Analysis of the impact of limitation of medical treatment orders during unplanned transfers from sub-acute care to emergency departments

BACKGROUND: The impact of limitation of medical treatment orders (LOMT) on patient outcomes following transfer from sub-acute care to the Emergency Department remains unclear.

METHODS: Retrospective medical record review of 431 adult in-patients who required ambulance transfer following clinical deterioration during a sub-acute care admission during 2010.

RESULTS: Common reasons for transfer were respiratory (18.9%) or neurological (19.0%) conditions; 35.7% (154/431) were transferred within one week of sub-acute care admission. LOMT orders were in place for 37.8% (n=163) patients who were older (p<0.001), with more comorbidities (p<0.005), specifically cardiac, renal and pulmonary disease than patients without LOMT. Patients with LOMT orders had more physiological abnormalities before transfer; tachypnoea (43.7% vs 28.6%), hypoxaemia (63.5% vs 48.4%) and severe hypoxaemia (27.6% vs 14.5%). There were no differences in rates of admission, cardiac arrest, Medical Emergency Team activation or ICU admission. For admitted patients, those with LOMT orders had significantly (p≤0.005) higher mortality: in-hospital (21.9% vs 11.3%); 30 days (23.9% vs 12.3%) and 60 days (28.2% vs 13.4%).

CONCLUSIONS: Patients with LOMT had higher levels of comorbidity and were more acutely ill during their sub-acute care admission. Once transferred those with a LOMT had similar rates of cardiac arrest, MET activation and unplanned ICU admission, but higher mortality.

Future of medical engagement

Although it has long been recognised that doctors play a crucial role in the effectiveness and efficiency of health organisations, patient experience and clinical outcomes, over the past 20 years the topic of medical engagement has started to garner significant international attention. Australia currently lags behind other countries in its heedfulness to, and evidence base for, medical engagement. This Perspective piece explores the link between medical engagement and health system performance and identifies some key questions that need to be addressed in Australia if we are to drive more effective engagement.

Assessment of competency : a primer

Determination of testamentary capacity involves not only application of standard tests for decisional competency but also consideration of such special factors as the testator's "moral duty" to those entitled to her or his bounty (also referred to as "common obligations of life"), and the concept of emotional capacity. It is important for medical and legal practitioners who are involved in assessment of testamentary capacity to be aware of these special factors or requirements, their nature and their effect on the validity of the testator's will. The relevant tests and special factors are examined from an historical perspective.

The limits of medicine and the social consequences for sufferers of chronic fatigue syndrome

Chronic fatigue syndrome (CFS) appears to be made up of several clusters of illness categories acting alone or in tandem to cause the decline of health through; fatigue/exhaustion, sensitivity/allergies, pain, general muscle and joint pains, cognitive impairment and gastrointestinal problems. This study investigated how patients interpret, evaluate and respond to the complex and varied symptoms of chronic fatigue syndrome. Data were collected from persons with CFS using a survey (n=90) and an interview (n=45). The researchers investigated how chronic fatigue syndrome is diagnosed by medical practitioners, how the label of CFS is determined and the social consequences for the patient. The results confirm the limited ability of the biomedical paradigm to diagnose adequately and treat effectively 'socially constructed' and medically ambiguous illnesses like CFS. In the absence of a legitimated regime of medical treatment for CFS, a range of often expensive treatments are employed by CFS sufferers, from formal use of pharmaceutical drugs through to 'alternative' therapies, including herbal, vitamin, homeopathic, esoteric meditative techniques, spiritual healing and general counselling are taken in no particular order.

Spurious precision : variability in procedural validity of diagnostic procedures in psychotic disorders and implications for research and treatment

Very few studies have quantified the level of agreement among alternative diagnostic procedures that use a common set of fixed operational criteria. The authors examined the procedural validity of four independent methods of assigning DSM-III-R diagnoses of psychotic disorders. METHOD: The research was conducted as a satellite study to the DSM-IV Field Trial for Schizophrenia and Related Psychotic Disorders. The setting was the National Health and Medical Research Council Schizophrenia Research Unit's Early Psychosis Prevention and Intervention Centre, which focuses on first-episode psychosis. Consecutively admitted patients (N = 50) were assessed by independent raters who used four different procedures to determine a DSM-III-R diagnosis. These procedures were 1) the diagnostic instrument developed for the DSM-IV field trial, 2) the Royal Park Multidiagnostic Instrument for Psychosis, 3) the Munich Diagnostic Checklists, and 4) a consensus DSM-III-R diagnosis assigned by a team of clinician researchers who were expert in the use of diagnostic criteria. RESULTS: Concordance between pairs of diagnostic procedures was only moderate. Corresponding levels of percent agreement, however, ranged from 66% to 76%, with converse misclassification rates of 24%-34% (assuming one procedure to be "correct"). CONCLUSIONS: These findings have significant research and clinical implications. Despite the introduction of operationally defined diagnoses, there remained an appreciable level of differential classification or misclassification arising from variability in the method of assigning the diagnostic criteria rather than the criteria themselves. Such misclassification may impede neurobiological research and have harmful clinical effects on patients with first-episode psychosis.

Interpersonal features of talk in interpreted medical consultations

This linguistic study examined the interpersonal features of the talk between doctors and patients in consultations where a professional medical interpreter was required for them to communicate. Such features affect the relationship between doctor and patient and can impact on medical outcomes. The findings will assist interpreters and doctors in talking to patients and forms part of a larger project to develop a theory of medical interpreting.

A randomised trial of surgical, medical and expectant management of first trimester spontaneous miscarriage

Background: Medical management and expectant care have been considered possible alternatives to surgical evacuation of the uterus for first trimester spontaneous miscarriage in recent years.

Aim: To compare the effectiveness and safety of medical and expectant management with surgical management for first trimester incomplete or inevitable miscarriage.

Methods: Forty women were recruited following diagnosis of incomplete or inevitable miscarriage, and randomised to surgical, medical or expectant care via an off-site, computerised enrolment system. The primary outcome was the effectiveness of medical (vaginal misoprostol) and expectant management relative to surgical evacuation, assessed at 10–14 days and 8 weeks post-recruitment. Infection, pain, bleeding, anxiety, depression, physical and emotional recovery were assessed also. Analysis was by intention-to-treat.

Results: Effectiveness at 8 weeks was lower for medical (80.0%) and expectant (78.6%) than for surgical management (100.0%). Two women in the medical group had confirmed infections. Bleeding lasted longer in the expectant group than in the surgical group. There were no significant differences in pain, physical recovery, anxiety or depression between the groups. 54.6%, 42.9% and 57.1% of the surgical, medical and expectant groups respectively would opt for the same treatment again.

Conclusion: Expectant care appears to be sufficiently safe and effective to be offered as an option for women. Medical management might carry a higher risk of infection than surgical or expectant care.

Medical tourism : a comparison of Australian, French and South Korean medical and health tourists to Thailand.

The high cost of surgery in Western countries has led to an increase in the demand for surgery in developing countries (York, 2008). The objective of this article is to examine the utilization and satisfaction with medical and health services purchased by Australian, French and South Korean visitors to Thailand. In late 2006 a face-to-face survey was conducted with 1,200 randomly selected tourists who had visited Thailand. Results show substantial usage of medical and health services. Satisfaction levels vary across type of service provided and by country of origin of tourist. Recommendations are provided to the national tourism authority. Future research directions are discussed.

The role of the medical emergency team in end-of-life care : a multicenter, prospective, observational study

Objective: To investigate the role of medical emergency teams in end-of-life care planning.

Design: One month prospective audit of medical emergency team calls.

Setting: Seven university-affiliated hospitals in Australia, Canada, and Sweden.

Patients: Five hundred eighteen patients who received a medical emergency team call over 1 month.

Interventions: None.

Measurements and Main Results: There were 652 medical emergency team calls in 518 patients, with multiple calls in 99 (19.1%) patients. There were 161 (31.1%) patients with limitations of medical therapy during the study period. The limitation of medical therapy was instituted in 105 (20.3%) and 56 (10.8%) patients before and after the medical emergency team call, respectively. In 78 patients who died with a limitation of medical therapy in place, the last medical emergency team review was on the day of death in 29.5% of patients, and within 2 days in another 28.2%. Compared with patients who did not have a limitation of medical therapy, those with a limitation of medical therapy were older (80 vs. 66 yrs; p < .001), less likely to be male (44.1% vs. 55.7%; p .014), more likely to be medical admissions (70.8% vs. 51.3%; p < .001), and less likely to be admitted from home (74.5% vs. 92.2%, p < .001). In addition, those with a limitation of medical therapy were less likely to be discharged home (22.4% vs. 63.6%; p < .001) and more likely to die in hospital (48.4% vs. 12.3%; p < .001). There was a trend for increased likelihood of calls associated with limitations of medical therapy to occur out of hours (51.0% vs. 43.8%, p .089).

Conclusions: Issues around end-of-life care and limitations of medical therapy arose in approximately one-third of calls, suggesting a mismatch between patient needs for end-of-life care and resources at participating hospitals. These calls frequently occur in elderly medical patients and out of hours. Many such patients do not return home, and half die in hospital. There is a need for improved advanced care planning in our hospitals, and to confirm our findings in other organizations.

Adolescent chronic illness : a qualitative study of psychosocial adjustment

Introduction: The purpose of this study was to investigate the psychosocial issues facing young people living with a chronic medical condition.

Materials and Methods: Subjects were young people with a range of medical conditions who were on a waiting list to participate in the Chronic Illness Peer Support programme at the Centre for Adolescent Health, Royal Children's Hospital, Melbourne, Australia. Young people agreed to in-depth interviews which were taped and transcribed. Thematic analysis was undertaken by two researchers working independently.

Results: Thirty-five young people were interviewed. Thematic analysis revealed five broad themes: control (in control, under control, out of control); emotional reactions (happiness, frustration, anger, sadness, anxiety); acceptance (of illness, of others, of self); coping strategies, and; a search for meaning. The importance of social connections was emphasised. While illustrating the difficulties of managing a chronic medical condition during adolescence, a generally positive message emerges about these young people.

Conclusions: Many young people with chronic illness appear relatively resilient in the face of the adjustment challenges presented by their illness. Interventions that allow a young person to explore meaning, build self-esteem, and acceptance through positive social connections are likely to improve adjustment outcomes in this group.

Cost effectiveness of surveillance for isocyanate asthma : finding an occupational health policy framework

Wild et al present an original cost effectiveness analysis for medical surveillance for isocyanate asthma in this issue of OEM.1 The general case for surveillance for isocyanate asthma is a compelling one. Most occupational physicians, practitioners, and researchers might rightly expect that if a cost effectiveness (CE) case cannot be made for this agent, it would be hard to make a case for most others. The causal link between isocyanate exposure and asthma is well established, and more is known about the pathophysiology, natural history, long term consequences, and benefits of medical surveillance in this instance than for most other occupational exposures.A mathematical simulation model was developed based on a carefully specified set of clinical parameters, drawing from empirical studies where possible (for example, in estimating sensitisation rates ranging from 0.7% to 5.3% per year), and well qualified expert opinion otherwise (for example, in estimating the chance of removal from exposure if a patient is diagnosed versus undiagnosed). Their “state transition” model compared passive case finding to surveillance (the heart of the CE analysis question as proposed) for a theoretical population of 100 000 otherwise healthy and exposed workers, predicting their progression over 10 years across three mutually exclusive “states”: healthy and exposed; symptomatic; and disabled. This alone is an impressive and valuable piece of research, integrating a substantial body of empirical research to show that surveillance is estimated to result in 700 fewer cases of disability over 10 years compared to passive case finding. While such a modelling exercise necessarily requires numerous assumptions and simplifications, each was well articulated and defensible.

Determinants of the provision of ethylene oxide medical surveillance in Massachusetts hospitals

An in-depth survey of ethylene oxide (EtO) health and safety was conducted in Massachusetts hospitals (n = 92) to investigate the determinants of the provision of medical surveillance for EtO exposure. We have evaluated the relationships between provision of EtO medical surveillance and (1) activating OSHA-specified triggers for providing EtO medical surveillance, (2) worker training on EtO health and safety, and (3) various public policy, organizational, group, and individual characteristics. Among the Occupational Safety and Health Administration's (OSHA) five specified triggers for provision of EtO medical surveillance, only accidental worker exposures were related to provision of surveillance (RR = 2.56, P < 0.001). Exceeding the Action Level for 30 or more days, one of OSHA's EtO triggers that is also used in a number of other standards, was not related to provision of surveillance (RR = 0.84, P = 0.714). Reports of coverage of EtO medical surveillance issues in worker training were also correlated with the provision of EtO medical surveillance (RR = 3.68, P < 0.001), supporting OSHA's premise that worker training plays an important role in medical surveillance implementation. The presence of detailed written EtO medical surveillance policies was positively related to the provision of EtO medical surveillance (RR = 1.81, P < 0.001). The relationships between these potential determinants and provision of medical surveillance were also validated in multivariate analyses. Implications for improvement of OSHA medical surveillance implementation through revised trigger schemes, improved worker training efforts, and other measures are discussed. Findings are relevant to the future development of medical surveillance and exposure monitoring policies and practices in both substance-specific and generic contexts.

A delayed inheritance: The Medical Board of Victoria's 75-year wait to find doctors guilty of "infamous conduct in a professional respect"

The Medical Board of Victoria (Board) was created in 1844 to register “legally qualified medical practitioners”. It was not until 1933, however, that the Board attained the power to remove from its register a doctor who had engaged in “infamous conduct in a professional respect” (the power), even though the General Council of Medical Education and Registration of the United Kingdom on which the Board was modelled had been granted the power 75 years earlier. This article argues that the delay in the Board’s inheritance was attributable to successive Victorian Parliaments’ distrust of the Board and that this attitude was unwarranted, at least from early in the 20th century. The article maintains that the granting of the power to the Board was a crucial event in the history of the regulation of the Victorian medical profession. This is illustrated both by the difficulty encountered by the medical profession in dealing with doctors’ unethical conduct before 1933, and the Board’s concern to use its new authority responsibly and appropriately to protect the public and the profession in the three years after it attained the power.

Patterns of general practitioner usage among Pacific people: indicative results from the Waikato Medical Care Survey 1991-2

AIMS: To report patterns of medical contact in a representative sample of Pacific people attending the general practitioner. METHODS: The data were drawn from a survey of general practice in the Waikato region representing a one per cent sample of all weekday encounters. In total, 12,833 patient encounter forms were completed. Just over one per cent of all encounters were recorded for patients of Pacific Islands background. RESULTS: Rates of medical contact for Pacific patients were lower-3.4 visits per year versus 4.5 for the whole sample-fewer follow up visits were requested (71% versus 76.2%), presentation was delayed (4.9 days from onset versus 3.7 for the sample) and there was an apparently lower level of rapport achieved. CONCLUSION: Overall levels of medical contact and return visits among Pacific patients appear to be lower and presentation delayed in this Waikato sample.