailed a survey approximately three months after birth. Women (n=772) provided retrospective data on their pregnancy, labour and birth preferences and experiences, socio-demographic characteristics, and reproductive history. A series of logistic regressions were conducted to determine factors associated with having labour, having a vaginal birth, and having a normal birth. Findings Overall, 81.9% of women had labour, 66.4% had a vaginal birth, and 29.6% had a normal birth. After adjusting for other significant factors, women had significantly higher odds of having labour if they birthed in a public hospital and had a pre-existing preference for a vaginal birth. Of women who had labour, 80.8% had a vaginal birth. Women who had labour had significantly higher odds of having a vaginal birth if they attended antenatal classes, did not have continuous fetal monitoring, felt able to ‘take their time’ in labour, and had a pre-existing preference for a vaginal birth. Of women who had a vaginal birth, 44.7% had a normal birth. Women who had a vaginal birth had significantly higher odds of having a normal birth if they birthed in a public hospital, birthed outside regular business hours, had mobility in labour, did not have continuous fetal monitoring, and were non-supine during birth. Conclusions These findings provide a strong foundation on which to base resources aimed at increasing informed decision-making for maternity care consumers, providers, and policy-makers alike. Research to evaluate the impact of modifying key clinical practices (e.g., supporting women׳s mobility during labour, facilitating non-supine positioning during birth) on the likelihood of a normal birth is an important next step.

Reconstructing identity of older people in using day care services in Taiwan: A grounded theory study

Adult day care centers provide a means whereby frail or disabled older people can remain living at home particularly when their family care-givers engage in waged work. In Taiwan, adult day care services appear to meet the cultural needs of both older people and their families for whom filial care is vital. Little research attention has been paid to the use of day care services in Taiwan, the uptake rate of which is low. This grounded theory study explored the ways in which older people and family care-givers construct meanings around the use of day care services in Taiwan. The research methodology drew on the theoretical tenets of symbolic interactionism and methods were informed by the grounded theory. In-depth interviews with 30 participants were undertaken. Reconstructing identity in a shifting world is the core category of the study and reflects a process of reframing whereby older people came to new definitions of social responsibility and independence within the context of the day care center. The implications of the findings is that the older people, rather than seeking to be relieved of social responsibilities, worked very hard to frame and reframe a social role. Rather than letting the institutions undermine or disrupt their identity, the older people worked to actively negotiate and redefine the meaning of self. Thus, although reluctant to come to use the services at the outset, they found a way to manage their lives independently. Social roles and responsibilities as older parents were retained. This study explored the process of meaning construction of day care use and the ways in which this process entailed a reconstruction of the identities of the participants. The evidence from this study underlines the importance of recognizing and acknowledging subjectively conceived identities as work that older people undertake, when in care, to render their lives meaningful.

Standardising practices improves clinical diabetic foot management: the Queensland Diabetic Foot Innovation Project, 2006-09

Objective. The aim of this paper is to report the clinical practice changes resulting from strategies to standardise diabetic foot clinical management in three diverse ambulatory service sites in Queensland, Australia. Methods. Multifaceted strategies were implemented in 2008, including: multidisciplinary teams, clinical pathways, clinical training, clinical indicators, and telehealth support. Prior to the intervention, none of the aforementioned strategies were used, except one site had a basic multidisciplinary team. A retrospective audit of consecutive patient records from July 2006 to June 2007 determined baseline clinical activity (n = 101).Aclinical pathway teleform was implemented as a clinical activity analyser in 2008 (n = 327) and followed up in 2009 (n = 406). Pre- and post-implementation data were analysed using Chi-square tests with a significance level set at P < 0.05. Results. There was an improvement in surveillance of the high risk population of 34% in 2008 and 19% in 2009, and treating according to risk of 15% in 2009 (P < 0.05). The documentation of all best-practice clinical activities performed improved 13–66% (P < 0.03). Conclusion. These findings support the use of multifaceted strategies to standardise practice and improve diabetic foot complications management in diverse ambulatory services.

A review of the economic consequences of a policy of universal leucodepletion as compared to existing practices

Leucodepletion, the removal of leucocytes from blood products improves the safety of blood transfusion by reducing adverse events associated with the incidental non-therapeutic transfusion of leucocytes. Leucodepletion has been shown to have clinical benefit for immuno-suppressed patients who require transfusion. The selective leucodepletion of blood products by bed side filtration for these patients has been widely practiced. This study investigated the economic consequences in Queensland of moving from a policy of selective leucodepletion to one of universal leucodepletion, that is providing all transfused patients with blood products leucodepleted during the manufacturing process. Using an analytic decision model a cost-effectiveness analysis was conducted. An ICER of $16.3M per life year gained was derived. Sensitivity analysis found this result to be robust to uncertainty in the parameters used in the model. This result argues against moving to a policy of universal leucodepletion. However during the course of the study the policy decision for universal leucodepletion was made and implemented in Queensland in October 2008. This study has concluded that cost-effectiveness is not an influential factor in policy decisions regarding quality and safety initiatives in the Australian blood sector.

Benchmarking clinical indicators of quality for Australian residential aged care facilities

To undertake exploratory benchmarking of a set of clinical indicators of quality care in residential care in Australia, data were collected from 107 residents within four medium-sized facilities (40–80 beds) in Brisbane, Australia. The proportion of residents in each sample facility with a particular clinical problem was compared with US Minimum Data Set quality indicator thresholds. Results demonstrated variability within and between clinical indicators, suggesting breadth of assessment using various clinical indicators of quality is an important factor when monitoring quality of care. More comprehensive and objective measures of quality of care would be of great assistance in determining and monitoring the effectiveness of residential aged care provision in Australia, particularly as demands for accountability by consumers and their families increase. What is known about the topic? The key to quality improvement is effective quality assessment, and one means of evaluating quality of care is through clinical outcomes. The Minimum Data Set quality indicators have been credited with improving quality in United States nursing homes. What does this paper add? The Clinical Care Indicators Tool was used to collect data on clinical outcomes, enabling comparison of data from a small Australian sample with American quality benchmarks to illustrate the utility of providing guidelines for interpretation. What are the implications for practitioners? Collecting and comparing clinical outcome data would enable practitioners to better understand the quality of care being provided and whether practices required review. The Clinical Care Indicator Tool could provide a comprehensive and systematic means of doing this, thus filling a gap in quality monitoring within Australian residential aged care.

Prevalence and determinants of the health promotion and risk reduction practices of younger female survivors of breast cancer

This thesis describes a discrete component of a larger mixed-method (survey and interview) study that explored the health-promotion and risk-reduction practices of younger premenopausal survivors of ovarian, breast and haematological cancers. This thesis outlines my distinct contribution to the larger study, which was to: (1) Produce a literature review that thoroughly explored all longer-term breast cancer treatment outcomes, and which outlined the health risks to survivors associated with these; (2) Describe and analyse the health-promotion and risk-reduction behaviours of nine younger female survivors of breast cancer as articulated in the qualitative interview dataset; and (3) Test the explanatory power of the Precede-Proceed theoretical framework underpinning the study in relation to the qualitative data from the breast cancer cohort. The thesis reveals that breast cancer survivors experienced many adverse outcomes as a result of treatment. While they generally engaged in healthy lifestyle practices, a lack of knowledge about many recommended health behaviours emerged throughout the interviews. The participants also described significant internal and external pressures to behave in certain ways because of the social norms surrounding the disease. This thesis also reports that the Precede-Proceed model is a generally robust approach to data collection, analysis and interpretation in the context of breast cancer survivorship. It provided plausible explanations for much of the data in this study. However, profound sociological and psychological implications arose during the analysis that were not effectively captured or explained by the theories underpinning the model. A sociological filter—such as Turner’s explanation of the meaning of the body and embodiment in the social sphere (Turner, 2008)—and the psychological concerns teased out in Mishel’s (1990) Uncertainty in Illness Theory, provided a useful dimension to the findings generated through the Precede-Proceed model. The thesis concludes with several recommendations for future research, clinical practice and education in this context.

Review of refugee mental health assessment: Best practices and recommendations

This article focuses on mental health assessment of refugees in clinical, educational and administrative-legal settings in order to synthesise research and practice designed to enhance and promote further development of culturally appropriate clinical assessment services during the refugee resettlement process. It specifically surveys research published over the last 25 years into the development, reliability measurement and validity testing of assessment instruments, which have been used with children, adolescents and adults from refugee backgrounds, prior to or following their arrival in a resettlement country, to determine whether the instruments meet established crosscultural standards of conceptual, functional, linguistic, technical and normative equivalence. The findings suggest that, although attempts have been made to develop internally reliable, appropriately normed tests for use with refugees from diverse cultural and linguistic backgrounds, matters of conceptual and linguistic equivalence and test–retest reliability are often overlooked. Implications of these oversights for underreporting refugees' mental health needs are considered. Efforts should also be directed towards development of culturally comparable, valid and reliable measures of refugee children's mental health and of refugee children's and adults' psychoeducational, neuropsychological and applied memory capabilities.

Proteomics science & society : the role of knowledge translation in moving towards clinical applications

Background: Outside the mass-spectrometer, proteomics research does not take place in a vacuum. It is affected by policies on funding and research infrastructure. Proteomics research both impacts and is impacted by potential clinical applications. It provides new techniques & clinically relevant findings, but the possibilities for such innovations (and thus the perception of the potential for the field by funders) are also impacted by regulatory practices and the readiness of the health sector to incorporate proteomics-related tools & findings. Key to this process is how knowledge is translated. Methods: We present preliminary results from a multi-year social science project, funded by the Canadian Institutes of Health Research, on the processes and motivations for knowledge translation in the health sciences. The proteomics case within this wider study uses qualitative methods to examine the interplay between proteomics science and regulatory and policy makers regarding clinical applications of proteomics. Results: Adopting an interactive format to encourage conference attendees’ feedback, our poster focuses on deficits in effective knowledge translation strategies from the laboratory to policy, clinical, & regulatory arenas. An analysis of the interviews conducted to date suggests five significant choke points: the changing priorities of funding agencies; the complexity of proteomics research; the organisation of proteomics research; the relationship of proteomics to genomics and other omics sciences; and conflict over the appropriate role of standardisation. Conclusion: We suggest that engagement with aspects of knowledge translation, such as those mentioned above, is crucially important for the eventual clinical application ofproteomics science on any meaningful scale.

National Institute for Clinical Studies Report for Phase 1, Evidence Uptake Network : Best Practice Community Care for Clients with Chronic Venous Leg Ulcers

Chronic leg ulcers cause significant pain, cost, decreased quality of life and morbidity for a considerable segment of the older population (Graham et al., 2003a). At any given time the prevalence of patients with open leg ulcers receiving treatment is between 0.11% - 0.18% (Briggs & Closs 2003). Chronic leg ulcers occur in approximately 1 - 2% of the over 60 population in the US, UK, Europe and Australia (Baker & Stacey 1994; Johnson 1995; Lees & Lambert 1992; Margolis et al. 2002). Considerable research has been undertaken to determine the best treatment practices that will aid in the management and the healing of these ulcers, and practical and effective strategies and techniques for healing venous leg ulcers have been trialled to demonstrate their beneficial effects (Nelson et al. 2004; Cullum et al. 2001)...

Standardising practices improves ambulatory diabetic foot management and reduces amputations : the Queensland Diabetic Foot Innovation Project, 2006 – 2009

Background Diabetic foot complications are recognised as the most common reason for diabetic related hospitalisation and lower extremity amputations. Multi-faceted strategies to reduce diabetic foot hospitalisation and amputation rates have been successful. However, most diabetic foot ulcers are managed in ambulatory settings where data availability is poor and studies limited. The project aimed to develop and evaluate strategies to improve the management of diabetic foot complications in three diverse ambulatory settings and measure the subsequent impact on ospitalisation and amputation. Methods Multifaceted strategies were implemented in 2008, including: multi-disciplinary teams, clinical pathways and training, clinical indicators, telehealth support and surveys. A retrospective audit of consecutive patient records from July 2006 – June 2007 determined baseline clinical indicators (n = 101). A clinical pathway teleform was implemented as a clinical record and clinical indicator analyser in all sites in 2008 (n = 327) and followed up in 2009 (n = 406). Results Prior to the intervention, clinical pathways were not used and multi-disciplinary teams were limited. There was an absolute improvement in treating according to risk of 15% in 2009 and surveillance of the high risk population of 34% and 19% in 2008 and 2009 respectively (p < 0.001). Improvements of 13 – 66% (p < 0.001) were recorded in 2008 for individual clinical activities to a performance > 92% in perfusion, ulcer depth, infection assessment and management, offloading and education. Hospitalisation impacts recorded reductions of up to 64% in amputation rates / 100,000 population (p < 0.001) and 24% average length of stay (p < 0.001) Conclusion These findings support the use of multi-faceted strategies in diverse ambulatory services to standardise practice, improve diabetic foot complications management and positively impact on hospitalisation outcomes. As of October 2010, these strategies had been rolled out to over 25 ambulatory sites, representing 66% of Queensland Health districts, managing 1,820 patients and 13,380 occasions of service, including 543 healed ulcer patients. It is expected that this number will rise dramatically as an incentive payment for the use of the teleform is expanded.

Baby-friendly hospital accreditation, in-hospital care practices and breastfeeding : a population based survey

OBJECTIVES: To investigate the effect of Baby-Friendly Hospital Initiative (BFHI) accreditation and hospital care practices on breastfeeding rates at 1 and 4 months. METHODS: All women who birthed in Queensland, Australia, from February 1 to May 31, 2010, received a survey 4 months postpartum. Maternal, infant, and hospital characteristics; pregnancy and birth complications; and infant feeding outcomes were measured. RESULTS: Sample size was 6752 women. Breastfeeding initiation rates were high (96%) and similar in BFHI-accredited and nonaccredited hospitals. After adjustment for significant maternal, infant, clinical, and hospital variables, women who birthed in BFHI-accredited hospitals had significantly lower odds of breastfeeding at 1 month (adjusted odds ratio 0.72, 95% confidence interval 0.58–0.90) than those who birthed in non–BFHI-accredited hospitals. BFHI accreditation did not affect the odds of breastfeeding at 4 months or exclusive breastfeeding at 1 or 4 months. Four in-hospital practices (early skin-to-skin contact, attempted breastfeeding within the first hour, rooming-in, and no in-hospital supplementation) were experienced by 70% to 80% of mothers, with 50.3% experiencing all 4. Women who experienced all 4 hospital practices had higher odds of breastfeeding at 1 month (adjusted odds ratio 2.20, 95% confidence interval 1.78–2.71) and 4 months (adjusted odds ratio 2.93, 95% confidence interval 2.40–3.60) than women who experienced fewer than 4. CONCLUSIONS: When breastfeeding-initiation rates are high and evidence-based practices that support breastfeeding are common within the hospital environment, BFHI accreditation per se has little effect on both exclusive or any breastfeeding rates.C

Nutrition care practices in hospital wards : results from the Nutrition Care Day Survey 2010.

Background & aim: This paper describes nutrition care practices in acute care hospitals across Australia and New Zealand. Methods: A survey on nutrition care practices in Australian and New Zealand hospitals was completed by Directors of dietetics departments of 56 hospitals that participated in the Australasian Nutrition Care Day Survey 2010. Results: Overall 370 wards representing various specialities participated in the study. Nutrition risk screening was conducted in 64% (n=234) of the wards. Seventy nine percent(n=185) of these wards reported using the Malnutrition Screening Tool, 16% using the Malnutrition Universal Screening Tool (n=37), and 5% using local tools (n=12). Nutrition risk rescreening was conducted in 14% (n=53) of the wards. More than half the wards referred patients at nutrition risk to dietitians and commenced a nutrition intervention protocol. Feeding assistance was provided in 89% of the wards. “Protected” meal times were implemented in 5% of the wards. Conclusion: A large number of acute care hospital wards in Australia and New Zealand do not comply with evidence-based practice guidelines for nutritional management of malnourished patients. This study also provides recommendations for practice.

Compounding practices in Queensland : experiences and perceptions of pharmacists and pharmacy students

Background: Changes in the roles of the contemporary pharmacist has seen a decline in the number and variety of extemporaneously compounded dosage forms. Pharmacy curricula reflect this change with a reduction in the emphasis on extemporaneous compounding practice. Aim: To elicit information about extemporaneously compounded dosage forms and perceptions of compounding practice from pharmacists and pharmacy students. Method: Self-administered surveys were mailed to 1063 pharmacists and offered online to 896 pharmacy undergraduates across the 4 years of a Bachelor of Pharmacy program in Queensland. Results: 382 (36%) pharmacists and 455 (51%) students completed the survey. Most pharmacists (96%) reported compounding a product in the 12 months prior to the survey, particularly semi-solids (89%) and liquids (64%) for external use. Most pharmacies (> 96%) owned basic compounding equipment, such as a slab and spatula, mortar and pestle, and cylindrical/conical measures. Half of the pharmacies used mechanical rather than electronic balances. Students expressed greater confidence in their ability to use basic compounding equipment and to perform basic compounding tasks as they progressed through the 4-year degree course. Pharmacists’ views on students’ ability to compound basic products at the end of their degree were generally similar to the proportion of final-year students who reported they could confidently complete the task. Conclusion: Despite a decline in extemporaneously compounded products in community pharmacy, pharmacy graduates need to be competent in compounding techniques.