National health and hospital network for Australia's future : Implications for emergency medicine

The proposals arising from the agreement reached between the Rudd government and the States and Territories (except Western Australia) in April 2010 represent the most fundamental realignment of health responsibilities since the creation of Medicare in 1984. They will change the health system, and the structures that will craft its future direction and design. These proposals will have a significant impact on Emergency Medicine; an impact from not only the system-wide effects of the proposals but also those that derive from the specific recommendations to create an activity-based funding mechanism for EDs, to implement the four hour rule and to develop a performance indicator framework for EDs. The present paper will examine the potential impact of the proposals on Emergency Medicine to inform those who work within the system and to help guide further developments. More work is required to better evaluate the proposals and to guide the design and development of specific reform instruments. Any such efforts should be based upon a proper analysis of the available evidence, and a structured approach to research and development so as to deliver on improved services to the community, and on improved quality and safety of emergency medical care.

A 'conceptual models' approach to organisational resilience

Gibson and Tarrant discuss the range of inter-dependant factors needed to manage organisational resilience. Over the last few years there has been considerable interest in the idea of resilience across all areas of society. Like any new area or field this has produced a vast array of definitions, processes, management systems and measurement tools which together have clouded the concept of resilience. Many of us have forgotten that ultimately resilience is not just about ‘bouncing back from adversity’ but is more broadly concerned with adaptive capacity and how we better understand and address uncertainty in our internal and external environments. The basis of organisational resilience is a fundamental understanding and treatment of risk, particularly non-routine or disruption related risk. This paper presents a number of conceptual models of organisational resilience that we have developed to demonstrate the range of inter-dependant factors that need to be considered in the management of such risk. These conceptual models illustrate that effective resilience is built upon a range of different strategies that enhance both ‘hard’ and ‘soft’ organisational capabilities . They emphasise the concept that there is no quick fix, no single process, management system or software application that will create resilience.

The organisation : risk, resilience and governance

Tarrant argues that a solid risk management strategy is critical to building effective, transformational and adaptive organisations. Organisations are a fundamental part of our society and economic system whether they are private, public or not-for-profits. There are very few aspects of our society and economy that don’t rely wholly or in part on the performance of organisations. Disasters and crises are complex and very challenging environments for organisations. How can effective transformational and adaptive capacity become institutionalised and a core part of good governance of organisations? Effective risk management is a critical element in meeting organisational objectives in a turbulent and uncertain environment.

Gaseous air pollution and emergency hospital visits for hypertension in Beijing, China : a time-stratified case-crossover study

Background: A number of epidemiological studies have been conducted to research the adverse effects of air pollution on mortality and morbidity. Hypertension is the most important risk factor for cardiovascular mortality. However, few previous studies have examined the relationship between gaseous air pollution and morbidity for hypertension. ---------- Methods: Daily data on emergency hospital visits (EHVs) for hypertension were collected from the Peking University Third Hospital. Daily data on gaseous air pollutants (sulfur dioxide (SO2) and nitrogen dioxide (NO2)) and particulate matter less than 10 μm in aerodynamic diameter (PM10) were collected from the Beijing Municipal Environmental Monitoring Center. A time-stratified case-crossover design was conducted to evaluate the relationship between urban gaseous air pollution and EHVs for hypertension. Temperature and relative humidity were controlled for. ---------- Results: In the single air pollutant models, a 10 μg/m3 increase in SO2 and NO2 were significantly associated with EHVs for hypertension. The odds ratios (ORs) were 1.037 (95% confidence interval (CI): 1.004-1.071) for SO2 at lag 0 day, and 1.101 (95% CI: 1.038-1.168) for NO2 at lag 3 day. After controlling for PM10, the ORs associated with SO2 and NO2 were 1.025 (95% CI: 0.987-1.065) and 1.114 (95% CI: 1.037-1.195), respectively.---------- Conclusion: Elevated urban gaseous air pollution was associated with increased EHVs for hypertension in Beijing, China.

An innovative robust reactive surgery assignment model

Online scheduling in the Operating Theatre Department is a dynamic process that deals with both elective and emergency patients. Each business day begins with an elective schedule determined in advance based on a mastery surgery schedule. Throughout the course of the day however, disruptions to this baseline schedule occur due to variations in treatment time, emergency arrivals, equipment failure and resource unavailability. An innovative robust reactive surgery assignment model is developed for the operating theatre department. Following the completion of each surgery, the schedule is re-solved taking into account any disruptions in order to minimise cancellations of pre-planned patients and maximise throughput of emergency cases. The single theatre case is solved and future work on the computationally more complex multiple theatre case under resource constraints is discussed.

Longitudinal investigation of wandering behavior in department of veterans affairs nursing home care units

Objectives To explore the extent of and factors associated with male residents who change wandering status post nursing home admission. Design Longitudinal design with secondary data analyses. Admissions over a 4-year period were examined using repeat assessments with the Minimum Data Set (MDS) to formulate a model understanding the development of wandering behavior. Setting One hundred thirty-four Veterans Administration (VA) nursing homes throughout the United States. Participants: Included 6673 residents admitted to VA nursing homes between October 2000 and October 2004. Measurements MDS variables (cognitive impairment, mood, behavior problems, activities of daily living and wandering) included ratings recorded at residents’ admission to the nursing home and a minimum of two other time points at quarterly intervals. Results The majority (86%) of the sample were classified as non wanderers at admission and most of these (94%) remained non wanderers until discharge or the end of the study. Fifty one per cent of the wanderers changed status to non wanderers with 6% of these residents fluctuating in status more than two times. Admission variables associated with an increased risk of changing status from non-wandering to wandering included older age, greater cognitive impairment, more socially inappropriate behavior, resisting care, easier distractibility, and needing less help with personal hygiene. Requiring assistance with locomotion and having three or more medical comorbidities were associated with a decreased chance of changing from non-wandering to wandering status. Conclusion A resident’s change from non-wandering to wandering status may reflect an undetected medical event that affects cognition, but spares mobility.

Anticipated behaviours of emergency prehospital medical care providers during an influenza pandemic

Introduction: Emergency prehospital medical care providers are frontline health workers during emergencies. However, little is known about their attitudes, perceptions, and likely behaviors during emergency conditions. Understanding these attitudes and behaviors is crucial to mitigating the psychological and operational effects of biohazard events such as pandemic influenza, and will support the business continuity of essential prehospital services. ----- ----- Problem: This study was designed to investigate the association between knowledge and attitudes regarding avian influenza on likely behavioral responses of Australian emergency prehospital medical care providers in pandemic conditions. ----- ----- Methods: Using a reply-paid postal questionnaire, the knowledge and attitudes of a national, stratified, random sample of the Australian emergency prehospital medical care workforce in relation to pandemic influenza were investigated. In addition to knowledge and attitudes, there were five measures of anticipated behavior during pandemic conditions: (1) preparedness to wear personal protective equipment (PPE); (2) preparedness to change role; (3) willingness to work; and likely refusal to work with colleagues who were exposed to (4) known and (5) suspected influenza. Multiple logistic regression models were constructed to determine the independent predictors of each of the anticipated behaviors, while controlling for other relevant variables. ----- ----- Results: Almost half (43%) of the 725 emergency prehospital medical care personnel who responded to the survey indicated that they would be unwilling to work during pandemic conditions; one-quarter indicated that they would not be prepared to work in PPE; and one-third would refuse to work with a colleague exposed to a known case of pandemic human influenza. Willingness to work during a pandemic (OR = 1.41; 95% CI = 1.0–1.9), and willingness to change roles (OR = 1.44; 95% CI = 1.04–2.0) significantly increased with adequate knowledge about infectious agents generally. Generally, refusal to work with exposed (OR = 0.48; 95% CI = 0.3–0.7) or potentially exposed (OR = 0.43; 95% CI = 0.3–0.6) colleagues significantly decreased with adequate knowledge about infectious agents. Confidence in the employer’s capacity to respond appropriately to a pandemic significantly increased employee willingness to work (OR = 2.83; 95% CI = 1.9–4.1); willingness to change roles during a pandemic (OR = 1.52; 95% CI = 1.1–2.1); preparedness to wear PPE (OR = 1.68; 95% CI = 1.1–2.5); and significantly decreased the likelihood of refusing to work with colleagues exposed to (suspected) influenza (OR = 0.59; 95% CI = 0.4–0.9). ----- ----- Conclusions:These findings indicate that education and training alone will not adequately prepare the emergency prehospital medical workforce for a pandemic. It is crucial to address the concerns of ambulance personnel and the perceived concerns of their relationship with partners in order to maintain an effective prehospital emergency medical care service during pandemic conditions.

Attitudes to living and working in pandemic conditions among emergency prehospital medical care personnel

Introduction: Little is known about the risk perceptions and attitudes of healthcare personnel, especially of emergency prehospital medical care personnel, regarding the possibility of an outbreak or epidemic event. Problem: This study was designed to investigate pre-event knowledge and attitudes of a national sample of the emergency prehospital medical care providers in relation to a potential human influenza pandemic, and to determine predictors of these attitudes. Methods: Surveys were distributed to a random, cross-sectional sample of 20% of the Australian emergency prehospital medical care workforce (n = 2,929), stratified by the nine services operating in Australia, as well as by gender and location. The surveys included: (1) demographic information; (2) knowledge of influenza; and (3) attitudes and perceptions related to working during influenza pandemic conditions. Multiple logistic regression models were constructed to identify predictors of pandemic-related risk perceptions. Results: Among the 725 Australian emergency prehospital medical care personnel who responded, 89% were very anxious about working during pandemic conditions, and 85% perceived a high personal risk associated with working in such conditions. In general, respondents demonstrated poor knowledge in relation to avian influenza, influenza generally, and infection transmission methods. Less than 5% of respondents perceived that they had adequate education/training about avian influenza. Logistic regression analyses indicate that, in managing the attitudes and risk perceptions of emergency prehospital medical care staff, particular attention should be directed toward the paid, male workforce (as opposed to volunteers), and on personnel whose relationship partners do not work in the health industry. Conclusions: These results highlight the potentially crucial role of education and training in pandemic preparedness. Organizations that provide emergency prehospital medical care must address this apparent lack of knowledge regarding infection transmission, and procedures for protection and decontamination. Careful management of the perceptions of emergency prehospital medical care personnel during a pandemic is likely to be critical in achieving an effective response to a widespread outbreak of infectious disease.

Knowledge management strategy for the Building Division, Queensland Department of Public Works

This paper describes the background and methodology developed and employed in undertaking research developing a Knowledge Management Strategy for a key construction focused government agency. This paper reviews this methodology and examines a likely Knowledge Management Strategy. Two central objectives structure this Case Study: 1. Identify categories of important information generated by the Building Division, Queensland Department of Public Works in its service delivery to internal and external stake-holders, and 2. Formulate an appropriate and targeted Knowledge Management Strategy to meet the needs of the Queensland Building Capital Works program. The structure of this paper includes: *Description of the Queensland construction industry setting *Review the relevant literature *Design an appropriate research methodology *Analyse results *Formulate conclusions, contributions and implications of the targeted strategy.

Policy into practice : adoption of hazard mitigation measures by local government in Queensland : a collaborative research project between Queensland University of Technology and Emergency Management Queensland in association with Local Government of Queensland Disaster Management Alliance

The focus of the present research was to investigate how Local Governments in Queensland were progressing with the adoption of delineated DM policies and supporting guidelines. The study consulted Local Government representatives and hence, the results reflect their views on these issues. Is adoption occurring? To what degree? Are policies and guidelines being effectively implemented so that the objective of a safer, more resilient community is being achieved? If not, what are the current barriers to achieving this, and can recommendations be made to overcome these barriers? These questions defined the basis on which the present study was designed and the survey tools developed. While it was recognised that LGAQ and Emergency Management Queensland (EMQ) may have differing views on some reported issues, it was beyond the scope of the present study to canvass those views. The study resolved to document and analyse these questions under the broad themes of: • Building community capacity (notably via community awareness). • Council operationalisation of DM. • Regional partnerships (in mitigation/adaptation). Data was collected via a survey tool comprising two components: • An online questionnaire survey distributed via the LGAQ Disaster Management Alliance (hereafter referred to as the “Alliance”) to DM sections of all Queensland Local Government Councils; and • a series of focus groups with selected Queensland Councils

The Botanical Gardens X-tension, (Remnant Emergency Artlab)

This film, website and gallery installation shown at UTS Gallery, Sydney, presented a glimpse into the foregrounding process of the REMNANT/EMERGENCY Artlab - held in Sydney in November 2010.

A Multifaceted Strategy for Implementation of the Ottawa Ankle Rules in Two Emergency Departments

Problem Despite widespread acceptance of the Ottawa ankle rules for assessment of acute ankle injuries, their application varies considerably. Design Before and after study. Background and setting Emergency departments of a tertiary teaching hospital and a community hospital in Australia. Key measures for improvement Documentation of the Ottawa ankle rules, proportion of patients referred for radiography, proportion of radiographs showing a fracture. Strategies for change Education, a problem specific radiography request form, reminders, audit and feedback, and using radiographers as “gatekeepers.” Effects of change Documentation of the Ottawa ankle rules improved from 57.5% to 94.7% at the tertiary hospital, and 51.6% to 80.8% at the community hospital (P<0.001 for both). The proportion of patients undergoing radiography fell from 95.8% to 87.2% at the tertiary hospital, and from 91.4% to 78.9% at the community hospital (P<0.001 for both). The proportion of radiographs showing a fracture increased from 20.4% to 27.1% at the tertiary hospital (P=0.069), and 15.2% to 27.2% (P=0.002) at the community hospital. The missed fracture rate increased from 0% to 2.9% at the tertiary hospital and from 0% to 1.6% at the community hospital compared with baseline (P=0.783 and P=0.747). Lessons learnt Assessment of case note documentation has limitations. Clinician groups seem to differ in their capacity and willingness to change their practice. A multifaceted change strategy including a problem specific radiography request form can improve the selection of patients for radiography.