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.

Delivering crushed tablets using thickened fluids : is drug diffusion into gastric fluids restricted?

Solid medications are often crushed and mixed with food or thickened water to aid drug delivery for those who cannot or prefer not to swallow whole tablets or capsules. Dysphagic patients have the added problem of being unable to safely swallow thin fluids so water thickened with polysaccharides is used to deliver crushed medications and ensure safe swallowing. It is postulated that these polysaccharide systems may restrict drug release by reducing the diffusion of the drug into gastric fluids. METHODS By using a vertical diffusion cell separated with a synthetic membrane, the diffusion of a model drug (atenolol) was studied from a donor system containing the drug dispersed into thickened water with xanthan gum (concentration range from 0.005%-2.2%) into a receptor system containing simulated gastric fluid (SGF) at 37°C. The amount of drug transferred was measured over 8 hours and diffusion coefficients estimated using the Higuchi model approach. RESULTS Atenolol diffusion decreased with increasing xanthan gum concentration up to 1.0%, above which diffusion remained around 300 μ2s-1. The rheological measurements captured the influence of the structure and conformation of the polysaccharide in water on the movement and availability of the drug in SGF. DISCUSSION Dose form administration for dysphagic patients’ needs special attention from general practitioners, pharmacist and patients. Improving drug release of crushed tablets from thickening agents requires a reduction in the diffusion pathway (e.g. by decreasing drop size radius). This approach could make the drug available in SGF in a short time without compromising the mechanical aspects of thickening agents that guarantee safe swallowing.

Soft tissue human thigh and buttock finite element model to simulate vehicle seat cushion indentation

Accurate modelling of automotive occupant posture is strongly related to the mechanical interaction between human body soft tissue and flexible seat components. This paper presents a finite-element study simulating the deflection of seat cushion foam and supportive seat structures, as well as human buttock and thigh soft tissue when seated. The thigh-buttock surface shell model was based on 95th percentile male subject scan data and made of two layers, covering thin to moderate thigh and buttock proportions. To replicate the effects of skin and fat, the neoprene rubber layer was modelled as a hyperelastic material with viscoelastic behaviour. The analytical seat model is based on a Ford production seat. The result of the finite-element indentation simulation is compared to a previous simulation of an indentation with a hard shell human model of equal geometry, and to the physical indentation result. We conclude that SAE composite buttock form and human-seat indentation of a suspended seat cushion can be validly simulated.

Inhaled corticosteroids for sub-acute cough in children (Protocol)

This is the protocol for a review and there is no abstract. The objectives are as follows: To evaluate the efficacy of inhaled corticosteroids in reducing the severity of cough in children with sub-acute cough (defined as cough duration of two to four weeks).

Novel polymer synthesis methodologies using combination of thermally and photochemically-induced nitroxide mediated polymerisation

The combination of thermally- and photochemically-induced polymerization using light sensitive alkoxyamines was investigated. The thermally driven polymerizations were performed via the cleavage of the alkoxyamine functionality, whereas the photochemically-induced polymerizations were carried out either by nitroxide mediated photo-polymerization (NMP2) or by a classical type II mechanism, depending on the structure of the light-sensitive alkoxyamine employed. Once the potential of the various structures as initiators of thermally- and photo-induced polymerizations was established, their use in combination for block copolymer syntheses was investigated. With each alkoxyamine investigated, block copolymers were successfully obtained and the system was applied to the post-modification of polymer coatings for application in patterning and photografting.

Streamlined research funding using short proposals and accelerated peer review : an observational study

Background Despite the widely recognised importance of sustainable health care systems, health services research remains generally underfunded in Australia. The Australian Centre for Health Services Innovation (AusHSI) is funding health services research in the state of Queensland. AusHSI has developed a streamlined protocol for applying and awarding funding using a short proposal and accelerated peer review. Method An observational study of proposals for four health services research funding rounds from May 2012 to November 2013. A short proposal of less than 1,200 words was submitted using a secure web-based portal. The primary outcome measures are: time spent preparing proposals; a simplified scoring of grant proposals (reject, revise or accept for interview) by a scientific review committee; and progressing from submission to funding outcomes within eight weeks. Proposals outside of health services research were deemed ineligible. Results There were 228 eligible proposals across 4 funding rounds: from 29% to 79% were shortlisted and 9% to 32% were accepted for interview. Success rates increased from 6% (in 2012) to 16% (in 2013) of eligible proposals. Applicants were notified of the outcomes within two weeks from the interview; which was a maximum of eight weeks after the submission deadline. Applicants spent 7 days on average preparing their proposal. Applicants with a ranking of reject or revise received written feedback and suggested improvements for their proposals, and resubmissions composed one third of the 2013 rounds. Conclusions The AusHSI funding scheme is a streamlined application process that has simplified the process of allocating health services research funding for both applicants and peer reviewers. The AusHSI process has minimised the time from submission to notification of funding outcomes.

Segmenting Australian high school students : two-step cluster analysis preliminary results

A one size fits all approach dominates alcohol programs in school settings (Botvin et al., 2007), which may limit program effectiveness (Snyder et al., 2004). Programs tailored to the meet the needs and wants of adolescent groups may be more effective. Limited attention has been directed towards employing a full segmentation process. Where segmentation has been examined, the focus has remained on socio-demographic characteristics and more recently psychographic variables (Mathijssen et al., 2012). The current study aimed to identify whether the addition of behaviour could be used to identify segments. Variables included attitudes towards binge drinking (α = 0.86), behavioral intentions’ (α = 0.97), perceived behavioral control (PBC), injunctive norms (α = 0.94); descriptive norms (α = 0.87), knowledge and reported behaviour. Data was collected from five schools, n = 625 (32.96% girls). Two-Step cluster analysis produced a sample (n = 625) with a silhouette measure of cohesion and separation of 0.4. The intention measure and whether students reported previously consuming alcohol were the most distinguishing characteristics - predictor importance scores of (1.0). A four segment solution emerged. The first segment (“Male abstainers” – 37.2%) featured the highest knowledge score (M: 5.9) along with the lowest-risk drinking attitudes and intentions to drink excessively. Segment 2 (“At risk drinkers” - 11.2%) were characterised by their high-risk attitudes and high-risk drinking intentions. Injunctive (M: 4.1) and descriptive norms (M: 4.9) may indicate a social environment where drinking is the norm. Segment 3 (”Female abstainers” – 25.9%) represents young girls, who have the lowest-risk attitudes and low intentions to drink excessively. The fourth and final segment (boys = 67.4%) (“Moderate drinkers” – 25.7%) all report previously drinking alcohol yet their attitudes and intentions towards excessive alcohol consumption are lower than other segments. Segmentation focuses on identifying groups of individuals who feature similar characteristics. The current study illustrates the importance of including reported behaviour in addition to psychographic and demographic characteristics to identify unique groups to inform intervention planning and design. Key messages The principle of segmentation has received limited attention in the context of school-based alcohol education programs. This research identified four segments amongst 14-16 year high school students, each of which can be targeted with a unique, tailored program to meet the needs and wants of the target audience.

Game On: Know Alcohol - Co-creating a tailored alcohol social marketing program

Research demonstrates that education programs are more effective when their target audiences and other key stakeholder groups are involved in the design. The majority of programs continue to be researcher and expert driven. This study extends upon previous research by employing a co-creation research design to offer a consumer driven alternative to education program design. Two co-creation groups involving twenty 14-16 year old Year 10 students who had previously participated in the Game On:Know Alcohol (GOKA) program, which aims to moderate alcohol drinking attitudes and behaviour, were conducted. Analysis revealed that a co-created GOKA program will differ substantially from the researcher and expert driven program that is currently being field tested. Students prefer interactive activities and activities that engage and challenge. Co-creation offers the potential to contest researcher and expert views and may offer to assist in the generation of new insights for the development of education programs.

Game On: Know Alcohol - Interim findings from the first nine schools

A six module program designed to 1) show students the effects of alcohol, 2) impart knowledge of standard drinks and 3) provide students with strategies to moderate (or abstain) from alcohol drinking, is currently being tested in a cluster randomised control design in Queensland. This paper presents immediate evaluation results for the program that was designed using the eight National Social Marketing Centre (2009) benchmark criteria. Students have participated in baseline and/or immediate follow up evaluation in six intervention and three control schools to date. Early results suggest that Game On:Know Alcohol increases knowledge relating to alcohol and moderates attitudes towards binge drinking while maintaining behavioural intentions to drink alcohol excessively. Limitations of the current study and opportunities for future research are outlined.

Maintaining or changing a drinking behavior? GOKA's short-term outcomes

During the critical neurobiological and social developmental period of adolescence, binge drinking of alcohol increases the risk of mental health problems, school exclusion, convictions, fatal and non-fatal accidents. The present research utilizes a simple cluster randomized control trial design to evaluate a social marketing program, Game On: Know Alcohol (GOKA), employing innovative online edutainment games to target binge drinking. Pre and post data were collected for seven program (942 students, mean age: 14.6 years) and five control schools (578 students, mean age: 14.4 years). Significant improvements in alcohol knowledge and affective attitude toward binge drinking was observed for adolescents who participated in GOKA compared to the control group, with maintenance of desirable subjective norms, instrumental attitudes and intentions. Given considerable external competition from messages promoting the benefits of alcohol use, a one-off program that modifies incorrect knowledge and alters perceptions of binge drinking as a fun, recreational activity represents an important step. This research contributes to current understanding of social marketing’s capacity to change drivers and maintain inhibitors of binge drinking intentions of adolescents and provides an important basis for future research in the domain.