Antimicrobial stewardship activities : a survey of Queensland hospitals

Objective: In 2011, the Australian Commission on Safety and Quality in Health Care (ACSQHC) recommended that all hospitals in Australia must have an Antimicrobial Stewardship (AMS) program by 2013. Nevertheless, little is known about current AMS activities. This study aimed to determine the AMS activities currently undertaken, and to identify gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. Methods: The AMS activities of 26 facilities from 15 hospital and health services in Queensland were surveyed during June 2012 to address strategies for effective AMS: implementing clinical guidelines, formulary restriction, reviewing antimicrobial prescribing, auditing antimicrobial use and selective reporting of susceptibility results. Results: The response rate was 62%. Nineteen percent had an AMS team (a dedicated multidisciplinary team consisting of a medically trained staff member and a pharmacist). All facilities had access to an electronic version of Therapeutic Guidelines: Antibiotic, with a further 50% developing local guidelines for antimicrobials. One-third of facilities had additional restrictions. Eighty-eight percent had advice for restricted antimicrobials from in-house infectious disease physicians or clinical microbiologists. Antimicrobials were monitored with feedback given to prescribers at point of care by 76% of facilities. Deficiencies reported as barriers to establishing AMS programs included: pharmacy resources, financial support by hospital management, and training and education in antimicrobial use. Conclusions: Several areas for improvement were identified: reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use. There also appears to be a lack of resources to support AMS programs in some facilities. What is known about the topic? The ACSQHC has recommended that all hospitals implement an AMS program by 2013 as a requirement of Standard 3 (Preventing and Controlling Healthcare-Associated Infections) of the National Safety and Quality Health Service Standards. The intent of AMS is to ensure appropriate prescribing of antimicrobials as part of the broader systems within a health service organisation to prevent and manage healthcare-associated infections, and improve patient safety and quality of care. This criterion also aligns closely with Standard 4: Medication Safety. Despite this recommendation, little is known about what AMS activities are undertaken in these facilities and what additional resources would be required in order to meet these national standards. What does the paper add? This is the first survey that has been conducted of public hospital and health services in Queensland, a large decentralised state in Australia. This paper describes what AMS activities are currently being undertaken, identifies practice gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. What are the implications for practitioners? Several areas for improvement such as reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use have been identified. In addition, there appears to be a lack of resources to support AMS programs in some facilities.

Teaching and assessment of prescribing medicines : how does pharmacy perform?

BACKGROUND Prescribing is a complex task, requiring specific knowledge and skills combined with effective, context-specific clinical reasoning. Prescribing errors can result in significant morbidity and mortality. For all professions with prescribing rights, a clear need exists to ensure students graduate with a well-defined set of prescribing skills, which will contribute to competent prescribing. AIM To describe the methods employed to teach and assess the principles of effective prescribing across five non-medical professions at Queensland University of Technology. METHOD The NPS National Prescribing Competencies Framework (PCF) was used as the prescribing standard. A curriculum mapping exercise was undertaken to determine how well the PCF was addressed across the disciplines of paramedic science, pharmacy, podiatry, nurse practitioner and optometry. Identified gaps in teaching and/or assessment were noted. RESULTS Prescribing skills and knowledge are taught and assessed using a range of methods across disciplines. A multi-modal approach is employed by all disciplines. The Pharmacy discipline uses more tutorial sessions to teach prescribing principles and relies less on case studies and clinical appraisal to assess prescribing when compared to other disciplines. Within the pharmacy discipline approximately 90% of the PCF competencies are taught and assessed. This compares favourably with the other disciplines. CONCLUSION Further work is required to establish a practical, effective approach to the assessment of prescribing competence especially between the university and clinical settings. Effective and reliable assessment of prescribing undertaken by students in diverse settings remains challenging.

Rethinking restrictive practices : a comparative analysis

This paper undertakes the first comparative analysis of restrictive practices legislation in Australia. This legislation, which regulates practices used to manage ‘challenging behaviours’ of people with intellectual disability or cognitive impairment, currently exists in four Australian jurisdictions. The paper demonstrates the gaps in coverage of this legislation and the wide variation of law nationally. We argue that legislation governing restrictive practices is needed, it should regulate the provision of all restrictive practices (not just some) and that there should be a national consistent approach.

Health states for schizophrenia and bipolar disorder within the Global Burden of Disease 2010 Study

A comprehensive revision of the Global Burden of Disease (GBD) study is expected to be completed in 2012. This study utilizes a broad range of improved methods for assessing burden, including closer attention to empirically derived estimates of disability. The aim of this paper is to describe how GBD health states were derived for schizophrenia and bipolar disorder. These will be used in deriving health state-specific disability estimates. A literature review was first conducted to settle on a parsimonious set of health states for schizophrenia and bipolar disorder. A second review was conducted to investigate the proportion of schizophrenia and bipolar disorder cases experiencing these health states. These were pooled using a quality-effects model to estimate the overall proportion of cases in each state. The two schizophrenia health states were acute (predominantly positive symptoms) and residual (predominantly negative symptoms). The three bipolar disorder health states were depressive, manic, and residual. Based on estimates from six studies, 63% (38%-82%) of schizophrenia cases were in an acute state and 37% (18%-62%) were in a residual state. Another six studies were identified from which 23% (10%-39%) of bipolar disorder cases were in a manic state, 27% (11%-47%) were in a depressive state, and 50% (30%-70%) were in a residual state. This literature review revealed salient gaps in the literature that need to be addressed in future research. The pooled estimates are indicative only and more data are required to generate more definitive estimates. That said, rather than deriving burden estimates that fail to capture the changes in disability within schizophrenia and bipolar disorder, the derived proportions and their wide uncertainty intervals will be used in deriving disability estimates.

Public health interventions for increasing physical activity in children, adolescents and adults : an overview of systematic reviews

This is the protocol for a review and there is no abstract. The objectives are as follows: This overview intends to: a) summarise the existing evidence on interventions that aim to increase PA; b) explore whether any effects of the intervention are different within and between populations, and whether these differences form an equity gradient such as an effect that differs according the advantage/disadvantage (e.g. low income and ethnic minorities); c) highlight gaps in the present evidence base that may warrant a Cochrane systematic review to be completed; and c) identify 'up to date' Cochrane reviews. .

Estimating the mean critical gap

The estimation of the critical gap has been an issue since the 1970s, when gap acceptance was introduced to evaluate the capacity of unsignalized intersections. The critical gap is the shortest gap that a driver is assumed to accept. A driver’s critical gap cannot be measured directly and a number of techniques have been developed to estimate the mean critical gaps of a sample of drivers. This paper reviews the ability of the Maximum Likelihood technique and the Probability Equilibrium Method to predict the mean and standard deviation of the critical gap with a simulation of 100 drivers, repeated 100 times for each flow condition. The Maximum Likelihood method gave consistent and unbiased estimates of the mean critical gap. Whereas the probability equilibrium method had a significant bias that was dependent on the flow in the priority stream. Both methods were reasonably consistent, although the Maximum Likelihood Method was slightly better. If drivers are inconsistent, then again the Maximum Likelihood method is superior. A criticism levelled at the Maximum Likelihood method is that a distribution of the critical gap has to be assumed. It was shown that this does not significantly affect its ability to predict the mean and standard deviation of the critical gaps. Finally, the Maximum Likelihood method can predict reasonable estimates with observations for 25 to 30 drivers. A spreadsheet procedure for using the Maximum Likelihood method is provided in this paper. The PEM can be improved if the maximum rejected gap is used.

Soil Magnetism Research: State of the Art and Future Directions

Magnetic properties of soils have been highlighted as a primary detrimental environmental effect on the performance of geophysical systems for detection of unexploded ordnance (UXO) and mine targets. A recent workshop at Cranfield University, U.K., aimed to identify knowledge gaps related to soil magnetism. Eight invited speakers from multidisciplinary areas provided briefings on state‐of‐the‐art research linked to soil magnetism and geophysical sensing. Contributions from other participants provided additional insights from a range of disciplines through case studies and applications. The workshop included break‐out sessions to identify current gaps in knowledge and to determine priority areas for investment in research to further developments in UXO and mine detection in magnetic soil environments. Key recommendations for future research investments have been grouped in categories including soils, theory and modeling, instrumentation, and communication.

Global, regional, and national age–sex specifi c all-cause and cause-specifi c mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background Up-to-date evidence on levels and trends for age-sex-specific all-cause and cause-specific mortality is essential for the formation of global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013) we estimated yearly deaths for 188 countries between 1990, and 2013. We used the results to assess whether there is epidemiological convergence across countries. Methods We estimated age-sex-specific all-cause mortality using the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data. We generally estimated cause of death as in the GBD 2010. Key improvements included the addition of more recent vital registration data for 72 countries, an updated verbal autopsy literature review, two new and detailed data systems for China, and more detail for Mexico, UK, Turkey, and Russia. We improved statistical models for garbage code redistribution. We used six different modelling strategies across the 240 causes; cause of death ensemble modelling (CODEm) was the dominant strategy for causes with sufficient information. Trends for Alzheimer's disease and other dementias were informed by meta-regression of prevalence studies. For pathogen-specific causes of diarrhoea and lower respiratory infections we used a counterfactual approach. We computed two measures of convergence (inequality) across countries: the average relative difference across all pairs of countries (Gini coefficient) and the average absolute difference across countries. To summarise broad findings, we used multiple decrement life-tables to decompose probabilities of death from birth to exact age 15 years, from exact age 15 years to exact age 50 years, and from exact age 50 years to exact age 75 years, and life expectancy at birth into major causes. For all quantities reported, we computed 95% uncertainty intervals (UIs). We constrained cause-specific fractions within each age-sex-country-year group to sum to all-cause mortality based on draws from the uncertainty distributions. Findings Global life expectancy for both sexes increased from 65·3 years (UI 65·0–65·6) in 1990, to 71·5 years (UI 71·0–71·9) in 2013, while the number of deaths increased from 47·5 million (UI 46·8–48·2) to 54·9 million (UI 53·6–56·3) over the same interval. Global progress masked variation by age and sex: for children, average absolute differences between countries decreased but relative differences increased. For women aged 25–39 years and older than 75 years and for men aged 20–49 years and 65 years and older, both absolute and relative differences increased. Decomposition of global and regional life expectancy showed the prominent role of reductions in age-standardised death rates for cardiovascular diseases and cancers in high-income regions, and reductions in child deaths from diarrhoea, lower respiratory infections, and neonatal causes in low-income regions. HIV/AIDS reduced life expectancy in southern sub-Saharan Africa. For most communicable causes of death both numbers of deaths and age-standardised death rates fell whereas for most non-communicable causes, demographic shifts have increased numbers of deaths but decreased age-standardised death rates. Global deaths from injury increased by 10·7%, from 4·3 million deaths in 1990 to 4·8 million in 2013; but age-standardised rates declined over the same period by 21%. For some causes of more than 100 000 deaths per year in 2013, age-standardised death rates increased between 1990 and 2013, including HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anaemias. Diarrhoeal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than 5 years. The most important pathogens are rotavirus for diarrhoea and pneumococcus for lower respiratory infections. Country-specific probabilities of death over three phases of life were substantially varied between and within regions. Interpretation For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries. Important gaps exist in the empirical data for cause of death estimates for some countries; for example, no national data for India are available for the past decade.

Sport development programmes for Indigenous Australians : innovation, inclusion and development, or a product of ‘white guilt’?

Under the legacy of neoliberalism, it is important to consider how the indigenous people, in this case of Australia, are to advance, develop and achieve some approximation of parity with broader societies in terms of health, educational outcomes and economic participation. In this paper, we explore the relationships between welfare dependency, individualism, responsibility, rights, liberty and the role of the state in the provision of Government-funded programmes of sport to Indigenous communities. We consider whether such programmes are a product of ‘white guilt’ and therefore encourage dependency and weaken the capacity for independence within communities and individuals, or whether programmes to increase rates of participation in sport are better viewed as good investments to bring about changes in physical activity as (albeit a small) part of a broader social policy aimed at reducing the gaps between Indigenous and non-Indigenous Australians in health, education and employment.

Early years national curriculum documents : revisiting inclusive education

Early years education encompasses early childhood education and care (ECEC) and the early years of school across the age range birth to eight years. The introduction of two national curriculum documents for early years education – the Early Years Learning Framework (Department of Education, Employment and Workplace Relations DEEWR, 2009) for ECEC programs and the Australian Curriculum (Australian Curriculum, Assessment and Reporting Authority ACARA, 2011a) – indicates a trend towards national coherence, yet highlights a gap between notions of inclusion in the ECEC and school sectors of early years education. These gaps have the potential to impact negatively on school transition experiences through reductions in continuity of pedagogy and partnerships with families. Australian definitions of inclusion have moved beyond integration (i.e., mainstream classroom placement with support services and accommodations to address disability or lack of English), to encompass curricular and pedagogic differentiation catering for the participation rights and sense of belonging of children with a diverse range of abilities and backgrounds. This paper considers improved curriculum alignment and pedagogic continuity through enactment of elements relevant to inclusion.

Job satisfaction of preventive medicine workers in northern Vietnam : a multi-method approach

In the health care industry, Job Satisfaction (JS) is linked with work performance, psychological well-being and employee turnover. Although research into JS among health professionals has a long history worldwide, there has been very little analysis in Vietnam. No study has addressed JS of preventive medicine workers in Vietnam, and there is no reliable and valid instrument in Vietnamese language and context for evaluation of JS in this group. This project was conducted to fill these gaps. The findings contribute evidence regarding factors that influence JS in this sector of the health industry that should be applied to personnel management policies and practices in Vietnam.

Enhancing the auditor's report : to what extent is there support for the IAASB's proposed changes?

This article outlines proposed reforms to auditor reporting currently being considered by the International Auditing and Assurance Standards Board (IAASB), and other key national and transnational standard-setters and regulatory bodies. It adds to recent academic contributions on reforming the auditor’s report by analyzing the 165 stakeholder responses to the IAASB’s 2012 Invitation to Comment: Improving the Auditor’s Report to determine levels of support for the IAASB’s proposed reforms, and the differences, if any, between the views of various respondents based on stakeholder groups (e.g. audit and assurance firms, users, preparers, regulators, etc.) and regional classifications. Guided by insights from communication theory, our results show the levels of stakeholder support for the IAASB’s proposed reforms addressing auditors’ expectations, information and communication gaps are mixed. The strongest overall support was for enhanced auditor reporting on other information attached to, or intended to be read with, the financial statements, and the least supported initiative was including additional information in the auditor’s report about the auditor’s judgements and processes. Whilst overall there is generally consensus across both stakeholder groups and regions concerning the various questions investigated, we highlight where statistically significant differences between groups do exist. Notably, North American respondents were less likely to support a number of the IAASB’s proposed reforms than their counterparts from other regions.

How costs change with infection prevention efforts

Purpose of review: To describe articles since January 2013 that include information on how costs change with infection prevention efforts. Recent findings: Three articles described only the costs imposed by nosocomial infection and so provided limited information about whether or not infection prevention efforts should be changed. One article was found that described the costs of supplying alcohol-based hand run in low-income countries. Eight articles showed the extra costs and cost savings from changing infection prevention programmes and discussed the health benefits. All concluded that the changes are economically worthwhile. There was a systematic review of the costs of methicillin-resistant Staphylococcus aureus control programmes and a methods article for how to make cost estimates for infection prevention programmes. Summary: The balance has shifted away from studies that report the high cost of nosocomial infections toward articles that address the value for money of infection prevention. This is good as simply showing a disease is high cost does not inform decisions to reduce it. More research, done well, on the costs of implementation, cost savings and change to health benefits in this area needs to be done as many gaps exist in our knowledge.

The Why, What, and How of Global Biodiversity Indicators Beyond the 2010 Target

The 2010 biodiversity target agreed by signatories to the Convention on Biological Diversity directed the attention of conservation professionals toward the development of indicators with which to measure changes in biological diversity at the global scale. We considered why global biodiversity indicators are needed, what characteristics successful global indicators have, and how existing indicators perform. Because monitoring could absorb a large proportion of funds available for conservation, we believe indicators should be linked explicitly to monitoring objectives and decisions about which monitoring schemes deserve funding should be informed by predictions of the value of such schemes to decision making. We suggest that raising awareness among the public and policy makers, auditing management actions, and informing policy choices are the most important global monitoring objectives. Using four well-developed indicators of biological diversity (extent of forests, coverage of protected areas, Living Planet Index, Red List Index) as examples, we analyzed the characteristics needed for indicators to meet these objectives. We recommend that conservation professionals improve on existing indicators by eliminating spatial biases in data availability, fill gaps in information about ecosystems other than forests, and improve understanding of the way indicators respond to policy changes. Monitoring is not an end in itself, and we believe it is vital that the ultimate objectives of global monitoring of biological diversity inform development of new indicators. ©2010 Society for Conservation Biology.

Issues to consider when developing mandatory reporting legislation and policy to improve discovery of child abuse

In the United Kingdom, recent investigations into child sexual abuse occurring within schools, the Catholic Church and the British Broadcasting Corporation, have intensified debate on ways to improve the discovery of child sexual abuse, and child maltreatment generally. One approach adopted in other jurisdictions to better identify cases of severe child maltreatment is the introduction of some form of legislative mandatory reporting to require designated persons to report known and suspected cases. The debate in England has raised the prospect of whether adopting a strategy of some kind of mandatory reporting law is advisable. The purpose of this article is to add to this debate by identifying fundamental principles, issues and complexities underpinning policy and even legislative developments in the interests of children and society. The article will first highlight the data on the hidden nature of child maltreatment and the background to the debate. Secondly, it will identify some significant gaps in knowledge that need to be filled. Thirdly, the article will summarise the barriers to reporting abuse and neglect. Fourthly, we will identify a range of options for, and clarify the dilemmas in developing, legislative mandatory reporting, addressing two key issues: who should be mandated to report, and what types of child maltreatment should they be required to report? Finally, we draw attention to some inherently different goals and competing interests, both between and within the various institutions involved in the safeguarding of children and the criminal prosecution of some offenders. Based on this analysis we offer some concluding observations that we hope contribute to informed and careful debate about mandatory reporting.