Issues concerning the on-going care of patients with comorbidities in acute care and post-discharge in Australia: a literature review

Issues concerning the on-going care of patients with comorbidities in acute care and post-discharge in Australia: a literature review

Background. Advances in medical science and improved lifestyles have reduced mortality rates in Australia and most western countries. This has resulted in an ageing population with a concomitant growth in the number of people who are living with chronic illnesses. Indeed a significant number of younger people experience more than one chronic illness. Large numbers of these may require repeated admissions to hospital for acute or episodic care that is superimposed upon the needs of their chronic conditions.

Aim. To explore the issues that circumscribe the complexities of caring for people with concurrent chronic illnesses, or comorbidities, in the acute care setting and postdischarge.

Methods. A literature review to examine the issues that impact upon the provision of comprehensive care to patients with comorbidities in the acute care setting and postdischarge.

Findings. Few studies have investigated this subject. From an Australian perspective, it is evident that the structure of the current health care environment has made it difficult to meet the needs of patients with comorbidities in the acute care setting and postdischarge. This is of major concern for nurses attempting to provide comprehensive care to an increasingly prevalent group of chronically ill people.

Conclusion. Further research is necessary to explore how episodic care is integrated into the on-going management of patients with comorbidities and how nurse clinicians can better use an episode of acute illness as an opportunity to review their overall management.

Lack of integration of medical education in Australia: the need for change

The lack of cohesion across health and education sections and national and state jurisdictions is counterproductive to effective national policies in medical education and training. Existing systems in Australia for medical education and training lack coordination, and are under resourced and under pressure. There is a need for a coordinated national approach to assessment of international medical graduates, and for meeting their education and training needs. The links between prevocational and vocational training must be improved. Tensions between workforce planning, education and training can only be resolved if workforce and training agencies work collaboratively. All prevocational positions should be designed and structured to ensure that service, training, teaching and research are appropriately balanced. There is a need for more health education research in Australia.

Sustainability and health : supporting global ecological integrity in public health

Radical changes in the biosphere and human interaction with the environment are increasingly impacting on the health of populations across the world. Diseases are crossing the species barrier, and spreading rapidly through globalized transport systems. From new patterns of cancer to the threat of global pandemics, it is imperative that public health practitioners acknowledge the interdependence between the sustainability of the environment and the sustainability of the human species.* Why are issues of global and local sustainability of increasing importance to the public's health?* Why do issues of sustainability require new practices within the professions of public health?* How can future and current public health practitioners develop those new practices?Drawing on scientific evidence of global and local environmental changes, Sustainability and Health offers a thorough background and practical solutions to the overlapping issues in environment and health. It examines potential and existing responses to global and local environment and health issues, involving individuals, community, industry and government. The authors introduce a range of emerging conceptual frameworks and theoretical perspectives, link IT and epidemiology and explain how scoping can link program design, delivery, data collection and evaluation in projects from their very beginning. Public health practitioners need to be able to manage health issues that cut across environmental, economic and social systems and to develop the capacity for leadership in facilitating change. Incorporating learning activities, readings, international case studies and an open learning approach, this is a valuable resource for students of public and environmental health, as well as medical, environmental and health science professionals.

Where pain = no gain : perspectives on sport, exercise and health, c. 1850-1920

A common perspective today is that sportspeople must train and compete to a level of exertion beyond the ‘pain threshold’ if they are to succeed; a view that has given rise to the popular expression ‘No Pain, No Gain’. Indeed, a common aphorism is that the health and quality of life of individuals and of the wider population is positively correlated with the frequency and vigour of physical exercise. In the period when modern sports were taking on their present characteristics (approximately 1850-1920), the prevailing opinions about the health and well-being effects of exercise were far more cautious, however. While the benefits of moderate exercise for physical and mental well-being went without question, too great an exertion was considered to be as risky as too little, causing ‘strain’ with the potential to inflict lasting and potentially fatal damage, including mental and physical complaints as diverse as neuralgia and ‘athletes’ heart’. The supposedly more strenuous sports, such as football, athletics and rowing, and the training required for them came under particular scrutiny in medical and popular discourses. This paper, an exercise in historical sociology, examines these discourses to demonstrate how advice about the risks on health of participating in sports and of too little or too much exercise more generally, was informed by prevailing physiological models and the interpretation of these within the medical profession and the wider population. The data sources include medical journals and texts, and sports training manuals from the period under investigation.

Train without strain : health and amateur athletes

An exercise in historical sociology, this paper investigates the association between training and health made by amateur athletes between about 1860 and WWI. It examines the idea that while exercise benefited a person’s health and well-being, excessive exertion caused potentially life-threatening ‘strain’. The paper sets out the interpretation of contemporary scientific knowledge about the body–which the author terms the ‘physiology of strain’–that underpinned the advice given to those undergoing a training program for amateur competition. The point is made that the imputed effects of exercise on health were deduced from this scientific knowledge; it did not derive from bio-medical investigations specifically addressing these issues. Amateur athletes included people drawn from the professionally educated elite and medical practitioners figured significantly among them. Using insights from Bourdieu and Foucault, it is argued that their social power and professional connections served to legitimate their interpretation of the physiological effects of exercise (denying the value of the training practices of working class professional athletes) and cemented the physiology of strain as a ‘factual’ statement about exercise and health until well into the twentieth century. The data for the paper comes from training manuals, medical journals and other contemporary publications.

Use of medical orders in acute care oxygen therapy

The life of every living organism is sustained by the presence of oxygen and the acute deprivation of oxygen will, therefore, result in hypoxia and ultimately death. Although oxygen is normally present in the air, higher concentrations are required to treat many disease processes. Oxygen is therefore considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription. Administration is typically authorized by a physician following legal written instructions to a qualified nurse. This standard procedure helps prevent incidence of misuse or oxygen deprivation which could worsen the patients hypoxia and ultimate outcome. Delaying the administration of oxygen until a written medical prescription is obtained could also have the same effect. Clearly, defined protocols should exist to allow for the legal administration of oxygen by nurses without a physicians order because any delay in administering oxygen to patients can very well lead to their death.

The decision-making journey of a family carer : information and social needs in a cultural context

While the important role of family as carer has been increasingly recognised in healthcare service provision, particularly for patients with acute or chronic illnesses, the carer's information and social needs have not been well understood and adequately supported. In order to provide continuous and home-based care for the patient, and to make informed decisions about the care, a family carer needs sufficient access to medical information in general, the patient's health information specifically, and supportive care services. Two key challenges are the carer's lack of medical knowledge and the many carers with non-English speaking and different cultural backgrounds. The informational and social needs of family carers are not yet well understood. This paper analyses the web-log of a husband-carer who provided support for his wife, who at the time of care was a lung cancer patient. It examines the decision-making journey of the carer and identifies the key issues faced in terms of informational and social practices surrounding care provision.

Why do medical graduates choose rural careers?

Introduction: This study is based on the metaphor of the ‘rural pipeline’ into medical practice. The four stages of the rural
pipeline are: (1) contact between rural secondary schools and the medical profession; (2) selection of rural students into medical
programs; (3) rural exposure during medical training; and (4) measures to address retention of the rural medical workforce.
Methods: Using the rural pipeline template we conducted a literature review, analysed the selection methods of Australian
graduate entry medical schools and interviewed 17 interns about their medical career aspirations.
Results: Literature review: The literature was reviewed to assess the effectiveness of selection practices to predict successful
gradation and the impact of rural pipeline components on eventual rural practice. Undergraduate academic performance is the
strongest predictor of medical course academic performance. The predictive power of interviews is modest. There are limited data
on the predictive power of other measures of non-cognitive performance or the content of the undergraduate degree. Prior rural
residence is the strongest predictor of choice of a rural career but extended rural exposure during medical training also has a
significant impact. The most significant influencing factors are: professional support at national, state and local levels; career
pathway opportunities; contentedness of the practitioner’s spouse in rural communities; preparedness to adopt a rural lifestyle;
educational opportunities for children; and proximity to extended family and social circle. Analysis of selection methods: Staff
involved in student selection into 9 Australian graduate entry medical schools were interviewed. Four themes were identified:
(1) rurality as a factor in student selection; (2) rurality as a factor in student selection interviews; (3) rural representation on student
selection interview panels; (4) rural experience during the medical course. Interns’ career intentions: Three themes were identified:
(1) the efficacy of the rural pipeline; (2) community connectedness through the rural pipeline; (3) impediments to the effect of the
rural pipeline, the most significant being a partner who was not committed to rural life
Conclusion: Based on the literature review and interviews, 11 strategies are suggested to increase the number of graduates
choosing a career in rural medicine, and one strategy for maintaining practitioners in rural health settings after graduation.

Older people playing ball : what is the risk of falling and injury?

Increasing physical activity amongst seniors is important for public health, yet guidance is needed to minimise injury risks. To describe the incidence of falls/injuries in a walking team ball game (Lifeball) designed for seniors, a prospective cohort study was undertaken amongst community dwelling Lifeball participants in Australia. Players completed a telephone survey soon after commencing Lifeball (2004) and 12 months later (2005). Attendance and incident records were audited for the period. Subjects joined a Lifeball group with opportunity to play at least once per week. Baseline was completed by 284 players aged between 40 and 96 years (mean 67 years), with most (83.8%, 238/284) female. Of 263 followed up, the average attendances was 25, with 19.3% attending on fewer than 4 occasions and 14.3% attending 52 or more times. Most (93.9%) reported no injuries requiring medical attention. However, 16 (6.1%) had injuries requiring medical attention and their 27 injuries represent an injury rate of 3.3 per 1000 hours of participation. Twenty participants (7.6%) had a Lifeball fall equating to a fall rate of 2.8 per 1000 hours of participation. Falls in Lifeball were not associated with measured predictors (age, gender, falls history, perceived falls risk or hours played). Incident records showed a trip/stumble involving rushing, walking backwards, or overextending (all against rules) as common falling causes. Lifeball is not ‘risk free’ however due to a lack of comparative data it is difficult to compare injury rate to relevant activities. Prevention of injury should concentrate on enforcing safety rules.

Pituitary disease - perspectives of patients and partners

Aim. To explore experiences of pituitary disease of people with pituitary disease (PD) and their partners (PT).

Background. Pituitary disease encompasses a range of hormonal abnormalities that produce a variety of signs and symptoms depending on the underlying cause.

Design. A triangulated exploratory study.

Methods. The study was conducted in three phases: (a) non-participant monitoring of an Internet pituitary chat room over four months; (b) in-depth structured interviews with PD attending a pituitary outpatient clinic (n = 8) and PT (n = 6), (c) focus groups (n = 12). Data were collected in 2005.

Results. Four themes emerged from the discussion in each phase: 'need to be normal', 'emotional merry-go-round', 'damage to the self', and 'doctor ignorance'. Symptoms of pituitary disease were often mistaken for sinusitis, 'getting old before my time', hypochondria, stress, and 'something sinister changing the way I look'. Time to diagnosis varied from four weeks to 15 years. PD felt included in decision-making but partners relied on PD for information. Body image changes were significant making PD feel like a 'freak show for medical students' and the emotional distress persisted after treatment and 'cure'. The word 'tumour' caused significant stress and anxiety and depression was common. PD and PT felt general practitioners (GP) lacked information about pituitary disease.

Conclusions. Pituitary disease has a major impact on psychological well-being. PD but not PT felt involved in decisions about their management. GPs may need more education about pituitary disease. The study adds important information about the emotional effects of pituitary disease and its treatment.

Relevance to clinical practice. Pituitary disease is a generic term encompassing a range of underlying disease processes that often produce vague symptoms, often attributed to other causes, which delays diagnosis and treatment. Pituitary disease has a significant under recognised impact on people's mental and physical wellbeing and self-concept. Although the underlying hormonal imbalances associated with pituitary disease are largely reversible (cured), emotional distress persists. Regular monitoring of emotional wellbeing as well as medical and hormone status is warranted.

Reaching and influencing consumers in the prescription medicine market

Purpose – Celebrex became the first of a new class of drugs known as COX-2 selective non-steroidal anti-inflammatory drugs. It improves treatment for arthritis sufferers without compromising the protective lining of the stomach. The purpose of this paper is to illustrate how direct-to-consumer advertising (DTCA) of prescription medicines can be used to rebuild faith in the cyclooxygenase-2 (COX-2) product category.

Design/methodology/approach – The case is developed using published sources and no input is required from company representatives. The presentation style follows the classic comprehensive case format used in postgraduate teaching programmes.

Findings – Business executives and strategic marketing students would benefit from a discussion on how external environmental factors can suddenly impose a review of marketing strategy. The reader learns how management addresses the business dilemma using DTCA.

Research limitations/implications – A blockbuster rival drug Vioxx is withdrawn due to cardiovascular (CV) health safety concerns. A resulting dominant market situation soon becomes a business dilemma. The Federal Drug Administration calls for a “black box” warning label on Celebrex, the most serious type of warning.

Practical implications – The implications are that having a product in a class of its own is not enough. It highlights the need to communicate to different audiences, to both the medical profession and the end-user. Getting doctors to recommend the medicine and pulling the product through the channel by stimulating patient demand after a health scare are paramount.

Originality/value – This is the first pharmaceutical business case where the withdrawal of a rival product leaves the dominant competitor in a monopoly situation. Contrary to expectation, market share plummets despite the absence of competition.

Patients and nurses' perspective on oxygen therapy : a qualitative study

Aim. This paper is a report of a study to describe patients' and nurses' perspectives on oxygen therapy.
Background. Failure to correct significant hypoxaemia may result in cardiac arrest, need for mechanical ventilation or death. Nurses frequently make clinical decisions about the selection and management of low-flow oxygen therapy devices. Better understanding of patients' and nurses' experiences of oxygen therapy could inform clinical decisions about oxygen administration using low-flow devices.
Methods. Face-to-face interviews with a convenience sample of 37 adult patients (17 cardio-thoracic: 20 medical surgical) and 25 intensive care unit nurses were conducted from February 2007 to September 2007. Interviews were audio-taped, transcribed verbatim and then analysed using a thematic analysis approach.
Findings. The patients identified three key factors that underpinned their compliance with oxygen therapy: (i) device comfort; (ii) ability to maintain activities of daily living; and (iii) therapeutic effect. The nurses identified factors, such as: (i) therapeutic effect, (ii) issues associated with compliance, (iii) strategies to optimize compliance, (iv) familiarity with device, (v) triggers for changing oxygen therapy devices, as being key to the effective management of oxygen therapy.
Conclusion. Differences between the patients' and nurses' perspective of oxygen therapy illustrate the variety of factors that impact on effective oxygen administration. Further research should seek to provide a further in-depth understanding of the current oxygen administration practices of nurses and the patient factors that enhance or hinder effectiveness of oxygen therapy. Detailed information about nurse and patient factors that influence oxygen therapy will inform a sound evidence base for nurses' oxygen administration decisions.

Saw palmetto supplement use and prostate cancer risk

Saw palmetto is an herb used to treat the symptoms of benign prostatic hyperplasia. In vitro studies have found that saw palmetto inhibits growth of prostatic cancer cells and may induce apoptosis. To evaluate whether saw palmetto supplements are associated with a reduced risk of prostate cancer, we conducted a prospective cohort study of 35,171 men aged 50-76 yr in western Washington state. Subjects completed questionnaires between 2000 and 2002 on frequency of use of saw palmetto supplements and saw palmetto-containing multivitamins over the previous 10 yr in addition to other information on supplement intake, medical history, and demographics. Men were followed through December 2003 (mean of 2.3 yr of follow-up) via the western Washington Surveillance, Epidemiology, and End Results cancer registry, during which time 580 developed prostate cancer. Ten percent of the cohort used saw palmetto at least once per week for a year in the 10 yr before baseline. No association was found between this level of use of saw palmetto and risk of prostate cancer development [hazard ratio (HR) = 0.95; 95% confidence interval = 0.74-1.23] or with increasing frequency or duration of use. In this free-living population, use of commercial saw palmetto, which varies widely in dose and constituent ratios, was not associated with prostate cancer risk.

Lived experience of gay men caring for others with HIV/AIDS : living, loving and dying in the era of HIV/AIDS

This thesis explored gay male carers’ experience of caring for their partner, brother or friend who had HIV/AIDS. Through using phenomenological methodology (van Manen, 1990), the day-to-day caring experiences were uncovered. The data gathered were then analysed through a nursing ‘lens’, with the concept of stigma as an anchoring point. The dual stigmas of homophobia and AIDS phobia impacted on the daily lives of these men as they cared for their loved one. The research identified six themes. These were: 1) the relationship; 2) coping with HIV and AIDS; 3) the corporal impact of HIV/AIDS; 4) experiences of carers including the absence of others; 5) living daily with the virus: Demands of people living with HIV/AIDS (PLWHA); and 6) saying goodbye, but wanting to keep the memory alive. The caring these men undertook, for which they were frequently unprepared, was intensive and complex, but because of their commitment and love they battled on. Because of a sense of shame associated with AIDS phobia on the part of the PLWHA, the carer often had to undertake this care in isolation, without support from family, friends or home health care agencies. The carers struggled with not only the demands of day-to-day care, but also with non-acceptance from family, both of the nature of the relationship with their partner and of their homosexuality. Family members were forced, often with great difficulty, to acknowledge the close commitment the men had to each other. Recognition that one had a terminal disease, HIV/AIDS was also required. The fear of potential transmission was high among carers, friends and family members. Notably, there was an absence of blame on the part of the carer towards his partner for contracting HIV/AIDS. The physical decline and marking of the body further stigmatised the PLWHA, which added to carers’ burdens. They endeavoured to minimise the physical decline in their partner, so he could continue to pass as healthy, and attempted to make the day-to-day living as normal as possible. The methods of combating weight loss and opportunistic infections meant frequent medical appointments, complex intensive medical procedures and help with personal care, which was undertaken at home largely without support from health care staff. Carers frequently struggled also with their partner’s denial of being ill. One strategy all carers used was to escape with their partners from their everyday life in Melbourne and attempt metaphorically to leave the HIV/AIDS behind; this was a time when they could rekindle their life together as it was before HIV/AIDS came into their lives. Some carers chose to holiday without their partner, to give themselves a break from the day-to-day caring, while others planned and took holidays with their partner. The decline of the health in the PLWHA meant that family members had to recognise and accept both the nature of the relationship and the presence of the disease. This recognition and acceptance often came only when the partner was very ill, even at the point of dying. Carers and their partners discussed the potential use of euthanasia, as a means of ending the final phase of life with some dignity. One carer and his partner used euthanasia, despite its illegal status. The main concern for all carers was providing comfort and a reduction in the pain associated with HIV/AIDS for the partner. The widespread grief associated with HIV/AIDS was evident amongst these carers. All had known other gay men who had died, some carers own partner had died, or was about to die. There was an overwhelming sense of grief, which at times was repressed as a means of coping day-to-day. All carers felt it was important and necessary to remember those lost to HIV/AIDS through the various public memorials, as they did not want their partner to be just another faceless person lost to this disease. This phenomenological study of carers’ experience highlights the need for health care workers to be aware of the differing strategies that gay men use to cope with HIV/AIDS. While it may seem that the carers are coping with care of their partner, the outer façade is not always an accurate portrayal of the true situation. Health care workers should enquire as to the assistance these carers need from health care services in order to continue to care for their loved one. Such assistance can be the simple recognition of the partner and acceptance of them as part of the PLWHA’s network; this inclusion and acceptance is half the battle.

Examination of the "all hazards" approach to disaster management as applied to field disaster management and pre-hospital care in Australia

Disasters, emergencies, incidents, and major incidents - they all come back to the same thing regardless of what they are called. The common denominator is that there is loss of life, injury to people and animals and damage and destruction of property. The management of such events relies on four phases: 1. Prevention 2. Preparation 3. Response 4. Recovery Each of these phases is managed in a different way and often by different teams. Here, concentration has been given to phases 2 and 3, with particular emphasis on phase 3, Response. The words used to describe such events are often related to legislation. The terminology is detailed later. However, whatever the description, whenever prevention is not possible, or fails, then the need is to respond. Response is always better when the responders are prepared. Training is a major part of response preparation and this book is designed to assist those in the health industry who need to be ready when something happens. One of the training packages for responders is the Major Incident Medical Management and Support (MIMMS) Course and this work was designed to supplement the manual prepared by Hodgetts and Macway-Jones(87) in the UK. Included is what the health services responder, who may be sent to an event in which the main concern is trauma, should know. Concentration is on the initial response and does not deal in any detail with hospital reaction, the public health aspects, or the mental health support that provides psychological help to victims and responders, and which are also essential parts of disaster management. People, in times of disaster, have always been quick to offer assistance. It is now well recognised however, that the 'enthusiastic amateur', whilst being a well meaning volunteer, isn't always what is needed. All too often such people have made things worse and have sometimes ended up as victims themselves. There is a place now for volunteers and there probably always will be. The big difference is that these people must be well informed, well trained and well practiced if they are to be effective. Fortunately such people and organisations do exist. Without the work of the St John Ambulance, the State Emergency Service, the Rural Fire Service the Red Cross and the Volunteer Rescue Association, to mention only a few, our response to disasters would be far less effective. There is a strong history of individuals being available to help the community in times of crisis. Mostly these people were volunteers but there has also always been the need for a core of professional support. In the recent past, professional support mechanisms have been developed from lessons learned, particularly to situations that need a rapid and well organised response. As lessons are learned from an analysis of events, philosophy and methods have changed. Our present system is not perfect and perhaps never will be. The need for an 'all-hazards approach' makes detailed planning very difficult and so there will probably always be criticisms about the way an event was handled. Hindsight is a wonderful thing, provided we learn from it. That means that this text is certainly not the 'last word' and revisions as we learn from experience will be inevitable. Because the author works primarily in New South Wales, many of the explanations and examples are specific to that state. In Australia disaster response is a State, rather than a Commonwealth, responsibility and consequently, and inevitably, there are differences in management between the states and territories within Australia. With the influence of Emergency Management Australia, these differences are being reduced. This means that across state and territory boundaries, assistance is common and interstate teams can be deployed and assimilated into the response rapidly, safely, effectively and with minimum explanation. This text sets out to increase the understanding of what is required, what is in place and how the processes of response are managed. By way of introduction and background, examples are given of those situations that have occurred, or could happen. Man Made Disasters has been divided into two distinct sections. Those which are related to structures or transport and those related directly to people. The first section, Chapter 3, includes: • Transport accidents involving land, rail, sea or air vehicles. • Collapse of buildings for reasons other than earthquakes or storms. • Industrial accidents, including the release of hazardous substances and nuclear events. A second section dealing with the consequences of the direct actions of people is separated as Chapter 4, entitled 'People Disasters'. Included are: • Crowd incidents involving sports and entertainment venues. • Terrorism From Chapter 4 on, the emphasis is on the Response phase and deals with organisation and response techniques in detail. Finally there is a section on terminology and abbreviations. An appendix details a typical disaster pack content. War, the greatest of all man made disasters is not considered in this text.