Innovation in clinical learning for the acute hospital environment : nursing grand rounds

The literature reports that workload factors affect nurses' ability to fully engage in continuing professional development. Hence the work environment in acute care calls for innovative approaches to achieve continuous development of nursing practice and work satisfaction. This study employs a one group pre-test post-test design to test the effectiveness of nursing grand rounds on nursing worklife satisfaction and work environment in an acute surgical ward. The effect of nursing grand rounds was measured using the Nursing Worklife Satisfaction Scale and the Practice Environment Scale. There was no change between pre- and post-test on these measures but trends were evident in some component scores. Statistical results were inconclusive but observational data indicated that nursing grand rounds was found to be feasible, well attended with tested processes for implementation in an acute care environment.

Dying in hospital: medical failure or natural outcomes?

The purpose of this study was to describe patterns of medical and nursing practice in the care of patients dying of oncological and hematological malignancies in the acute care setting in Australia. A tool validated in a similar American study was used to study the medical records of 100 consecutive patients who died of oncological or hematological malignancies before August 1999 at The Canberra Hospital in the Australian Capital Territory. The three major indicators of patterns of end-of-life care were documentation of Do Not Resuscitate (DNR) orders, evidence that the patient was considered dying, and the presence of a palliative care intention. Findings were that 88 patients were documented DNR, 63 patients' records suggested that the patient was dying, and 74 patients had evidence of a palliative care plan. Forty-six patients were documented DNR 2 days or less prior to death and, of these, 12 were documented the day of death. Similar patterns emerged for days between considered dying and death, and between palliative care goals and death. Sixty patients had active treatment in progress at the time of death. The late implementation of end-of-life management plans and the lack of consistency within these plans suggested that patients were subjected to medical interventions and investigations up to the time of death. Implications for palliative care teams include the need to educate health care staff and to plan and implement policy regarding the management of dying patients in the acute care setting. Although the health care system in Australia has cultural differences when compared to the American context, this research suggests that the treatment imperative to prolong life is similar to that found in American-based studies.

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

Impact of a stroke unit on length of hospital stay and in-hospital case fatality

Background and Purpose Randomized trials have demonstrated reduced morbidity and mortality with stroke unit care; however, the effect on length of stay, and hence the economic benefit, is less well-defined. In 2001, a multidisciplinary stroke unit was opened at our institution. We observed whether a stroke unit reduces length of stay and in-hospital case fatality when compared to admission to a general neurology/medical ward. Methods A retrospective study of 2 cohorts in the Foothills Medical Center in Calgary was conducted using administrative databases. We compared a cohort of stroke patients managed on general neurology/medical wards before 2001, with a similar cohort of stroke patients managed on a stroke unit after 2003. The length of stay was dichotomized after being centered to 7 days and the Charlson Index was dichotomized for analysis. Multivariable logistic regression was used to compare the length of stay and case fatality in 2 cohorts, adjusted for age, gender, and patient comorbid conditions defined by the Charlson Index. Results Average length of stay for patients on a stroke unit (n=2461) was 15 days vs 19 days for patients managed on general neurology/medical wards (n=1567). The proportion of patients with length of stay >7 days on general neurology/medical wards was 53.8% vs 44.4% on the stroke unit (difference 9.4%; P<0.0001). The adjusted odds of a length of stay >7 days was reduced by 30% (P<0.0001) on a stroke unit compared to general neurology/medical wards. Overall in-hospital case fatality was reduced by 4.5% with stroke unit care. Conclusions We observed a reduced length of stay and reduced in-hospital case-fatality in a stroke unit compared to general neurology/medical wards.

Trends in hospital admission for stroke in Calgary

Background Stroke incidence has fallen since 1950. Recent trends suggest that stroke incidence may be stabilizing or increasing. We investigated time trends in stroke occurrence and in-hospital morbidity and mortality in the Calgary Health Region. Methods All patients admitted to hospitals in the Calgary Health Region between 1994 and 2002 with a primary discharge diagnosis code (ICD-9 or ICD-10) of stroke were included. In-hospital strokes were also included. Stroke type, date of admission, age, gender,discharge disposition (died, discharged) and in-hospital complications (pneumonia, pulmonary embolism, deep venous thrombosis) were recorded. Poisson and simple linear regression was used to model time trends of occurrence by stroke type and age-group and to extrapolate future time trends. Results From 1994 to 2002, 11642 stroke events were observed. Of these, 9879 patients (84.8%) were discharged from hospital, 1763 (15.1%) died in hospital, and 591 (5.1%) developed in-hospital complications from pneumonia, pulmonary embolism or deep venous thrombosis. Both in-hospital mortality and complication rates were highest for hemorrhages. Over the period of study, the rate of stroke admission has remained stable. However, total numbers of stroke admission to hospital have faced a significant increase (p=0.012) due to the combination of increases in intracerebral hemorrhage (p=0.021) and ischemic stroke admissions (p=0.011). Sub-arachnoid hemorrhage rates have declined. In-hospital stroke mortality has experienced an overall decline due to a decrease in deaths from ischemic stroke, intracerebral hemorrhage and sub-arachnoid hemorrhage. Conclusions Although age-adjusted stroke occurrence rates were stable from 1994 to 2002, this is associated with both a sharp increase in the absolute number of stroke admissions and decline in proportional in-hospital mortality. Further research is needed into changes in stroke severity over time to understand the causes of declining in-hospital stroke mortality rates.

Fall rates in hospital rehabilitation units after individualised patient and staff education programmes: A pragmatic, stepped-wedge, cluster-randomised controlled trial

- Background Falls are the most frequent adverse events that are reported in hospitals. We examined the effectiveness of individualised falls-prevention education for patients, supported by training and feedback for staff, delivered as a ward-level programme. - Methods Eight rehabilitation units in general hospitals in Australia participated in this stepped-wedge, cluster-randomised study, undertaken during a 50 week period. Units were randomly assigned to intervention or control groups by use of computer-generated, random allocation sequences. We included patients admitted to the unit during the study with a Mini-Mental State Examination (MMSE) score of more than 23/30 to receive individualised education that was based on principles of changes in health behaviour from a trained health professional, in addition to usual care. We provided information about patients' goals, feedback about the ward environment, and perceived barriers to engagement in falls-prevention strategies to staff who were trained to support the uptake of strategies by patients. The coprimary outcome measures were patient rate of falls per 1000 patient-days and the proportion of patients who were fallers. All analyses were by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials registry, number ACTRN12612000877886). - Findings Between Jan 13, and Dec 27, 2013, 3606 patients were admitted to the eight units (n=1983 control period; n=1623 intervention period). There were fewer falls (n=196, 7·80/1000 patient-days vs n=380, 13·78/1000 patient-days, adjusted rate ratio 0·60 [robust 95% CI 0·42–0·94], p=0·003), injurious falls (n=66, 2·63/1000 patient-days vs 131, 4·75/1000 patient-days, 0·65 [robust 95% CI 0·42–0·88], p=0·006), and fallers (n=136 [8·38%] vs n=248 [12·51%] adjusted odds ratio 0·55 [robust 95% CI 0·38 to 0·81], p=0·003) in the intervention compared with the control group. There was no significant difference in length of stay (intervention median 11 days [IQR 7–19], control 10 days [6–18]). - Interpretation Individualised patient education programmes combined with training and feedback to staff added to usual care reduces the rates of falls and injurious falls in older patients in rehabilitation hospital-units.

Facial feature detection for in-car environment

Acoustically, vehicles are extremely noisy environments and as a consequence audio-only in-car voice recognition systems perform very poorly. Seeing that the visual modality is immune to acoustic noise, using the visual lip information from the driver is seen as a viable strategy in circumventing this problem. However, implementing such an approach requires a system being able to accurately locate and track the driver’s face and facial features in real-time. In this paper we present such an approach using the Viola-Jones algorithm. Using this system, we present our results which show that using the Viola-Jones approach is a suitable method of locating and tracking the driver’s lips despite the visual variability of illumination and head pose.

Professional education in built environment and design

Early and rich conversations with a range of stakeholders – academics, professionals and graduates in their early years of practice – quickly clarified that the singular challenge for most parties centres on the ways in which courses prepare graduates for the pace, diversity and flux of contemporary professional practice.---------In pursuing understanding of this central challenge this study has focused on new graduates in BED disciplines by canvassing their views and those of two other major stakeholder groups (academic staff and professional practitioners in the disciplines studied). The first crucial years of a young graduate’s life in the workforce are shaped by a number of factors including the quality of the transition-to-work experience. The quality of this life-shaping transition is dependent on a range of factors including the ways in which graduates are educated in universities, their personal developmental characteristics and those of the professional people around them and the preparedness of workplaces and other professional groups to guide new recruits through the transition experience. This study makes recommendations about how the variations in transition experience, resulting from the vagaries of all these factors across a range of worksites, may be better understood, perhaps normalised, and, at least, supported. . Early and rich conversations with a range of stakeholders – academics, professionals and graduates in their early years of practice – quickly clarified that the singular challenge for most parties centres on the ways in which courses prepare graduates for the pace, diversity and flux of contemporary professional practice. The study proceeded through literature review, focus group interviews, national online survey and workshops. Through all these methods a number of challenges and factors essential to the transition experience, and the quality of education which precedes it, were identified. Firstly the study found further evidence of the importance of higher-order graduate capabilities, namely, the development of judgment, critical enquiry and strategic thinking. Alongside these capabilities the importance of the development of emotional intelligence, particularly interpersonal and social skills, was stressed by all stakeholders. At the time of writing the global economic crisis was providing challenges to the sector and its young graduates. This phenomenon proved the value of the development of resilience and persistence in graduates, the education system was called upon by all stakeholders as a place where the future-proofing of neophytes would ensure that the unknown challenges of the future could also be confronted. The study found that the challenges of transition to work are best supported by authentic undergraduate experiences both on and off campus, inside and outside classrooms, and that commencing professional life is made easier for new graduates when university courses and workplace settings develop, sustain and support high standards and high expectations of students. All these findings indicate the importance of stakeholder expectations, roles and responsibilities in respect of the transition-to-work experience. Whilst full agreement about how these things should occur is not necessary, a process (amongst stakeholders) which seeks value alignment around transition through discussion, debate and agenda-setting would probably assist to address what is seen as a major challenge in built environment and design education.

Lip detection for audio-visual speech recognition in-car environment

Acoustically, car cabins are extremely noisy and as a consequence audio-only, in-car voice recognition systems perform poorly. As the visual modality is immune to acoustic noise, using the visual lip information from the driver is seen as a viable strategy in circumventing this problem by using audio visual automatic speech recognition (AVASR). However, implementing AVASR requires a system being able to accurately locate and track the drivers face and lip area in real-time. In this paper we present such an approach using the Viola-Jones algorithm. Using the AVICAR [1] in-car database, we show that the Viola- Jones approach is a suitable method of locating and tracking the driver’s lips despite the visual variability of illumination and head pose for audio-visual speech recognition system.

Micro-family-owned businesses in hostile environment : future engine for growth?

Using panel data from the four waves of the Indonesia Family Life Survey in 1993, 1997, 2000 and 2007 we investigate the prerequisite for and contribution of micro-family-businesses to economic development. We find that family-owned firms are on average fairly profitable compared with the industrial sector profit standard. Failure rates between 1997 and 2000 are very low (about 10%), while the industrial sector experimented a massive shakeout of about 33% in the wake of the 1997 crisis (Ter Wengel & Rodriguez, 2006), with an increase in the number of family-businesses between the two years of observation. This paper contributes to the economics of entrepreneurship studies by continuing the discussion of entrepreneurship in hostile business environments (Baumol, 1990; Sobel, 2008).