Referral to rehabilitation following traumatic brain injury: practitioners and the process of decision-making

The study aimed to examine the factors influencing referral to rehabilitation following traumatic brain injury (TBI) by using social problems theory as a conceptual model to focus on practitioners and the process of decision-making in two Australian hospitals. The research design involved semi-structured interviews with 18 practitioners and observations of 10 team meetings, and was part of a larger study on factors influencing referral to rehabilitation in the same settings. Analysis revealed that referral decisions were influenced primarily by practitioners' selection and their interpretation of clinical and non-clinical patient factors. Further, practitioners generally considered patient factors concurrently during an ongoing process of decision-making, with the combinations and interactions of these factors forming the basis for interpretations of problems and referral justifications. Key patient factors considered in referral decisions included functional and tracheostomy status, time since injury, age, family, place of residence and Indigenous status. However, rate and extent of progress, recovery potential, safety and burden of care, potential for independence and capacity to cope were five interpretative themes, which emerged as the justifications for referral decisions. The subsequent negotiation of referral based on patient factors was in turn shaped by the involvement of practitioners. While multi-disciplinary processes of decision-making were the norm, allied health professionals occupied a central role in referral to rehabilitation, and involvement of medical, nursing and allied health practitioners varied. Finally, the organizational pressures and resource constraints, combined with practitioners' assimilation of the broader efficiency agenda were central factors shaping referral. (C) 2004 Elsevier Ltd. All rights reserved.

The costs of caring for patients in a tertiary referral Australian intensive care unit

We determined the direct cost of an Intensive Care Unit (ICU) bed in a tertiary referral Australian ICU and the cost drivers thereof, by retrospectively analysing a number of prospectively designed Hospital- and Unit-specific electronic databases. The study period was a financial year, from 1 July 2002 to 30 June 2003. There were 1615 patients occupying 5692 fractional occupied bed days at a total cost of A$15,915,964, with an average length of stay of 3.69 days (range 0.5-77, median 1.06, interquartile range 2.33). The main cost driver not incorporated into this analysis was blood products (paid for centrally). The average costs of an ICU day and total stay per patient were A$2670 and A$9852 respectively. Staff-related charges were 68.76%, with consumables related expenditure making up 19.65%, clinical support services 9.55% and capital equipment 2.04%. Overtime charges and nursing agency staff were 19.4% of staff-related charges (2.9% for agency staff), 3.9% lower than expenditure associated with full-time employment charges, such as pension and leave. The emergency nature of ICU means it is difficult to accurately set a nursing establishment to cater for all admissions and therefore it is hard to decide what is an acceptable percentage difference between agency/overtime costs compared with the costs associated with full-time staff appointments. Consumable expenditure is likely to increase the most with new innovation and therapies. Using protocol driven practices may tighten and control costs incurred in ICU.

Factors influencing Hong Kong Chinese patients' decision-making in seeking early treatment for acute myocardial infarction

The purpose of this study was to identify, through in-depth interview, factors that influenced 27 Hong Kong Chinese patients' decision-making in seeking early treatment for acute myocardial infarction (AMI). The median delay time from the onset of symptoms to arrival at the hospital was 15.6 hours for men and 53.7 hours for women. Three major categories emerged from the data: (a) becoming aware of the threat, (b) maintaining a sense of normality, and (c) struggling to mobilize resources. A variety of decisions were made by patients from the onset of chest Pain to seeking help. These decisions were heavily influenced by healthcare factors (access to emergency medical service (EMS) and treatment), personal factors (cognitive interpretations of symptoms), sociocultural factors (family situation, cultural beliefs, and practices), and coping strategies. (c) 2006 Wiley Periodicals, Inc.

End-of-life decision making in Europe and Australia - A physician survey

Background: The frequencies with which physicians make different medical end-of-life decisions (ELDs) may differ between countries, but comparison between countries has been difficult owing to the use of dissimilar research methods. Methods: A written questionnaire was sent to a random sample of physicians from 9 specialties in 6 European countries and Australia to investigate possible differences in the frequencies of physicians' willingness to perform ELDs and to identify predicting factors. Response rates ranged from 39% to 68% (N= 10 139). Using hypothetical cases, physicians were asked whether they would ( probably) make each of 4 ELDs. Results: In all the countries, 75% to 99% of physicians would withhold chemotherapy or intensify symptom treatment at the request of a patient with terminal cancer. In most cases, more than half of all physicians would also be willing to deeply sedate such a patient until death. However, there was generally less willingness to administer drugs with the explicit intention of hastening death at the request of the patient. The most important predictor of ELDs was a request from a patient with decisional capacity (odds ratio, 2.1-140.0). Shorter patient life expectancy and uncontrollable pain were weaker predictors but were more stable across countries and across the various ELDs (odds ratios, 1.1-2.4 and 0.9-2.4, respectively). Conclusion: Cultural and legal factors seem to influence the frequencies of different ELDs and the strength of their determinants across countries, but they do not change the essence of decision making.

Effects of patient-focused care on seclusion in a psychiatric intensive care unit

The objective of the study was to evaluate whether the introduction of patient-focused nursing care affected the number of seclusions and the length of time patients spent in seclusion, in an acute psychiatric unit. The study used a pre-intervention–post-intervention design and was conducted in an eight-bed locked unit within a large regional general hospital in Queensland, Australia. The medical records of all people who were secluded as part of their management while in hospital, during two 6-month periods, were retrospectively reviewed. Changes to the ways in which nurses conducted their daily activities were implemented during the time between the data collection periods. There were no differences between the groups with respect to the number of times a patient was secluded. However, following implementation of patient-focused care, there was a reduction in the length of time for which patients were secluded. The only change in medication administration was that post-implementation, Haloperidol was used in fewer seclusion episodes. The findings indicate that changes to nursing practice may result in closer monitoring of patients and a reduction in the time patients spend secluded in acute inpatient psychiatric settings.

Factors influencing PRN medication use in nursing homes

Objective: To identify determinants of PRN ( as needed) drug use in nursing homes. Decisions about the use of these medications are made expressly by nursing home staff when general medical practitioners (GPs) prescribe medications for PRN use. Method: Cross-sectional drug use data were collected during a 7-day window from 13 Australian nursing homes. Information was collected on the size, staffing-mix, number of visiting GPs, number of medication rounds, and mortality rates in each nursing home. Resident specific measures collected included age, gender, length of stay, recent hospitalisation and care needs. Main outcome measures: The number of PRN orders prescribed per resident and the number of PRN doses given per week averaged over the number of PRN medications given at all in the seven-day period. Results: Approximately 35% of medications were prescribed for PRN use. Higher PRN use was found for residents with the lower care needs, recent hospitalisation and more frequent doses of regularly scheduled medications. With increasing length of stay, PRN medication orders initially increased then declined but the number of doses given declined from admission. While some resident-specific characteristics did influence PRN drug use, the key determinant for PRN medication orders was the specific nursing home in which a resident lived. Resident age and gender were not determinants of PRN drug use. Conclusion: The determinants of PRN drug use suggest that interventions to optimize PRN medications should target the care of individual residents, prescribing and the nursing home processes and policies that govern PRN drug use.

Survey of intensive care nurses' knowledge relating to the pulmonary artery catheter

In 2003 there was an increase in the use of pulmonary artery catheters in Australia from 12, 000 to 16, 000 units in intensive care and peri-operative care. This survey of intensive care nurses in five intensive care units in Queensland addressed knowledge of use, safety and complications of the pulmonary artery catheter, using a previously validated 31 question multiple choice survey. One hundred and thirty-nine questionnaires were completed, a response rate of 46%. The mean score was 13.3, standard deviation +/-4.2 out of a total of 31 (42.8% correct). The range was 4 to 25. Scores were significantly higher in those participants with more ICU experience, higher nursing grade, a higher self-assessed level of knowledge and greater frequency of PAC supervision. There was no significant correlation between total score and hospital- or university-based education, or total score and public or private hospital participants. Fifty-one per cent were unable to correctly identify the significant pressure change as the catheter is advanced from the right ventricle to the pulmonary artery.

A randomised controlled study of the efficacy of hypromellose and Lacri-Lube combination versus polyethylene/Cling wrap to prevent corneal epithelial breakdown in the semiconscious intensive care patient

Objective. To compare the efficacy of two forms of eye care (hypromellose and Lacri-Lube combination vs polyethylene/Cling wrap covers) for intensive care patients. Design. Randomised-controlled trial. Setting. University affiliated, tertiary referral hospital. Patients and participants. One hundred ten patients with a reduced or absent blink reflex were followed through until they regained consciousness, were discharged from the facility during study enrolment, died or developed a positive corneal ulcer or eye infection. Interventions. All patients received standard eye cleansing every 2 h. In addition to this, group one (n=60) received a treatment combining hypromellose drops and Lacri-Lube (HL) to each eye every 2 h. Group two (n=50) had polyethylene covers only placed over the eye to create a moisture chamber. Measurements and results. Corneal ulceration was determined using corneal fluorescein stains and mobile slit lamp evaluation, performed daily. No patients had corneal ulceration in the polyethylene cover group, but 4 patients had corneal ulceration in the HL group. Conclusions. Polyethylene covers are as effective as HL in reducing the incidence of corneal damage in intensive care patients.

A work domain analysis framework for modelling intensive care unit patients

Work domain analysis (WDA) has been applied to a range of complex work domains, but few WDAs have been undertaken in medical contexts. One pioneering effort suggested that clinical abstraction is not based on means-ends relations, whereas another effort downplayed the role of bio-regulatory mechanisms. In this paper it is argued that bio-regulatory mechanisms that govern physiological behaviour must be part of WDA models of patients as the systems at the core of intensive care units. Furthermore it is argued that because the inner functioning of patients is not completely known, clinical abstraction is based on hypothetico-deductive abstract reasoning. This paper presents an alternative modelling framework that conforms to the broader aspirations of WDA. A modified version of the viable systems model is used to represent the patient system as a nested dissipative structure while aspects of the recognition primed decision model are used to represent the information resources available to clinicians in ways that support lsquoif...thenrsquo conceptual relations. These two frameworks come together to form the recursive diagnostic framework, which may provide a more appropriate foundation for information display design in the intensive care unit.

Adoption of a sedation scoring system and sedation guideline in an intensive care unit

Aim. The paper presents a study assessing the rate of adoption of a sedation scoring system and sedation guideline. Background. Clinical practice guidelines including sedation guidelines have been shown to improve patient outcomes by standardizing care. In particular sedation guidelines have been shown to be beneficial for intensive care patients by reducing the duration of ventilation. Despite the acceptance that clinical practice guidelines are beneficial, adoption rates are rarely measured. Adoption data may reveal other factors which contribute to improved outcomes. Therefore, the usefulness of the guideline may be more appropriately assessed by collecting adoption data. Method. A quasi-experimental pre-intervention and postintervention quality improvement design was used. Adoption was operationalized as documentation of sedation score every 4 hours and use of the sedation and analgesic medications suggested in the guideline. Adoption data were collected from patients' charts on a random day of the month; all patients in the intensive care unit on that day were assigned an adoption category. Sedation scoring system adoption data were collected before implementation of a sedation guideline, which was implemented using an intensive information-giving strategy, and guideline adoption data were fed back to bedside nurses. After implementation of the guideline, adoption data were collected for both the sedation scoring system and the guideline. The data were collected in the years 2002-2004. Findings. The sedation scoring system was not used extensively in the pre-intervention phase of the study; however, this improved in the postintervention phase. The findings suggest that the sedation guideline was gradually adopted following implementation in the postintervention phase of the study. Field notes taken during the implementation of the sedation scoring system and the guideline reveal widespread acceptance of both. Conclusion. Measurement of adoption is a complex process. Appropriate operationalization contributes to greater accuracy. Further investigation is warranted to establish the intensity and extent of implementation required to positively affect patient outcomes.

The effect of an algorithm-based sedation guideline on the duration of mechanical ventilation in an Australian intensive care unit

To examine the effect of an algorithm-based sedation guideline developed in a North American intensive care unit (ICU) on the duration of mechanical ventilation of patients in an Australian ICU. The intervention was tested in a pre-intervention, post-intervention comparative investigation in a 14-bed adult intensive care unit. Adult mechanically ventilated patients were selected consecutively (n =322) The pre-intervention and post-intervention groups were similar except for a higher number of patients with a neurological diagnosis in the pre-intervention group. An algorithm-based sedation guideline including a sedation scale was introduced using a multifaceted implementation strategy. The median duration of ventilation was 5.6 days in the post-intervention group, compared with 4.8 days for the pre-intervention group (P = 0.99). The length of stay was 8.2 days in the post-intervention group versus 7.1 days in the pre-intervention group (P = 0.04). There were no statistically significant differences for the other secondary outcomes, including the score on the Experience of Treatment in ICU 7 item questionnaire, number of tracheostomies and number of self-extubations. Records of compliance to recording the sedation score during both phases revealed that patients were slightly more deeply sedated when the guideline was used. The use of the algorithm-based sedation guideline did not reduce duration of mechanical ventilation in the setting of this study.