Effect of emergency department fast track on emergency department length of stay : a case-control study

Objective: To examine the effect of fast track on emergency department (ED) length of stay (LOS).

Design and setting: Pair-matched case–control design in a public teaching hospital in metropolitan Melbourne, Australia.

Participants: Patients treated by the ED fast track (cases) between 1 January and 31 March 2007 were compared with patients treated by the usual ED processes (controls) from 1 July to 15 November 2006 (n = 822 matched pairs).

Intervention: ED fast track was established in November 2006 and focused on the management of patients with non-urgent complaints.

Main outcome measures: The primary outcome measure was ED LOS for fast-track patients. Secondary outcomes were waiting times and ED LOS for other ED patients.

Results: Median ED LOS for non-admitted patients was 132 minutes (interquartile range (IQR) 83–205.25) for controls and 116 minutes (IQR 75.5–159.0) for cases (p<0.01). Fast-track patients had a significantly higher incidence of discharge within 2 h (53% vs 44%, p<0.01) and 4 h (92% vs 84%, p<0.01).

Conclusions: ED fast track decreased ED LOS for non-admitted patients without compromising waiting times and ED LOS for other ED patients

Fire fighters' assessments of fireground risk

Fire fighters are often required to work in dynamic and hazardous environments involving a high level of uncertainty. The present study investigated 110 volunteer fire fighters’ assessments of levels of risk associated with a photographic depiction of a typical grassland fire situation. The fire fighters used a standard fire agency risk-rating matrix procedure requiring them to specify the severity of the hazards depicted and the probability of a mishap in order to rate overall level of risk (1 = Low; 4 = Extreme). The risk ratings made by the fire fighters varied greatly. The overall rate of agreement with the risk level rating of the situation made by a panel of expert fire officers (=1, Low) was only 27%. It seems that use of a standard risk-rating matrix procedure by fire fighters at incidents, as recommended currently by many fire agencies, is likely to result in unreliable risk assessments, at least in the absence of effective training in the risk assessment procedure. The 110 volunteers were also asked to identify the total number of potential hazards apparent in five photographs depicting different kinds of emergency incidents. Identifying more hazards was found to be associated with (a) previous personal experience of a ‘near-miss’; and (b) higher levels of education. The findings imply that when faced with identical fire ground situations, individual fire fighters are likely to differ in their situational awareness of hazards and consequent risk assessments.

Applying outcomes of lifelong learning to organisational achievement

The focus of this doctoral research study is making the most what a person knows and can do, as an outcome from their lifelong learning, so as to better contribute to organisational achievement. This has been motivated by a perceived gap in the extensive literature linking knowledge with organisational achievement. Whereas there is a rich body of literature addressing the meta-philosophies giving rise to the emergence of learning organisations there is, as yet, scant attention paid to the detail of planning and implementing action which would reveal individual/organisational opportunities of mutual advantage and motivate, and sustain, participation at the day-to-day level of the individual. It is in this space that this dissertation seeks to contribute by offering a mechanism for bringing the, hindsight informed, response “but that’s obvious” into the abiding explicit realm at the level of the individual. In moving beyond the obvious which is prone to be overlooked, the emphasis on “better” in the introductory sentence, is very deliberately made and has a link to awakening latent individual, and hence organisational, capabilities that would otherwise languish. The evolved LCM Model – a purposeful integration valuing the outcomes from lifelong learning (the L) with nurturing a culture supporting this outcome (the C) and with responsiveness to potentially diverse motivations (the M) – is a reflective device for bringing otherwise tacit, and latent, logic into the explicit realm of action. In the course of the development of the model, a number of supplementary models included in this dissertation have evolved from the research. They form a suite of devices which inform action and lead to making the most of what an individual knows and can do within the formal requirements of a job and within the informal influences of a frequently invisible community of practice. The initial inquiry drew upon the views and experiences of water industry engineering personnel and training facilitators associated with the contract cleaning and waste management industries. However, the major research occurred as an Emergency Management Australia (EMA) project with the Country Fire Authority (CFA) as the host organisation. This EMA/CFA research project explored the influence of making the most of what a CFA volunteer knows and can do upon retention of that volunteer. In its aggregate, across the CFA volunteer body, retention is a critical community safety objective. A qualitative research, ethnographic in character, approach was adopted. Data was collected through interviews, workshops and outcomes from attempts at action research projects. Following an initial thirteen month scoping study including respondents other than from the CFA, the research study moved into an exploration of the efficacy of an indicative model with four contextual foci – i.e. the manner of welcoming new members to the CFA, embracing training, strengthening brigade sustainability and leadership. Interestingly, the research environment which forced a truncated implementation of action research projects was, in itself, an informing experience indicative of inhibitors to making the most of what people know and can do. Competition for interest, time and commitment were factors governing the manner in which CFA respondents could be called upon to explore the efficacy of the model, and were a harbinger of the influences shaping the more general environment of drawing upon what CFA volunteers know and can do. Subsequent to the development of the indicative model, a further 16 month period was utilised in the ethnographic exploration of the relevance of the model within the CFA as the host organisation. As a consequence, the model is a more fully developed tool (framework) to aid reflection, planning and action. Importantly, the later phase of the research study has, through application of the model to specific goals within the CFA, yielded operational insight into its effective use, and in which activity systems have an important place. The model – now confidently styled as the LCM Model – has three elements that when enmeshed strengthen the likelihood of organisational achievement ; and the degree of this meshing, as relevant to the target outcome, determines the strength of outcome. i.e. - • Valuing outcomes from learning: When a person recognises and values (appropriately to achievement by the organisation) what they know and can do, and associated others recognise and value what this person knows and can do, then there is increased likelihood of these outcomes from learning being applied to organisational achievement. • Valuing a culture that is conducive to learning: When a person, and associated others, are further developing and drawing upon what they know and can do within the context of a culture that is conducive to learning, then there is increased likelihood that outcomes from learning will be applied to organisational achievement. • Valuing motivation of the individual: When a person’s motivation to apply what they know and can do is valued by them, and associated others, as appropriate to organisational achievement then there is increased likelihood that appropriately drawing upon outcomes from learning will occur. Activity theory was employed as a device to scope and explore understanding of the issues as they emerged in the course of the research study. Viewing the data through the prism of activity theory led not only to the development of the LCM Model but also to an enhanced understanding of the role of leadership as a foundation for acting upon the model. Both formal and informal leadership were found to be germane in asserting influence on empowering engagement with learning and drawing upon its outcomes. It is apparent that a “leaderful organisation”, as postulated by Raelin (2003), is an environment which supports drawing upon the LCM model; and it may be the case that the act of drawing upon the model will move a narrowly leadership focused organisation toward leaderful attributes. As foreshadowed at the beginning of this synopsis, nurturing individual and organisational capability is the guiding mantra for this dissertation - “Capability embraces competence but is also forward-looking, concerned with the realisation of potential” (Stephenson 1998, p. 3). Although the inquiry focussed upon a need for CFA volunteer retention, it began with a broader investigation as part of the scoping foundation and the expanded usefulness of the LCM Model invites further investigation. The dissertation concludes with the encapsulating sentiment that “You have really got to want to”. With this predisposition in mind, this dissertation contributes to knowledge through the development and discussion of the LCM model as a reflective device informing transformative learning (Mezirow and Associates 1990). A leaderful environment (Raelin 2003) aids transformative learning – accruing to the individual and the organisation - through engendering and maintaining making the most of knowledge and skill – motivating and sustaining “the will”. The outcomes from this research study are a strong assertion that wanting to make the most of what is known and can be done is a hallmark of capability. Accordingly, this dissertation is a contribution to the “how” of strengthening the capability, and the commitment to applying that capability, of an individual and an organisation.

Pre-cursors to physical employment standards for rural tanker-based bushfire suppression work

This thesis quantified the physical demands of Australian rural bushfire suppression and developed a controlled bushfire simulation suitable for ongoing bushfire research. The findings of this thesis will be used to develop physical employment standards and OH&S strategies to protect the 200,000 volunteer firefighters Australia wide.

Is a contained fire less risky than a going fire? Career and volunteer firefighters

Since fighting fires can pose a great risk to the lives of firefighters, it is important to understand how they perceive risks in dynamic wildfire situations. The aim of the current study was to determine whether career and volunteer firefighters differ in their perception of the risk of a going vs. contained fire and whether descriptions of a fire as either going or contained affected perceptions of risk. It was expected that career firefighters would rate a contained fire as significantly riskier than would volunteer firefighters. The sample consisted of 55 career and 84 volunteer CFA Victorian firefighters (134 males and 5 females). An ambiguous wildfire scenario was presented and described as either going or contained and risk ratings were recorded. Two-way ANOVA results showed that career firefighters rated a going fire as equally risky as a contained fire. On the other hand, volunteer firefighters perceived a fire described as contained to be significantly less risky than a fire described as going, despite the fact that the same fireground conditions were described in both cases. It was concluded that a framing effect had occurred and that career firefighters demonstrated a higher level of situation awareness than volunteer firefighters due to their heightened levels of risk perception when exposed to contained wildfire scenarios. A practical implication of the current research is that those conducting firefighting briefings need to be aware of possible framing effects in the way information is presented to firefighters and need to ensure that all briefings make risks cognitively salient to firefighters.

Effect of clinician designation on emergency department fast track performance

Objective To examine the effect of clinician designation on emergency department (ED) fast track performance.
Design and Setting A retrospective audit of patients managed in the fast track area of an ED in metropolitan Melbourne, Australia.
Participants Patients triaged to ED fast track from 1 January 2008 to 31 December 2008 (n=8714).
Main Outcome Measures Waiting times in relation to Australasian triage scale (ATS) recommendations and ED length of stay (LOS) for non-admitted patients were examined for each clinician group.
Results Compliance with ATS waiting time recommendations was highest (82.5%) for emergency nurse practitioners/candidates and lowest (48.2%) for junior medical officers. Median ED LOS was less than 3 h for non-admitted patients, and 85.8% of non-admitted fast track patients (n=6278) left the ED within 4 h. Patients managed by emergency nurse practitioners/ candidates had the shortest ED LOS (median 1.7 h) and patients managed by junior medical officers and locum medical officers the longest ED LOS (median 2.7 h) (x²=498.539, df=6, p<0.001).
Conclusions Clinician designation does impact on waiting times and, to a lesser extent, ED LOS for patients managed in ED fast track systems. Future research should focus on obtaining a better understanding of the relationship between clinician expertise, time-based performance measures and quality of care indicators.

The elimination race in track cycling : patterns and predictors of performance

The track cycling Omnium is a multi-event competition that has recently been expanded to include the Elimination Race (ER), which presents a unique set of physical and tactical demands. The purpose of this research was to characterise the performance attributes of successful and unsuccessful cyclists in the ER, that are also predictive of performance. Video recordings of four international level ERs were analysed. The performance attributes measured related to the cyclists’ velocity and two dimensional position in the peloton. The average velocity of the peloton up to lap 30 (of 50) was relatively high and consistent (52.2±1.5 km/h). After lap 30, there was a significant (p<0.001) change in velocity (49.9±2.4 km/h), characterised by more fluctuations in lap-to-lap velocity. Successful ER cyclists adopted a tactic of remaining in the middle of the peloton, in the lower lanes of the velodrome, thus avoiding the risk of elimination at the rear and the extra effort required to remain on the front of the peloton. Unsuccessful cyclists tended to reside in the rear and upper (higher) portions of the peloton, risking elimination more often and having to ride faster than those in the lower lanes of the velodrome. The physiological demands of the Elimination Race that are determined by velocity, vary throughout the Elimination Race and the pattern of movement within the peloton is different for successful and unsuccessful cyclists. The findings of the present study may confirm some aspects of race tactics that are currently thought to be optimal, but they also reveal novel information that is useful to coaches and cyclists who compete in the Elimination Race.

The relationship between start performance and race outcome in elite 500-m short-track speed skating

Initial short-track speed-skating 14-m start performance has substantial influence on 500-m race outcome at the international level, yet the relationship has not been systematically quantified. The purpose of this investigation was to examine the relationship between rank position entering first corner (RPEFC) and race outcome and to understand how this relationship changes with competition round and absolute race intensity. Data were compiled from 2011-2014 World Cup seasons and 2010 and 2014 Olympic Winter Games. Association between RPEFC and race outcome was determined through Kendall tau-rank correlations. A visual comparison was made of how the relationship changes with relative competition level (race tau correlations were sorted by competition round) and with race intensity (race tau correlations were sorted by within-event winning time). A very large relationship between RPEFC and race outcome was observed (correlations for cohort, τ = .60; men, τ = .53; women, τ= .67). When examined by competition round (quarter- to A-finals), no substantial change in relationship was observed (men, τ= .57-.46; women, τ= .73-.53). However, when the start-performance relationship was considered by within-event winning time, the relationship strength increased with decreasing time (men, τ = .61 to .46; women, τ = .76 to .57; fastest to 7th- and 8th-fastest combined, respectively). These results establish and quantify RPEFC as an important aspect of elite short-track 500-m race outcome. RPEFC as an indicator of race outcome becomes increasingly important with absolute race intensity, suggesting that RPEFC capability is a discriminating factor for competitors of similar top speed and speed endurance.

Getting your life back on track after stroke : a phase II multi-centered, single-blind, randomized, controlled trial of the Stroke Self-Management Program vs. the Stanford Chronic Condition Self-Management Program or standard care in stroke survivors

Background Self-management is seen as a primary mechanism to support the optimization of care for people with chronic diseases such as symptomatic vascular disease. There are no established and evidence-based stroke-specific chronic disease self-management programs. Our aim is to evaluate whether a stroke-specific program is safe and feasible as part of a Phase II randomized-controlled clinical trial.
Methods Stroke survivors are recruited from a variety of sources including: hospital stroke services, local paper advertisements, Stroke South Australia newsletter (volunteer peer support organization), Divisions of General Practice, and community service providers across Adelaide, South Australia. Subjects are invited to participate in a multi-center, single-blind, randomized, controlled trial. Eligible participants are randomized to either;
• standard care,
• standard care plus a six week generic chronic condition self-management group education program, or,
• standard care plus an eight week stroke specific self-management education group program.
Interventions are conducted after discharge from hospital. Participants are assessed at baseline, immediate post intervention and six months.
Study Outcomes The primary outcome measures determine study feasibility and safety, measuring, recruitment, participation, compliance and adverse events.
Secondary outcomes include:
• positive and active engagement in life measured by the Health Education Impact Questionnaire,
• improvements in quality of life measured by the Assessment of Quality of Life instrument,
• improvements in mood measured by the Irritability, Depression and Anxiety Scale,
• health resource utilization measured by a participant held diary and safety.

Conclusion The results of this study will determine whether a definitive Phase III efficacy trial is justified.