Access to cardiac rehabilitation does not equate to attendance

Background/Aims Timely access to appropriate cardiac care is critical for optimizing positive outcomes after a cardiac event. Attendance at cardiac rehabilitation (CR) remains less than optimal (10%–30%). Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services after a cardiac event in Australia. Methods An expert panel defined a single patient care pathway and a hierarchy of the minimum health services for CR and secondary prevention. Using geographic information systems a numeric/alpha index was modelled to describe access before and after a cardiac event. The aftercare phase was modelled into five alphabetical categories: from category A (access to medical service, pharmacy, CR, pathology within 1 h) to category E (no services available within 1 h). Results Approximately 96% or 19 million people lived within 1 h of the four basic services to support CR and secondary prevention, including 96% of older Australians and 75% of the indigenous population. Conversely, 14% (64,000) indigenous people resided in population locations that had poor access to health services that support CR after a cardiac event. Conclusion Results demonstrated that the majority of Australians had excellent ‘geographic’ access to services to support CR and secondary prevention. Therefore, it appears that it is not the distance to services that affects attendance. Our ‘geographic’ lens has identified that more research on socioeconomic, sociological or psychological aspects to attendance is needed.

Access to Cardiac Rehabilitation does not Equate to Attendance. (On Behalf of the Cardiac ARIA Project. Winner Nursing/Allied Health Professional Investigator Award)

Background/Aims Timely access to appropriate cardiac care is critical for optimizing positive outcomes after a cardiac event. Attendance at cardiac rehabilitation (CR) remains less than optimal (10%–30%). Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services after a cardiac event in Australia. Methods An expert panel defined a single patient care pathway and a hierarchy of the minimum health services for CR and secondary prevention. Using geographic information systems a numeric/alpha index was modelled to describe access before and after a cardiac event. The aftercare phase was modelled into five alphabetical categories: from category A (access to medical service, pharmacy, CR, pathology within 1 h) to category E (no services available within 1 h). Results Approximately 96% or 19 million people lived within 1 h of the four basic services to support CR and secondary prevention, including 96% of older Australians and 75% of the indigenous population. Conversely, 14% (64,000) indigenous people resided in population locations that had poor access to health services that support CR after a cardiac event. Conclusion Results demonstrated that the majority of Australians had excellent ‘geographic’ access to services to support CR and secondary prevention. Therefore, it appears that it is not the distance to services that affects attendance. Our ‘geographic’ lens has identified that more research on socioeconomic, sociological or psychological aspects to attendance is needed.

(Mis)Using Pulse Oximetry : A Review of Pulse Oximetry use in Acute Care Medical Wards

Background: Nurses routinely use pulse oximetry (SpO2) monitoring equipment in acute care. Interpretation of the reading involves physical assessment and awareness of parameters including temperature, haemoglobin, and peripheral perfusion. However, there is little information on whether these clinical signs are routinely measured or used in pulse oximetry interpretation by nurses. Aim: The aim of this study was to review current practice of SpO2 measurement and the associated documentation of the physiological data that is required for accurate interpretation of the readings. The study reviewed the documentation practices relevant to SpO2 in five medical wards of a tertiary level metropolitan hospital. Method: A prospective casenote audit was conducted on random days over a three-month period. The audit tool had been validated in a previous study. Results: One hundred and seventy seven episodes of oxygen saturation monitoring were reviewed. Our study revealed a lack of parameters to validate the SpO2 readings. Only 10% of the casenotes reviewed had sufficient physiological data to meaningfully interpret the SpO2 reading and only 38% had an arterial blood gas as a comparator. Nursing notes rarely documented clinical interpretation of the results. Conclusion: The audits suggest that medical and nursing staff are not interpreting the pulse oximetry results in context and that the majority of the results were normal with no clinical indication for performing this observation. This reduces the usefulness of such readings and questions the appropriateness of performing “routine” SpO2 in this context.

Dying in hospital: medical failure or natural outcomes?

The purpose of this study was to describe patterns of medical and nursing practice in the care of patients dying of oncological and hematological malignancies in the acute care setting in Australia. A tool validated in a similar American study was used to study the medical records of 100 consecutive patients who died of oncological or hematological malignancies before August 1999 at The Canberra Hospital in the Australian Capital Territory. The three major indicators of patterns of end-of-life care were documentation of Do Not Resuscitate (DNR) orders, evidence that the patient was considered dying, and the presence of a palliative care intention. Findings were that 88 patients were documented DNR, 63 patients' records suggested that the patient was dying, and 74 patients had evidence of a palliative care plan. Forty-six patients were documented DNR 2 days or less prior to death and, of these, 12 were documented the day of death. Similar patterns emerged for days between considered dying and death, and between palliative care goals and death. Sixty patients had active treatment in progress at the time of death. The late implementation of end-of-life management plans and the lack of consistency within these plans suggested that patients were subjected to medical interventions and investigations up to the time of death. Implications for palliative care teams include the need to educate health care staff and to plan and implement policy regarding the management of dying patients in the acute care setting. Although the health care system in Australia has cultural differences when compared to the American context, this research suggests that the treatment imperative to prolong life is similar to that found in American-based studies.

Changing learning to improve practice : hand hygiene education in Queensland medical schools

The aim of Queensland Health’s ‘Clean hands are life savers’ program is to change the culture and behaviour of healthcare workers related to hand hygiene. Hand hygiene is considered to be the most effective means of preventing pathogen cross-transmission and healthcare-associated infections. Most hospitals throughout Queensland as well as Australia now manage a hand hygiene program to increase the hand hygiene compliance of all healthcare workers. Reports taken from routine hand hygiene observations reveal that doctors are usually less compliant in their hand-washing practices than other healthcare worker groups. The Centre for Healthcare Related Infection Surveillance and Prevention (CHRISP) has attempted to have an impact on this challenging group through their Medical Leadership Initiative. With education as a core component of the program, efforts were made to ensure our future doctors were receiving information that aligned with Queensland Health standards during their formative years at medical school. CHRISP met with university instructors to understand what infection prevention education was currently included in the curriculum and support the introduction of new learning activities that specifically focused on hand hygiene. This prompted change to the existing curriculum and a range of interventions were employed with mixed success. Although met with challenges, methods to integrate more infection prevention teaching were found.

The predictors of active ageing of older Australians : the triple a study

The concept of older adults contributing to society in a meaningful way has been termed ‘active ageing’. Active ageing reflects changes in prevailing theories of social and psychological aspects of ageing, with a focus on individuals' strengths as opposed to their deficits or pathology. In order to explore predictors of active ageing, the Australian Active Ageing (Triple A) project group undertook a national postal survey of participants over the age of 50 years recruited randomly through their 2004 membership of a large Australia-wide senior's organisation. The survey comprised 178 items covering paid and voluntary work, learning, social, spiritual, emotional, health and home, life events and demographic items. A 45% response rate (2655 returned surveys) reflected an expected balance of gender, age and geographic representation of participants. The data were analysed using data mining techniques to represent generalizations on individual situations. Data mining identifies the valid, novel, potentially useful and understandable patterns and trends in data. The results based on the clustering mining technique indicate that physical and emotional health combined with the desire to learn were the most significant factors when considering active ageing. The findings suggest that remaining active in later life is not only directly related to the maintenance of emotional and physical health, but may be significantly intertwined with the opportunity to engage in on-going learning activities that are relevant to the individual. The findings of this study suggest that practitioners and policy makers need to incorporate older peoples' learning needs within service and policy framework developments.

Graph-based concept weighting for medical information retrieval

This paper presents a graph-based method to weight medical concepts in documents for the purposes of information retrieval. Medical concepts are extracted from free-text documents using a state-of-the-art technique that maps n-grams to concepts from the SNOMED CT medical ontology. In our graph-based concept representation, concepts are vertices in a graph built from a document, edges represent associations between concepts. This representation naturally captures dependencies between concepts, an important requirement for interpreting medical text, and a feature lacking in bag-of-words representations. We apply existing graph-based term weighting methods to weight medical concepts. Using concepts rather than terms addresses vocabulary mismatch as well as encapsulates terms belonging to a single medical entity into a single concept. In addition, we further extend previous graph-based approaches by injecting domain knowledge that estimates the importance of a concept within the global medical domain. Retrieval experiments on the TREC Medical Records collection show our method outperforms both term and concept baselines. More generally, this work provides a means of integrating background knowledge contained in medical ontologies into data-driven information retrieval approaches.

Understanding QC and EQA : an authentic learning model for undergraduate students (Conference Abstract)

Introduction QC and EQA are integral to good pathology laboratory practice. Medical Laboratory Science students undertake a project exploring internal QC and EQA procedures used in chemical pathology laboratories. Each student represents an individual lab and the class group represents the peer group of labs performing the same assay using the same method. Methods Using a manual BCG assay for serum albumin, normal and abnormal controls are run with a patient sample over 7 weeks. The QC results are assessed each week using calculated z-scores and both 2S & 3S control rules to determine whether a run is ‘in control’. At the end of the 7 weeks a completed LJ chart is assessed using the Westgard Multirules. Students investigate causes of error and the implications for both lab practice and patient care if runs are not ‘in control’. Twice in the 7 weeks two EQA samples (with target values unknown) are assayed alongside the weekly QC and patient samples. Results from each student are collated and form the basis of an EQA program. ALP are provided and students complete a Youden Plot, which is used to analyse the performance of each ‘lab’ and the method to identify bias. Students explore the concept of possible clinical implications of a biased method and address the actions that should be taken if a lab is not in consensus with the peer group. Conclusion This project is a model of ‘real world’ practice in which student demonstrate an understanding of the importance of QC procedures in a pathology laboratory, apply and interpret statistics and QC rules and charts, apply critical thinking and analytical skills to quality performance data to make recommendations for further practice and improve their technical competence and confidence.

A prospective window into medical device-related pressure ulcers in intensive care

Objective: To determine the prevalence, severity, location, etiology, treatment, and healing of medical device-related pressure ulcers in intensive care patients for up to 7 days. Design: Prospective repeated measures study. Setting and participants: Patients in 6 intensive care units of 2 major medical centers, one each in Australia and the United States, were screened 1 day per month for 6 months. Those with device-related ulcers were followed daily up to 7 days. Outcome measures: Device-related ulcer prevalence, pain, infection, treatment, healing. Results: 15/483 patients had device-related ulcers and 9/15 with 11 ulcers were followed beyond screening. Their mean age was 60.5 years, most were men, over-weight, and at increased pressure ulcer risk. Endotracheal and nasogastric tubes were the cause of most device-related ulcers. Repositioning was the most frequent treatment. 4/11 ulcers healed within the 7 day observation period. Conclusion: Device-related ulcer prevalence was 3.1%, similar to that reported in the limited literature available, indicating an ongoing problem. Systematic assessment and repositioning of devices are the mainstays of care. We recommend continued prevalence determination and that nurses remain vigilant to prevent device-related ulcers, especially in patients with nasogastric and endotracheal tubes.