Monitoring and evaluating surgical care: defining perioperative mortality rate and standardising data collection

BACKGROUND: Case volume per 100 000 population and perioperative mortality rate (POMR) are key indicators to monitor and strengthen surgical services. However, comparisons of POMR have been restricted by absence of standardised approaches to when it is measured, the ideal denominator, need for risk adjustment, and whether data are available. We aimed to address these issues and recommend a minimum dataset by analysing four large mixed surgical datasets, two from well-resourced settings with sophisticated electronic patient information systems and two from resource-limited settings where clinicians maintain locally developed databases. METHODS: We obtained data from the New Zealand (NZ) National Minimum Dataset, the Geelong Hospital patient management system in Australia, and purpose-built surgical databases in Pietermaritzburg, South Africa (PMZ) and Port Moresby, Papua New Guinea (PNG). Information was sought on inclusion and exclusion criteria, coding criteria, and completeness of patient identifiers, admission, procedure, discharge and death dates, operation details, urgency of admission, and American Society of Anesthesiologists (ASA) score. Date-related errors were defined as missing dates and impossible discrepancies. For every site, we then calculated the POMR, the effect of admission episodes or procedures as denominator, and the difference between in-hospital POMR and 30-day POMR. To determine the need for risk adjustment, we used univariate and multivariate logistic regression to assess the effect on relative POMR for each site of age, admission urgency, ASA score, and procedure type. FINDINGS: 1 365 773 patient admissions involving 1 514 242 procedures were included, among which 8655 deaths were recorded within 30 days. Database inclusion and exclusion criteria differed substantially. NZ and Geelong records had less than 0·1% date-related errors and greater than 99·9% completeness. PMZ databases had 99·9% or greater completeness of all data except date-related items (94·0%). PNG had 99·9% or greater completeness for date of birth or age and admission date and operative procedure, but 80-83% completeness of patient identifiers and date related items. Coding of procedures was not standardised, and only NZ recorded ASA status and complete post-discharge mortality. In-hospital POMR range was 0·38% in NZ to 3·44% in PMZ, and in NZ it underestimated 30-day POMR by roughly a third. The difference in POMR by procedures instead of admission episodes as denominator ranged from 10% to 70%. Age older than 65 years and emergency admission had large independent effects on POMR, but relatively little effect in multivariate analysis on the relative odds of in-hospital death at each site. INTERPRETATION: Hospitals can collect and provide data for case volume and POMR without sophisticated electronic information systems. POMR should initially be defined by in-hospital mortality because post-discharge deaths are not usually recorded, and with procedures as denominator because details allowing linkage of several operations within one patient's admission are not always present. Although age and admission urgency are independently associated with POMR, and ASA and case mix were not included, risk adjustment might not be essential because the relative odds between sites persisted. Standardisation of inclusion criteria and definitions is needed, as is attention to accuracy and completeness of dates of procedures, discharge and death. A one-page, paper-based form, or alternatively a simple electronic data collection form, containing a minimum dataset commenced in the operating theatre could facilitate this process. FUNDING: None.

Development and interrater reliability of the UK Mental Health Triage Scale

Mental health triage scales are clinical tools used at point of entry to specialist mental health service to provide a systematic way of categorizing the urgency of clinical presentations, and determining an appropriate service response and an optimal timeframe for intervention. The aim of the present study was to test the interrater reliability of a mental health triage scale developed for use in UK mental health triage and crisis services. An interrater reliability study was undertaken. Triage clinicians from England and Wales (n = 66) used the UK Mental Health Triage Scale (UK MHTS) to rate the urgency of 21 validated mental health triage scenarios derived from real occasions of triage. Interrater reliability was calculated using Kendall's coefficient of concordance (w) and intraclass correlation coefficient (ICC) statistics. The average ICC was 0.997 (95% confidence interval (CI): 0.996-0.999 (F (20, 1300) = 394.762, P < 0.001). The single measure ICC was 0.856 (95% CI: 0.776-0.926 (F (20, 1300) = 394.762, P < 0.001). The overall Kendall's w was 0.88 (P < 0.001). The UK MHTS shows substantial levels of interrater reliability. Reliable mental health triage scales employed within effective mental health triage systems offer possibilities for not only improved patient outcomes and experiences, but also for efficient use of finite specialist mental health services.

Effects of low- versus high-fidelity simulations on the cognitive burden and performance of entry-level paramedicine students: a mixed-methods comparison trial using eye-tracking, continuous heart rate, difficulty rating scales, video observation and inte

INTRODUCTION: High-fidelity simulation-based training is often avoided for early-stage students because of the assumption that while practicing newly learned skills, they are ill suited to processing multiple demands, which can lead to "cognitive overload" and poorer learning outcomes. We tested this assumption using a mixed-methods experimental design manipulating psychological immersion. METHODS: Thirty-nine randomly assigned first-year paramedicine students completed low- or high-environmental fidelity simulations [low-environmental fidelity simulations (LFenS) vs. high-environmental fidelity simulation (HFenS)] involving a manikin with obstructed airway (SimMan3G). Psychological immersion and cognitive burden were determined via continuous heart rate, eye tracking, self-report questionnaire (National Aeronautics and Space Administration Task Load Index), independent observation, and postsimulation interviews. Performance was assessed by successful location of obstruction and time-to-termination. RESULTS: Eye tracking confirmed that students attended to multiple, concurrent stimuli in HFenS and interviews consistently suggested that they experienced greater psychological immersion and cognitive burden than their LFenS counterparts. This was confirmed by significantly higher mean heart rate (P < 0.001) and National Aeronautics and Space Administration Task Load Index mental demand (P < 0.05). Although group allocation did not influence the proportion of students who ultimately revived the patient (58% vs. 30%, P < 0.10), the HFenS students did so significantly more quickly (P < 0.01). The LFenS students had low immersion resulting in greater assessment anxiety. CONCLUSIONS: High-environmental fidelity simulation engendered immersion and a sense of urgency in students, whereas LFenS created assessment anxiety and slower performance. We conclude that once early-stage students have learned the basics of a clinical skill, throwing them in the "deep end" of high-fidelity simulation creates significant additional cognitive burden but this has considerable educational merit.

A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: a pre-post study using full immersion simulation

AIMS AND OBJECTIVES: The aim of this study was to evaluate the effect of the new evidence-informed nursing assessment framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) on the quality of patient assessment and fundamental nontechnical skills including communication, decision making, task management and situational awareness. BACKGROUND: Assessment is a core component of nursing practice and underpins clinical decisions and the safe delivery of patient care. Yet there is no universal or validated system used to teach emergency nurses how to comprehensively assess and care for patients. DESIGN: A pre-post design was used. METHODS: The performance of thirty eight emergency nurses from five Australian hospitals was evaluated before and after undertaking education in the application of the HIRAID assessment framework. Video recordings of participant performance in immersive simulations of common presentations to the emergency department were evaluated, as well as participant documentation during the simulations. Paired parametric and nonparametric tests were used to compare changes from pre to postintervention. RESULTS: From pre to postintervention, participant performance increases were observed in the percentage of patient history elements collected, critical indicators of urgency collected and reported to medical officers, and patient reassessments performed. Participants also demonstrated improvement in each of the four nontechnical skills categories: communication, decision making, task management and situational awareness. CONCLUSION: The HIRAID assessment framework improves clinical patient assessments performed by emergency nurses and has the potential to enhance patient care. RELEVANCE TO CLINICAL PRACTICE: HIRAID should be considered for integration into clinical practice to provide nurses with a systematic approach to patient assessment and potentially improve the delivery of safe patient care.

if not in paint

if not in paint is an attempt to deploy the concept of the text as a space in which to bring to light the sense of hospitality. It is inspired by Jacques Derrida’s exploration of the theme (in Derrida & Dufourmantelle 1997), which has taken increasing urgency in the first decades of the millennium with the global refugee crisis. The sequence aspires to a poetics of attentiveness and radical passivity associated with Maurice Blanchot (1986) and informing Alan Loney’s poetry (Loney 2005, 2007 & 2008). The poem operates a transformation of the concept of home from the narrow one, sentimentally associated with familial and personal identity, via betrayal and calamity, to the possibility of home as openness to the other.

Sex differences in in-hospital mortality following a first acute myocardial infarction: symptomatology, delayed presentation, and hospital setting

BACKGROUND: Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated.

METHODS: Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated.

RESULTS: Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or ICU, while for females this age-adjusted attributable risk was 4.1 %.

CONCLUSIONS: Our study stresses the need to reappraise decision making in patient selection for admission to specialised care units, whilst raising awareness of possible sex-related bias in management of patients diagnosed with an AMI.

Landscape properties mediate the homogenization of bird assemblages during climatic extremes

Extreme weather events, such as drought, have marked impacts on biotic communities. In many regions, a predicted increase in occurrence of such events will be imposed on landscapes already heavily modified by human land use. There is an urgency, therefore, to understand the way in which the effects of such events may be exacerbated, or moderated, by different patterns of landscape change. We used empirical data on woodlanddependent birds in southeast Australia, collected during and after a severe drought, to document temporal change in the composition of bird assemblages in 24 landscapes (each 100 km2) representing a gradient in the cover of native wooded vegetation (from 60% to <2%). We examined (a) whether drought caused region-wide homogenization of the composition of landscape bird assemblages, and (b) whether landscape properties influenced the way assemblages changed in response to drought. To quantify change, we used pairwise indices of assemblage dissimilarity, partitioned into components that represented change in the richness of assemblages and change in the identity of constituent species (turnover). There was widespread loss of woodland birds in response to drought, with only partial recovery following drought-breaking rains. Region-wide, the composition of landscape assemblages became more different over time, primarily caused by turnover-related differentiation. The response of bird assemblages to drought varied between landscapes and was strongly associated with landscape properties. The extent of wooded vegetation had the greatest influence on assemblage change: landscapes with more native vegetation had more stable bird assemblages over time. However, for the component processes of richness- and turnoverrelated compositional change, measures of landscape productivity had a stronger effect. For example, landscapes with more riparian vegetation maintained more stable assemblages in terms of richness. These results emphasize the importance of the total extent of native vegetation, both overall cover and that occurring in productive parts of the landscape, for maintaining bird communities whose composition is resistant to severe drought. While extreme climatic events cannot be prevented, their effects can be ameliorated by managing the pattern of native vegetation in anthropogenic landscapes, with associated benefits for maintaining ecological processes and human well-being.

Affect and the politics of testimony in Holocaust museums

In 2010, the Jewish Holocaust Centre (JHC) in Melbourne unveiled its new permanent exhibition, replacing one that had remained, mostly unchanged, for the past twenty years since a major redevelopment in 1990. The former exhibition had received many plaudits from visitors and reviewers for its homespun, intimate aesthetics and display techniques, largely based on photographs (Light, 2002). Central to the JHC’s role as a site of mourning and education, the exhibition included the use of personal testimony from Melbourne’s Holocaust survivors, both in the exhibition displays and through the survivors who ran the museum and shared their stories with individuals and groups. A continuing anxiety over the thirty-year history of the JHC has been the passing of Holocaust survivors. These survivor guides were central to the discourse of a “living museum,” seen as giving the organization its uniqueness compared to other Holocaust institutions as well as other museums generally. Oral survivor testimony was perceived as a key aspect of the museum’s pedagogic potential: The affective encounter with survivors telling their stories while the visitor was viewing the exhibition was identified as having a transformative function, particularly for school-age students who comprised the majority of the visitors. The exhibition redevelopment in 2010 was, in part, a manifestation of that anxiety, with the urgency to incorporate survivor video-testimony increasing as the survivors aged and their memories faded. However, replacing a much-loved exhibition was fraught with difficulties, as the survivors were still very much part of the museum decision-making process. As the JHC had gradually moved from a survivor-volunteer based place of mourning to a professionally run museum with paid employees, there was a need to preserve the voices of the survivors who had been guides at the museum since its opening. Approaching a time when the survivors are not bodily present to share their stories, how might their testimonies still have transformative potential and inform interpretive techniques?

Editors’ introduction: archives and archivists

Today, questions about online access to media history, digital research infrastructure, and cultural and political pedagogy have come to the fore. A host of related questions has acquired a new urgency: What is lost and gained in the shift from physical to digital archiving? What and how do archives preserve, and how do they curate public access? How do we search for digital material? Which tools are used to modify and limit our search options, and what does this tell us about digital networks and our relationships to them?

The ‘camps system’ in Italy : corruption, inefficiencies and practices of resistance

The alarming proliferation of ‘campi nomadi’ (nomad camps) in Italy intensifies the urgency of analysing their internal mechanism and the complex relation between all the parties [1]; ‘camp dwellers’, government agencies and Civil Society organisations [CSOs][2], involved in their production and reification. To arrive at an adequate appreciation of this nexus, the three components of what has been termed the ‘camps system’ have been analysed separately. This approach helped to pinpoint how they have combined to produce a hegemonic perspective on Romani issues, which yields a simplistic binary interpretation of a complex and dynamic phenomenon: Romanies are generally viewed as either victims or threats, narrowing the range of responses to charity or hostility. Only in recent years a growing awareness regarding the agency of camp inhabitants has re-emerged more consistently after a period in which an ‘encamped life’ was at times associated to Agamben’s (1998) ‘bare life’ and Foucault’s (1977) ‘biopolitics’. Nevertheless, scholars are still hesitant in developing a current of study looking specifically at camps, not only as ‘resistance sites’, but more broadly as ‘all-inclusive systems’, where interacting and interdependent agents form an integrated whole. Through in-depth analysis of this specific socio-political context I was able to observe the existence of a democratic deficit in the way these actors operate and co-operate with each other: competition and antagonisms, corruption, lack of transparency and accountability, and inefficiencies have all contributed over the years to producing and maintaining the present living situation of the Romani peoples.

Clayton's law of amor fati & other poems

As is true of new poetry in the US, much of the work here reflects the complexity and urgency of political thinking within the aesthetic sphere.

Physical activity habits, limitations, and predictors in people with inflammatory bowel disease: a large cross-sectional online survey

BACKGROUND: Limited evidence suggests that physical activity has beneficial effects in people with inflammatory bowel disease (IBD). This study aimed to determine the physical activity habits of adults with IBD, the limitations to physical activity they experience because of their disease, and the extent to which their physical activity is affected by various demographic, clinical, and psychological factors. METHODS: Data were collected on 859 adult participants (52% with Crohn's disease, 75% women) through an online survey conducted between May and June 2016. Measures included physical activity (International Physical Activity Questionnaire), psychological symptoms (Hospital Anxiety and Depression Scale), fatigue (subitems of IBD fatigue scale), exercise perceptions (Exercise Benefits/Barriers Scale), and disease activity. Regression analyses were used to identify predictors of physical activity. RESULTS: Only 17% of respondents were categorized as "high active." Self-reported physical activity levels decreased, and fatigue and psychological scores increased, with increasing disease activity. Walking was the most common activity performed (57% of respondents) and running/jogging the most commonly avoided (34%). Many participants (n = 677) reported that IBD limited their physical activity, for reasons including abdominal/joint pain (70%), fatigue/tiredness (69%), disease flare-up (63%), and increased toilet urgency (61%). Physical activity was independently associated with depression, disease activity, and perceived barriers to exercise in people with Crohn's disease, and depression and age in people with ulcerative or indeterminate colitis (all P ≤ 0.038). CONCLUSIONS: This survey highlights several important factors that should be considered by designers of future physical activity interventions for people with IBD.

Risk management in research and development (R&D) projects: the case of South Australia

A definition of the effective methods of risk management in R&D projects has remained elusive. Similarly, there have been calls to devise effective risk management methods in R&D projects. To develop this area further, the purpose of this study is twofold. First, it validates the veracity of claims about the urgency of introducing effective methods of risk management to R&D projects in South Australia based on nine unstructured interviews with experts. Second, the study presents the outcomes of two case studies that deployed the extended version of the failure mode and effect analysis, namely, the RFMEA method in a South Australian organisation, to investigate how the method can facilitate the identification of effective contingency plans to mitigate high-priority risks. The findings showed that the RFMEA method would be effective for project managers in dealing with risk management issues in R&D projects. The discussions presented will provide guidelines for practitioners in the industry.

Some of these girls can be real drama queens : issues of gender, sexual harassment and schooling

Since the 1970s many feminists working for gender justice in education have highlighted the predominance and seriousness of sexual harassment in schools and condemned the enduring trivialization of such behaviours. This paper develops this body of work by focusing on how issues of sexual harassment are located within prevailing contemporary western educational contexts that position boys as 'victims' of feminism and 'girl-friendly' schooling. It is argued here that such contexts draw attention away from the powerful spaces that many boys continue to inhabit in schools. Counter to the popular notion that girls no longer face problems in relation to their schooling, the paper foregrounds the voices of four (14-year-old) Grade Eight girls from Tasmania, Australia who detail their disturbing experiences of sexual harassment. Pointing to the grave inadequacies of common remedies used to address these behaviours, such as prescriptive discipline systems that ignore issues of gender and power and boy-friendly remedies that collude in the perpetuation of inequitable gender relations, the paper highlights the imperative of disrupting the erasure of these issues from current dominant equity debates and the urgency of better addressing this problem in schools. Along these lines, the paper calls for teacher practice that acts against the grain of broader anti-feminist and performative school cultures to transform the masculinities of entitlement that contribute to these unacceptable behaviours.

‘Some of those girls can be real drama queens’: issues of gender, sexual harassment and schooling

Since the 1970s many feminists working for gender justice in education have highlighted the predominance and seriousness of sexual harassment in schools and condemned the enduring trivialization of such behaviours. This paper develops this body of work by focusing on how issues of sexual harassment are located within prevailing contemporary western educational contexts that position boys as ‘victims’ of feminism and ‘girl‐friendly’ schooling. It is argued here that such contexts draw attention away from the powerful spaces that many boys continue to inhabit in schools. Counter to the popular notion that girls no longer face problems in relation to their schooling, the paper foregrounds the voices of four (14‐year‐old) Grade Eight girls from Tasmania, Australia who detail their disturbing experiences of sexual harassment. Pointing to the grave inadequacies of common remedies used to address these behaviours, such as prescriptive discipline systems that ignore issues of gender and power and boy‐friendly remedies that collude in the perpetuation of inequitable gender relations, the paper highlights the imperative of disrupting the erasure of these issues from current dominant equity debates and the urgency of better addressing this problem in schools. Along these lines, the paper calls for teacher practice that acts against the grain of broader anti‐feminist and performative school cultures to transform the masculinities of entitlement that contribute to these unacceptable behaviours.