Malnutrition in hospitalised patients and clinical outcomes : a missed opportunity?

This research programme has resulted in 5 published papers in international peer-reviewed journals and contributed to better outcomes for patients. It has provided clear evidence that the adverse outcomes of malnutrition are not just a consequence of the disease process, and lead to substantial increases in length of hospital stay, readmission rate, mortality and hospitalisation cost when compared with well-nourished patients of similar diagnoses and complexities. The research programme led to the development and validation of a new nutrition screening tool called 3-Minute Nutrition Screening (3-MinNS). It has also implemented quality improvement initiatives which proved successful in improving the compliance to 3-MinNS and ensuring referral of malnourished or 'at risk' patients to dietitians. Finally, this research programme has provided an effective method for following up malnourished patients post-discharge, which resulted in improved nutritional status and quality of life.

Assessment Understood as Enabling

This chapter outlines a perspective of educational assessment as enabling, whereby the learner is central and assessment is focused on supporting the knowledge, skills and dispositions necessary for lifelong learning. It argues that better education for young people is achievable when educational policy and practice give priority to learning improvement, thereby making assessment for accountability a related, though secondary, concern. The chapter describes how this work of internationally recognized scholars brings together diverse perspectives and theoretical frameworks and, in so doing, provides readers with a range of ways to consider their pathway through the book. A ‘map’ and summaries of chapters suggest a reading according to a thematic approach, geographical setting, author/s profile or content purposes depending on the reader’s own priorities. A section on assessment past, present, and futures calls for a rebalancing of improvement and accountability goals, and for countries to be careful to avoid privileging large-scale testing over other forms of data about learning and achievement.

Why 'down under' is a cut above: a comparison of rates of and reasons for caesarean section in England and Australia

Background Most studies examining determinants of rising rates of caesarean section have examined patterns in documented reasons for caesarean over time in a single location. Further insights could be gleaned from cross-cultural research that examines practice patterns in locations with disparate rates of caesarean section at a single time point. Methods We compared both rates of and main reason for pre-labour and intrapartum caesarean between England and Queensland, Australia, using data from retrospective cross-sectional surveys of women who had recently given birth in England (n = 5,250) and Queensland (n = 3,467). Results Women in Queensland were more likely to have had a caesarean birth (36.2%) than women in England (25.1% of births; OR = 1.44, 95% CI = 1.28-1.61), after adjustment for obstetric characteristics. Between-country differences were found for rates of pre-labour caesarean (21.2% vs. 12.2%) but not for intrapartum caesarean or assisted vaginal birth. Compared to women in England, women in Queensland with a history of caesarean were more likely to have had a pre-labour caesarean and more likely to have had an intrapartum caesarean, due only to a previous caesarean. Among women with no previous caesarean, Queensland women were more likely than women in England to have had a caesarean due to suspected disproportion and failure to progress in labour. Conclusions The higher rates of caesarean birth in Queensland are largely attributable to higher rates of caesarean for women with a previous caesarean, and for the main reason of having had a previous caesarean. Variation between countries may be accounted for by the absence of a single, comprehensive clinical guideline for caesarean section in Queensland. Keywords: Caesarean section; Childbirth; Pregnancy; Cross-cultural comparison; Vaginal birth after caesarean; Previous caesarean section; Patient-reported data; Quality improvement

Wet tropics reef rescue impact report 2009

The Wet Tropics region has a unique water asset and is also considered a priority region for the improvement of water quality entering the Great Barrier Reef due to a combination of high rainfall, intensive agricultural use, urban areas and the proximity of valuable reef assets to the coast. Agricultural activities are one of many identified threats to water quality and water flows in the Wet Tropics in terms of sediment and pollutant-related water quality decline. Information describing the current state of agricultural management practices across the region is patchy at best. Based on the best available information on agricultural management practices in the Wet Tropics in 2008, it is clear that opportunities exist to improve nutrient, sediment and pesticide management practice to reduce the impact on the water asset and the Great Barrier Reef. Based on current understandings of practices and the relationship between practices and reef water quality, the greatest opportunities for improved water quality are as follows: · nutrients – correct rate and the placement of fertilisers; · pesticides – improve weed control planning, herbicide rates and calibration practice; and · soil and sediment – implement new farming system practices. The 2008-09 Reef Rescue program sought to accelerate the rate of adoption of improved management practices and through Terrain invested $6.8M in the 2008-09 year for: · landholder water quality improvement incentive payments; · cross regional catchment repair of wetlands and riparian lands in areas of high sediment or nutrient loss; and · partnerships in the region to lever resources and support for on-ground practice change. The program delivered $3,021,999 in onground incentives to landholders in the Wet Tropics to improve farm practices from D or C level to B or A level. The landholder Water Quality Incentives Grants program received 300 individual applications for funding and funded 143 individual landholders to implement practice change across 36,098 ha of farm land. It is estimated that the Reef Rescue program facilitated practice change across 21% of the cane industry, and 20% of the banana industry. The program levered an additional $2,441,166 in landholder cash contributions and a further $907,653 in non-cash in-kind contributions bringing the total project value of the landholder grants program in the Wet Tropics to $6,370,819. Most funded projects targeted multiple water quality objectives with a focus on nutrient and sediment reduction. Of the 143 projects funded, 115 projects addressed nutrient management either as the primary focus or in combination with strategies that targeted other water quality objectives. Overall, 82 projects addressed two or more water quality targets. Forty-five percent of incentive funds were allocated to new farming system practices (direct drill legumes, zonal tillage equipment, permanent beds, min till planting equipment, GPS units, laser levelling), followed by 24% allocated to subsurface fertiliser applicators (subsurface application of fertiliser using a stool splitter or beside the stool, at the correct Six Easy Steps rate). As a result, Terrain estimates that the incentive grants achieved considerable reductions in nitrogen, phosphorus, sediment and pesticide loads. The program supported nutrient management training of 167 growers managing farms covering over 20% of the area harvested in 2008, and 18 industry advisors and resellers. This resulted in 115 growers (155 farms) developing nutrient management plans. The program also supported Integrated Weed Management training of 80 growers managing farms covering 8% of the area harvested in 2008, and 6 industry advisors and resellers. This report, which draws on the best available Reef Rescue Management Monitoring, Evaluation, Reporting, and Improvement (MERI) information to evaluate program performance and impact on water quality outcomes, is the first in a series of annual reports that will assess and evaluate the impact of the Reef Rescue program on agricultural practices and water quality outcomes. The assessment is predominantly focused on the cane industry because of data availability. In the next stage, efforts will expand to: · improve practice data for the banana and grazing industry; · gain a better understanding of the water quality trends and the factors influencing them in the Wet Tropics; in particular work will focus on linking the results of the Paddock to Reef monitoring program and practice change data to assess program impact; · enhance estimations of the impact of practice change on pollutant loads from agricultural land use; · gain a better understanding of the extent of ancillary practice (change not directly funded) resulting from Reef Rescue training/ education/communication programs; and · provide a better understanding of the economic cost of practice change across the Wet Tropics region. From an ecological perspective, water quality trends and the factors that may be contributing to change, require further investigation. There is a critical need to work towards an enhanced understanding of the link between catchment land management practice change and reef water quality, so that reduced nutrient, sediment, and pesticide discharge to the Great Barrier Reef can be quantified. This will also assist with future prioritisation of grants money to agricultural industries, catchments and sub catchments. From a social perspective, the program has delivered significant water quality benefits from landholder education and training. It is believed that these activities are giving landholders the information and tools to implement further lasting change in their production systems and in doing so, creating a change in attitude that is supportive and inclusive of Natural Resource Management (NRM). The program in the Wet Tropics has also considerably strengthened institutional partnerships for NRM, particularly between NRM and industry and extension organisations. As a result of the Reef Rescue program, all institutions are actively working together to collectively improve water quality. The Reef Rescue program is improving water quality entering the Great Barrier Reef Lagoon by catalysing substantial activity in the Wet Tropics region to improve land management practices and reduce the water quality impact of agricultural landscapes. The solid institutional partnerships between the regional body, industry, catchment and government organisations have been fundamental to the successful delivery of the landholder grant and catchment rehabilitation programs. Landholders have generally had a positive perception and reaction to the program, its intent, and the practical, focused nature of grant-based support. Demand in the program was extremely high in 2008-09 and is expected to increase in 2009-2010.

A cascade multilevel STATCOM for wind generation systems

This paper presents a novel STATCOM configuration for voltage quality improvement in wind power generation systems. The proposed STATCOM is formed by cascading two 3-level inverters, `bulk inverter' and `conditioning inverter', through a coupling transformer. Both inverters are powered by dc-link capacitors and they are charged by a small amount of active power drawn from the grid. To minimize switching losses, the high power bulk inverter operates at low frequency while low power high frequency conditioning inverter is used to suppress harmonic content produced by the bulk inverter output. With only 24 switches this topology can synthesize a nine level inverter, if the dc-link voltage ratio is maintained at 3:1. Modulation and control techniques have been developed to meet this requirement. Reactive power of the STATCOM is controlled to mitigate voltage sags or swells caused by sudden wind changes. Simulation and experimental results are presented to verify the efficacy of the proposed modulation and control techniques used in the STATCOM.

Palliative care phase : inter-rater reliability and acceptability in a national study

Background: The concept of palliative care consisting of five distinct, clinically meaningful, phases (stable, unstable, deteriorating, terminal and bereavement) was developed in Australia about 20 years ago and is used routinely for communicating clinical status, care planning, quality improvement and funding. Aim: To test the reliability and acceptability of revised definitions of Palliative Care Phase. Design: Multi-centre cross-sectional study involving pairs of clinicians independently rating patients according to revised definitions of Palliative Care Phase. Setting/participants: Clinicians from 10 Australian palliative care services, including 9 inpatient units and 1 mixed inpatient/community-based service. Results: A total of 102 nursing and medical clinicians participated, undertaking 595 paired assessments of 410 patients, of which 90.7% occurred within 2 h. Clinicians rated 54.8% of patients in the stable phase, 15.8% in the unstable phase, 20.8% in the deteriorating phase and 8.7% in the terminal phase. Overall agreement between clinicians’ rating of Palliative Care Phase was substantial (kappa = 0.67; 95% confidence interval = 0.61–0.70). A moderate level of inter-rater reliability was apparent across all participating sites. The results indicated that Palliative Care Phase was an acceptable measure, with no significant difficulties assigning patients to a Palliative Care Phase and a good fit between assessment of phase and the definition of that phase. The most difficult phase to distinguish from other phases was the deteriorating phase. Conclusion: Policy makers, funders and clinicians can be confident that Palliative Care Phase is a reliable and acceptable measure that can be used for care planning, quality improvement and funding purposes.

Stormwater management: An introduction to Green Gully

In recent years there has been increasing interest in the use of water resources generated within the urban boundary for potable supply substitution as a means of augmenting the current supply capacity. These urban water resources include roof and stormwater runoff. Expanding the use of stormwater runoff to add to the water supply and reduce water pollution are important objectives all over Australia. This book presents the background, significance and objectives of the research, as well as the reasons why stormwater plays a significant role as an alternative source of water.

The sleeping elephant in the room: Practices and policies regarding sleep-rest time in ECEC

The National Quality Framework (NQF) for Early Childhood Education and Care (ECEC) in Australia identifies the need for services to make provision for each child’s sleep, rest and relaxation within a national early year’s policy framework that also requires that opportunities for learning and physical health are optimised, and that the agency of each child and their family is respected. Against this background, the scheduling of a standard sleep-time in ECEC centres remains a common practice, even in rooms catering for older children for whom daytime sleep may no longer be necessary. This article draws upon existing scholarship to explore the issues and tensions associated with sleep-rest, in the context of Australian curriculum and quality standards documents. We review accounts from educators, parents and children and contemporary views regarding high quality practice in ECEC, with an aim of supporting critical reflection on practice and continuous quality improvement in ECEC.

Supporting staff to identify residents in pain: A controlled pretest-posttest study in residential aged care

Practical strategies are needed to improve pain awareness among aged care staff and promote a systematic approach to pain identification using evidence-based tools. The purpose of this study was to evaluate a pain identification tool for use by nursing and non-professional staff in residential aged care facilities (RACFs). A controlled pretest-posttest intervention design was conducted in two RACFs in Brisbane, Australia. Completed surveys were returned by 216 staff and 74 residents at baseline and 218 staff and 94 residents at 3-month follow-up. Chart audits were conducted on 308 residents at baseline and 328 at follow-up. Groups were compared on: (1) staff knowledge and attitudes regarding pain, perceived confidence and skills for pain assessment, and perceived quality of pain management, (2) frequency of pain assessments and use of pain interventions, and (3) residents’ perceptions of the quality of pain management. Both groups had high knowledge scores and reported high levels of confidence, skills and perceived quality of pain management at baseline and follow-up. The intervention group showed significant improvement in routine pain assessment and use of non-drug pain interventions. However, due to unexpected changes in control group conditions, both groups increased episodic pain assessment. Overall, staff believed the intervention was clinically useful and fostered a team approach to pain assessment. We found the introduction of pain identification resources with implementation strategies to support frontline staff was partially effective in improving staff and resident outcomes. Nonetheless, our findings confirm the need for change and importance of translational pain research in RACFs.

“I have to rest all the time because you are not allowed to play”: Exploring children’s perceptions of autonomy during sleep-time in long day care services

Daytime sleep is a significant part of the daily routine for children attending early childhood education and care (ECEC) services in Australia and many other countries. The practice of sleep-time can account for a substantial portion of the day in ECEC and often involves a mandated sleep/rest period for all children, including older preschool-aged children. Yet, there is evidence that children have a reduced need for daytime sleep as they approach school entry age and that continuation of mandated sleep-time in ECEC for preschool-aged children may have a negative impact on their health, development, learning and well-being. Mandated sleep-time practices also go against current quality expectations for services to support children’s agency and autonomy in ECEC. This study documents children’s reports of their experiences of sleep-time in ECEC. Semi-structured interviews were conducted with 54 preschool-aged children (44–63 months) across four long day ECEC services that employed a range of sleep-time practices. Findings provide a snapshot of children’s views and experiences of sleep-time and perceptions of autonomy-supportive practices. These provide a unique platform to support critical reflection on sleep-time policies and practices, with a view to continuous quality improvement in ECEC. This study forms part of a programme of work from the Sleep in Early Childhood research group. Our work examines sleep practices in ECEC, the subsequent staff, parent and child experiences and impacts on family and child learning and development outcomes.

Development of innovative robust stability enhancement algorithms for distribution systems containing distributed generators

This project was a step forward in improving the voltage profile of traditional low voltage distribution networks with high photovoltaic generation or high peak demand. As a practical and economical solution, the developed methods use a Dynamic Voltage Restorer or DVR, which is a series voltage compensator, for continuous and communication-less power quality enhancement. The placement of DVR in the network is optimised in order to minimise its power rating and cost. In addition, new approaches were developed for grid synchronisation and control of DVR which are integrated with the voltage quality improvement algorithm for stable operation.

Developing Strategic Marketing Plan

This publication is first in a series targeted for Coordinators and Managers within Benefits Planning, Assistance and Outreach Programs concerned with developing continuous quality improvement approaches. This early publication focuses on understanding strategies for market position, strategic planning and provides a tool for conducting an organizational self-assessment along with a stakeholder analysis

Development and evaluation of training in culturally specific screening and brief intervention for hospital patients with alcohol-related injuries

Objective To evaluate health practitioners’ confidence and knowledge of alcohol screening, brief intervention and referral after training in a culturally adapted intervention on alcohol misuse and well-being issues for trauma patients. Design Mixed methods, involving semi-structured interviews at baseline and a post-workshop questionnaire. Setting: Targeted acute care within a remote area major tertiary referral hospital. Participants Ten key informants and 69 questionnaire respondents from relevant community services and hospital-based health care professionals. Intervention Screening and brief intervention training workshops and resources for 59 hospital staff. Main outcome measures Self-reported staff knowledge of alcohol screening, brief intervention and referral, and satisfaction with workshop content and format. Results After training, 44% of participants reported being motivated to implement alcohol screening and intervention. Satisfaction with training was high, and most participants reported that their knowledge of screening and brief intervention was improved. Conclusion Targeted educational interventions can improve the knowledge and confidence of inpatient staff who manage patients at high risk of alcohol use disorder. Further research is needed to determine the duration of the effect and influence on practice behaviour. Ongoing integrated training, linked with systemic support and established quality improvement processes, is required to facilitate sustained change and widespread dissemination.

Evaluation of an intervention for patients with alcohol-related injuries: results of a mixed methods study

Objective: To explore the effect of education and training on the delivery of alcohol screening and brief intervention and referral to high-risk patients in a hospital setting. Main outcome measures included; delivery of training; practice change in relation to staff performing alcohol screening, brief intervention and referrals. Methods: Observational study design using mixed methods set in a tertiary referral hospital. Pre-post assessment of medical records and semi-structured interviews with key informants. Results: Routine screening for substance misuse (9% pre / 71.4% post) and wellbeing concerns (6.6% pre / 15 % post) was more frequent following the introduction of resources and staff participation in educational workshops. There was no evidence of a concomitant increase in delivery of brief intervention or referrals to services. Implementation challenges, including time constraints and staff attitudes, and enablers such as collaboration and visible pathways, were identified. Conclusion: Rates of patient screening increased, however barriers to delivery of brief intervention and referrals remained. Implementation strategies targeting specific barriers and enablers to introducing interventions are both required to improve the application of secondary prevention for patients in acute settings. Implications: Educational training, formalised liaison between services, systematised early intervention protocols, and continuous quality improvement processes will progress service delivery in this area.

Paddock to Reef Monitoring and Evaluation: Economic analysis of ABCD cane management practices for the Mackay Whitsunday region

The economic analysis is based on the A, B, C and D management practice framework for water quality improvement developed in 2007/2008 by the respective natural resource management region. The Mackay Whitsunday ABCD management framework for sugarcane management practices was published in 2009 by the Department of Primary Industries & Fisheries (DPI&F), following the original version that was published in the Water Quality Improvement Plan: final report for Mackay Whitsunday region (2008).