A prospective cohort study of geriatric syndromes among older medical patients admitted to acute care hospitals

OBJECTIVES: To identify the prevalence of geriatric syndromes in the premorbid for all syndromes except falls (preadmission), admission, and discharge assessment periods and the incidence of new and significant worsening of existing syndromes at admission and discharge. DESIGN: Prospective cohort study. SETTING: Three acute care hospitals in Brisbane, Australia. PARTICIPANTS: Five hundred seventy-seven general medical patients aged 70 and older admitted to the hospital. MEASUREMENTS: Prevalence of syndromes in the premorbid (or preadmission for falls), admission, and discharge periods; incidence of new syndromes at admission and discharge; and significant worsening of existing syndromes at admission and discharge. RESULTS: The most frequently reported premorbid syndromes were bladder incontinence (44%), impairment in any activity of daily living (ADL) (42%). A high proportion (42%) experienced at least one fall in the 90 days before admission. Two-thirds of the participants experienced between one and five syndromes (cognitive impairment, dependence in any ADL item, bladder and bowel incontinence, pressure ulcer) before, at admission, and at discharge. A majority experienced one or two syndromes during the premorbid (49.4%), admission (57.0%), or discharge (49.0%) assessment period.The syndromes with a higher incidence of significant worsening at discharge (out of the proportion with the syndrome present premorbidly) were ADL limitation (33%), cognitive impairment (9%), and bladder incontinence (8%). Of the syndromes examined at discharge, a higher proportion of patients experienced the following new syndromes at discharge (absent premorbidly): ADL limitation (22%); and bladder incontinence (13%). CONCLUSION: Geriatric syndromes were highly prevalent. Many patients did not return to their premorbid function and acquired new syndromes.

Defences in medical negligence : to what extent has tort law reform in Australia limited the liability of health professionals?

Tort law reform has resulted in legislation being passed by all Australian jurisdictions in the past decade implementing the recommendations contained in the Ipp Report. The report was in response to a perceived crisis in medical indemnity insurance. The objective was to restrict and limit liability in negligence actions. This paper will consider to what extent the reforms have impacted on the liability of health professionals in medical negligence actions. After an analysis of the legislation, it will be argued in this paper that while there has been some limitation and restriction, courts have generally interpreted the civil liability reforms in compliance with the common law. It has been the impact of statutory limits on the assessment of damages through thresholds and caps which has limited the liability of health professionals in medical negligence actions.

Demand for public hospital emergency department services in Australia : 2000–2001 to 2009–2010

Objective: Hospital EDs are a significant and high-profile component of Australia’s health-care system, which in recent years have experienced considerable crowding. This crowding is caused by the combination of increasing demand, throughput and output factors. The aim of the present article is to clarify trends in the use of public ED services across Australia with a view to providing an evidence basis for future policy analysis and discussion. Methods: The data for the present article have been extracted, compiled and analysed from publicly available sources for a 10 year period between 2000–2001 and 2009–2010. Results: Demand for public ED care increased by 37% over the decade, an average annual increase of 1.8% in the utilization rate per 1000 persons. There were significant differences in utilization rates and in trends in growth among states and territories that do not easily relate to general population trends alone. Conclusions: This growth in demand exceeds general population growth, and the variability between states both in utilization rates and overall trends defies immediate explanation. The growth in demand for ED services is a partial contributor to the crowding being experienced in EDs across Australia. There is a need for more detailed study, including qualitative analysis of patient motivations in order to identify the factors driving this growth in demand.

Application of operations research techniques to improve efficiency in the emergency department

The main aim of this thesis is to analyse and optimise a public hospital Emergency Department. The Emergency Department (ED) is a complex system with limited resources and a high demand for these resources. Adding to the complexity is the stochastic nature of almost every element and characteristic in the ED. The interaction with other functional areas also complicates the system as these areas have a huge impact on the ED and the ED is powerless to change them. Therefore it is imperative that OR be applied to the ED to improve the performance within the constraints of the system. The main characteristics of the system to optimise included tardiness, adherence to waiting time targets, access block and length of stay. A validated and verified simulation model was built to model the real life system. This enabled detailed analysis of resources and flow without disruption to the actual ED. A wide range of different policies for the ED and a variety of resources were able to be investigated. Of particular interest was the number and type of beds in the ED and also the shift times of physicians. One point worth noting was that neither of these resources work in isolation and for optimisation of the system both resources need to be investigated in tandem. The ED was likened to a flow shop scheduling problem with the patients and beds being synonymous with the jobs and machines typically found in manufacturing problems. This enabled an analytic scheduling approach. Constructive heuristics were developed to reactively schedule the system in real time and these were able to improve the performance of the system. Metaheuristics that optimised the system were also developed and analysed. An innovative hybrid Simulated Annealing and Tabu Search algorithm was developed that out-performed both simulated annealing and tabu search algorithms by combining some of their features. The new algorithm achieves a more optimal solution and does so in a shorter time.

The Remnant Emergency Artlab

The REMNANT/EMERGENCY Artlab was funded by the Australia Council InterArts ArtLab Program in 2010 and involves 22 months of rigorous research and experimentation in several countries. The process will be developed between a core transdisciplinary team of practicing media artists, designers and engineers where possible working in consultation and collaboration with local creatives at each venue. Our team asserts that today’s environmental crisis is underpinned by a deep cultural crisis - and so to get our ‘house in order’ we urgently need to create better and more powerful ‘images’ of what a ‘citizen-led’, sustainable world might be. This ArtLab’s core aim is therefore to begin to understand how to develop and create such ‘powerful images’.

Applications of medical image processing in the diagnosis and treatment of spinal deformity

In Chapter 10, Adam and Dougherty describe the application of medical image processing to the assessment and treatment of spinal deformity, with a focus on the surgical treatment of idiopathic scoliosis. The natural history of spinal deformity and current approaches to surgical and non-surgical treatment are briefly described, followed by an overview of current clinically used imaging modalities. The key metrics currently used to assess the severity and progression of spinal deformities from medical images are presented, followed by a discussion of the errors and uncertainties involved in manual measurements. This provides the context for an analysis of automated and semi-automated image processing approaches to measure spinal curve shape and severity in two and three dimensions.

Bayesian mixtures for modelling complex medical data : a case study in Parkinson’s disease

Mixture models are a flexible tool for unsupervised clustering that have found popularity in a vast array of research areas. In studies of medicine, the use of mixtures holds the potential to greatly enhance our understanding of patient responses through the identification of clinically meaningful clusters that, given the complexity of many data sources, may otherwise by intangible. Furthermore, when developed in the Bayesian framework, mixture models provide a natural means for capturing and propagating uncertainty in different aspects of a clustering solution, arguably resulting in richer analyses of the population under study. This thesis aims to investigate the use of Bayesian mixture models in analysing varied and detailed sources of patient information collected in the study of complex disease. The first aim of this thesis is to showcase the flexibility of mixture models in modelling markedly different types of data. In particular, we examine three common variants on the mixture model, namely, finite mixtures, Dirichlet Process mixtures and hidden Markov models. Beyond the development and application of these models to different sources of data, this thesis also focuses on modelling different aspects relating to uncertainty in clustering. Examples of clustering uncertainty considered are uncertainty in a patient’s true cluster membership and accounting for uncertainty in the true number of clusters present. Finally, this thesis aims to address and propose solutions to the task of comparing clustering solutions, whether this be comparing patients or observations assigned to different subgroups or comparing clustering solutions over multiple datasets. To address these aims, we consider a case study in Parkinson’s disease (PD), a complex and commonly diagnosed neurodegenerative disorder. In particular, two commonly collected sources of patient information are considered. The first source of data are on symptoms associated with PD, recorded using the Unified Parkinson’s Disease Rating Scale (UPDRS) and constitutes the first half of this thesis. The second half of this thesis is dedicated to the analysis of microelectrode recordings collected during Deep Brain Stimulation (DBS), a popular palliative treatment for advanced PD. Analysis of this second source of data centers on the problems of unsupervised detection and sorting of action potentials or "spikes" in recordings of multiple cell activity, providing valuable information on real time neural activity in the brain.

Demand for hospital emergency departments : a conceptual understanding

BACKGROUND: Emergency departments (EDs) are critical to the management of acute illness and injury, and the provision of health system access. However, EDs have become increasingly congested due to increased demand, increased complexity of care and blocked access to ongoing care (access block). Congestion has clinical and organisational implications. This paper aims to describe the factors that appear to infl uence demand for ED services, and their interrelationships as the basis for further research into the role of private hospital EDs. DATA SOURCES: Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) and relevant journals were searched using terms related to EDs and emergency health needs. Literature pertaining to emergency department utilisation worldwide was identified, and articles selected for further examination on the basis of their relevance and significance to ED demand. RESULTS: Factors influencing ED demand can be categorized into those describing the health needs of the patients, those predisposing a patient to seeking help, and those relating to policy factors such as provision of services and insurance status. This paper describes the factors influencing ED presentations, and proposes a novel conceptual map of their interrelationship. CONCLUSION: This review has explored the factors contributing to the growing demand for ED care, the influence these factors have on ED demand, and their interrelationships depicted in the conceptual model.

Towards semantic search and inference in electronic medical records : an approach using concept-based information retrieval

For more than a decade research in the field of context aware computing has aimed to find ways to exploit situational information that can be detected by mobile computing and sensor technologies. The goal is to provide people with new and improved applications, enhanced functionality and better use experience (Dey, 2001). Early applications focused on representing or computing on physical parameters, such as showing your location and the location of people or things around you. Such applications might show where the next bus is, which of your friends is in the vicinity and so on. With the advent of social networking software and microblogging sites such as Facebook and Twitter, recommender systems and so on context-aware computing is moving towards mining the social web in order to provide better representations and understanding of context, including social context. In this paper we begin by recapping different theoretical framings of context. We then discuss the problem of context- aware computing from a design perspective.

Using operations research methodologies to improve operating theatre scheduling

A hospital consists of a number of wards, units and departments that provide a variety of medical services and interact on a day-to-day basis. Nearly every department within a hospital schedules patients for the operating theatre (OT) and most wards receive patients from the OT following post-operative recovery. Because of the interrelationships between units, disruptions and cancellations within the OT can have a flow-on effect to the rest of the hospital. This often results in dissatisfied patients, nurses and doctors, escalating waiting lists, inefficient resource usage and undesirable waiting times. The objective of this study is to use Operational Research methodologies to enhance the performance of the operating theatre by improving elective patient planning using robust scheduling and improving the overall responsiveness to emergency patients by solving the disruption management and rescheduling problem. OT scheduling considers two types of patients: elective and emergency. Elective patients are selected from a waiting list and scheduled in advance based on resource availability and a set of objectives. This type of scheduling is referred to as ‘offline scheduling’. Disruptions to this schedule can occur for various reasons including variations in length of treatment, equipment restrictions or breakdown, unforeseen delays and the arrival of emergency patients, which may compete for resources. Emergency patients consist of acute patients requiring surgical intervention or in-patients whose conditions have deteriorated. These may or may not be urgent and are triaged accordingly. Most hospitals reserve theatres for emergency cases, but when these or other resources are unavailable, disruptions to the elective schedule result, such as delays in surgery start time, elective surgery cancellations or transfers to another institution. Scheduling of emergency patients and the handling of schedule disruptions is an ‘online’ process typically handled by OT staff. This means that decisions are made ‘on the spot’ in a ‘real-time’ environment. There are three key stages to this study: (1) Analyse the performance of the operating theatre department using simulation. Simulation is used as a decision support tool and involves changing system parameters and elective scheduling policies and observing the effect on the system’s performance measures; (2) Improve viability of elective schedules making offline schedules more robust to differences between expected treatment times and actual treatment times, using robust scheduling techniques. This will improve the access to care and the responsiveness to emergency patients; (3) Address the disruption management and rescheduling problem (which incorporates emergency arrivals) using innovative robust reactive scheduling techniques. The robust schedule will form the baseline schedule for the online robust reactive scheduling model.

Bariatric patients and the use of mobile hoists : user experiences from three hospitals in South Australia

Nursing personnel are consistently identified as one of the occupational groups most at risk of work-related musculoskeletal disorders. During the moving and handling of bariatric patients, the weight of the patient combined with atypical body mass contributes to a significant risk of injury to the care provider and patient. This is further compounded by the shape, mobility and co-operation of the patient. The aim of this study was determine user experiences and design requirements for mobile hoists with bariatric patients. Structured interviews were conducted with six experienced injury management staff from the Manual Task Services department of three hospitals in Adelaide, South Australia. All staff had experience in patient handling, the use of patient handling equipment and the provision of patient handling training. A series of open-ended questions were structured around five main themes: 1) patient factors; 2) building/vehicle space and design; 3) equipment and furniture; 4) communication; and 5) staff issues. Questions focussed on the use of mobile hoists for lifting and transferring bariatric patients. Interviews were supplemented with a walk-through of the hospital to view the types of mobile hoists used, and the location and storage of equipment. Across the three hospitals there were differing classification systems to define bariatric patients. Ensuring patient dignity, respect and privacy were viewed as important in the management and rehabilitation of bariatric patients. Storage and space constraints were considered factors restricting the use of mobile floor hoists, with ceiling hoists being the preferred method for patient transfers. When using mobile floor hoists, the forces required to push, pull and manoeuvre, as well as sudden unstable movements of the hoist were considered important risks factors giving rise to a risk of injury to the care provider. Record keeping and purchasing policies appeared to inhibit the effective use of patient handling equipment. The moving and handling of bariatric patients presents complex and challenging issues. A co-ordinated and collaborative approach for moving and handling bariatric patients is needed across the range of care providers. Designers must consider both user and patient requirements.

Application of Geographic Modeling Techniques to Quantify Spatial Access to Health Services Before and After an Acute Cardiac Event: The Cardiac ARIA Project

Background: Access to cardiac services is essential for appropriate implementation of evidence-based therapies to improve outcomes. The Cardiac Accessibility and Remoteness Index for Australia (Cardiac ARIA) aimed to derive an objective, geographic measure reflecting access to cardiac services. Methods: An expert panel defined an evidence-based clinical pathway. Using Geographic Information Systems (GIS), a numeric/alpha index was developed at two points along the continuum of care. The acute category (numeric) measured the time from the emergency call to arrival at an appropriate medical facility via road ambulance. The aftercare category (alpha) measured access to four basic services (family doctor, pharmacy, cardiac rehabilitation, and pathology services) when a patient returned to their community. Results: The numeric index ranged from 1 (access to principle referral center with cardiac catheterization service ≤ 1 hour) to 8 (no ambulance service, > 3 hours to medical facility, air transport required). The alphabetic index ranged from A (all 4 services available within 1 hour drive-time) to E (no services available within 1 hour). 13.9 million (71%) Australians resided within Cardiac ARIA 1A locations (hospital with cardiac catheterization laboratory and all aftercare within 1 hour). Those outside Cardiac 1A were over-represented by people aged over 65 years (32%) and Indigenous people (60%). Conclusion: The Cardiac ARIA index demonstrated substantial inequity in access to cardiac services in Australia. This methodology can be used to inform cardiology health service planning and the methodology could be applied to other common disease states within other regions of the world.

Cardiac ARIA Index: Measuring Accessibility to Cardiovascular Services in Rural and Remote Australia via Applied Geographic Spatial Technology

Cardiovascular disease (CVD) continues to impose a heavy burden in terms of cost, disability and death in Australia. Evidence suggests that increasing remoteness, where cardiac services are scarce, is linked to an increased risk of dying from CVD. Fatal CVD events are reported to be between 20% and 50% higher in rural areas compared to major cities. The Cardiac ARIA project, with its extensive use of geographic Information Systems (GIS), ranks each of Australia’s 20,387 urban, rural and remote population centres by accessibility to essential services or resources for the management of a cardiac event. This unique, innovative and highly collaborative project delivers a powerful tool to highlight and combat the burden imposed by cardiovascular disease (CVD) in Australia. Cardiac ARIA is innovative. It is a model that could be applied internationally and to other acute and chronic conditions such as mental health, midwifery, cancer, respiratory, diabetes and burns services. Cardiac ARIA was designed to: 1. Determine by expert panel, what were the minimal services and resources required for the management of a cardiac event in any urban, rural or remote population locations in Australia using a single patient pathway to access care. 2. Derive a classification using GIS accessibility modelling for each of Australia’s 20,387 urban, rural and remote population locations. 3. Compare the Cardiac ARIA categories and population locations with census derived population characteristics. Key findings are as follows: • In the event of a cardiac emergency, the majority of Australians had very good access to cardiac services. Approximately 71% or 13.9 million people lived within one hour of a category one hospital. • 68% of older Australians lived within one hour of a category one hospital (Principal Referral Hospital with access to Cardiac Catheterisation). • Only 40% of indigenous people lived within one hour of the category one hospital. • 16% (74000) of indigenous people lived more than one hour from a hospital. • 3% (91,000) of people 65 years of age or older lived more than one hour from any hospital or clinic. • Approximately 96%, or 19 million, of people lived within one hour of the four key services to support cardiac rehabilitation and secondary prevention. • 75% of indigenous people lived within one hour of the four cardiac rehabilitation services to support cardiac rehabilitation and secondary prevention. Fourteen percent (64,000 persons) indigenous people had poor access to the four key services to support cardiac rehabilitation and secondary prevention. • 12% (56,000) of indigenous people were more than one hour from a hospital and only had access one the four key services (usually a medical service) to support cardiac rehabilitation and secondary prevention.

Overlapping medical alarms are almost indiscriminable

Objective: We explore how accurately and quickly nurses can identify melodic medical equipment alarms when no mnemonics are used, when alarms may overlap, and when concurrent tasks are performed. Background: The international standard IEC 60601-1-8 (International Electrotechnical Commission, 2005) has proposed simple melodies to distinguish seven alarm sources. Previous studies with nonmedical participants reveal poor learning of melodic alarms and persistent confusions between some of them. The effects of domain expertise, concurrent tasks, and alarm overlaps are unknown. Method: Fourteen intensive care and general medical unit nurses learned the melodic alarms without mnemonics in two sessions on separate days. In the second half of Day 2 the nurses identified single alarms or pairs of alarms played in sequential, partially overlapping, or nearly completely overlapping configurations. For half the experimental blocks nurses performed a concurrent mental arithmetic task. Results: Nurses' learning was poor and was no better than the learning of nonnurses in a previous study. Nurses showed the previously noted confusions between alarms. Overlapping alarms were exceptionally difficult to identify. The concurrent task affected response time but not accuracy. Conclusion: Because of a failure of auditory stream segregation, the melodic alarms cannot be discriminated when they overlap. Directives to sequence the sounding of alarms in medical electrical equipment must be strictly adhered to, or the alarms must redesigned to support better auditory streaming. Application: Actual or potential uses of this research include the implementation of IEC 60601-1-8 alarms in medical electrical equipment.