After hours medical ward duties in a teaching hospital

In many Australian hospitals a medical officer is available for urgent review of in-patients outside normal working hours. Current practice in nurse-initiated requests for medical officer involvement out of hours may adversely affect patient outcome as well as medical and nursing resource use at these times. Of 10 523 nurse-initiated requests for out-of-hours review recorded by medical officers at our hospital in 2002-2003, the most frequent reasons for the requests were medication review, IV fluid orders, IV resite, venesection and pathology review, none of which are related to acute changes in clinical condition. Requests for routine review of medication and fluid orders were found to be rarely essential and often inappropriate. Medical officer activity was highest before midnight and least after midnight, suggesting most requests are fulfilled in the evening. Several strategies to reduce inappropriate out-of-hours requests were identified. Routine tasks could be completed by primary treating unit staff before going off-duty. IV cannulation and venesection may be performed by appropriately trained phlebotomists or skilled advanced practice nursing staff. Meticulous ordering of 'as required' analgesia and night sedation would reduce unnecessary requests. Clinical protocols for nurse-initiated adjustment of drugs with variable dosing may also decrease inefficiencies. This would leave the ward cover medical officers more available for their primary function of urgent patient review.

Carvedilol reduces the costs of medical care in severe heart failure: An economic analysis of the COPERNICUS study applied to the United Kingdom

Background: The aim of this study was to determine the effects of carvedilol on the costs related to the treatment of severe chronic heart failure (CHF). Methods: Costs for the treatment for heart failure within the National Health Service (NHS) in the United Kingdom (UK) were applied to resource utilisation data prospectively collected in all patients randomized into the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) Study. Unit-specific, per them (hospital bed day) costs were used to calculate expenditures due to hospitalizations. We also included costs of carvedilol treatment, general practitioner surgery/office visits, hospital out-patient clinic visits and nursing home care based on estimates derived from validated patterns of clinical practice in the UK. Results: The estimated cost of carvedilol therapy and related ambulatory care for the 1156 patients assigned to active treatment was 530,771 pound (44.89 pound per patient/month of follow-up). However, patients assigned to carvedilol were hospitalised less often and accumulated fewer and less expensive days of admission. Consequently, the total estimated cost of hospital care was 3.49 pound million in the carvedilol group compared with 4.24 pound million for the 1133 patients in the placebo arm. The cost of post-discharge care was also less in the carvedilol than in the placebo group (479,200 pound vs. 548,300) pound. Overall, the cost per patient treated in the carvedilol group was 3948 pound compared to 4279 pound in the placebo group. This equated to a cost of 385.98 pound vs. 434.18 pound, respectively, per patient/month of follow-up: an 11.1% reduction in health care costs in favour of carvedilol. Conclusions: These findings suggest that not only can carvedilol treatment increase survival and reduce hospital admissions in patients with severe CHF but that it can also cut costs in the process.

Assessing professionalism: theory and practice

Professional attitudes and behaviours have only recently been explicitly recognized by medical educators as legitimate and necessary components of global competence, although the idea of Fitness to Practice has always presupposed acceptable professional behaviour. Medical schools have recently begun to introduce teaching and assessment of professionalism, including attitudes and behaviours. Partly as a result of the difficulty of assessment in this area, selection of students is receiving greater attention, in the pursuit of globally competent graduates. However, selection processes may be overrated for this purpose. Assessing actual attitudes and behaviour during the course is arguably a better way of ensuring that medical graduates are competent in these areas. I argue that judgments about attitudinal and behavioural competence are legitimate, and need be no more arbitrary than those made about scientific or clinical knowledge and skills, but also that these judgments should be restricted to what is agreed to be unacceptable behaviour, rather titan attempting to rate attitudes and behaviour positively. This model introduces students to the way in which their behaviours will be judged in their professional lives by registration authorities. These theoretical positions are illustrated by a recent case of academic failure based on inadequate attitudes and behaviours.

Learnability and discriminability of melodic medical equipment alarms

Melodic alarms proposed in the IEC 60601-1-8 standard for medical electrical equipment were tested for learnability and discriminability. Thirty-three non-anaesthetist participants learned the alarms over two sessions of practice, with or without mnemonics suggested in the standard. Fewer than 30% of participants could identify the alarms with 100% accuracy at the end of practice. Confusions persisted between pairs of alarms, especially if mnemonics were used during learning (p = 0.011). Participants responded faster (p < 0.00001) and more accurately (p = 0.002) to medium priority alarms than to high priority alarms, even though they rated the high priority alarms as sounding more urgent (p < 0.00001). Participants with at least 1 year of formal musical training identified the alarms more accurately (p = 0.0002) than musically untrained participants, and found the task easier overall (p < 0.00001). More intensive studies of the IEC 60601-1-8 alarms are needed for their effectiveness to be determined.

The multimodal world of medical monitoring displays

A vision of the future of intraoperative monitoring for anesthesia is presented-a multimodal world based on advanced sensing capabilities. I explore progress towards this vision, outlining the general nature of the anesthetist's monitoring task and the dangers of attentional capture. Research in attention indicates different kinds of attentional control, such as endogenous and exogenous orienting, which are critical to how awareness of patient state is maintained, but which may work differently across different modalities. Four kinds of medical monitoring displays are surveyed: (1) integrated visual displays, (2) head-mounted displays, (3) advanced auditory displays and (4) auditory alarms. Achievements and challenges in each area are outlined. In future research, we should focus more clearly on identifying anesthetists' information needs and we should develop models of attention in different modalities and across different modalities that are more capable of guiding design. (c) 2006 Elsevier Ltd. All rights reserved.

Near-hanging as presenting to hospitals in Queensland: Recommendations for practice

Near-hanging is an increasing presentation to hospitals in Australasia. We reviewed the clinical management and outcome of these patients as they presented to public hospitals in Queensland. A retrospective clinical record audit was made at five public hospitals between 1991 and 2000. Of 161 patients enrolled, 82% were male, 8% were Indigenous and 10% had made a previous hanging attempt. Chronic medical illnesses were documented in 11% and previous psychiatric disorders in 42%. Of the 38 patients with a Glasgow Coma Scale score (GCS) of 3 on arrival at hospital, 32% returned to independent living and 63% died. Fifty two patients received CPR, of whom 46% had an independent functional outcome. Independent predictors of mortality were a GCS on hospital arrival of 3 (AOR 150, CI 95% 12.4-1818, P

Predictors of failure by medical practitioners to report suspected child abuse in Queensland, Australia

Objective: The goal of this investigation was to examine the level of notification of child abuse and neglect and the perceived deterrents to reporting by medical practitioners, who a're mandated to report their suspicions but might choose not to do so. Design: A random sample of medical practitioners was surveyed. About three hundred medical practitioners were approached through the local Division of General Practice. 91 registered medical practitioners in Queensland, Australia, took part in the study. Results: A quarter of medical practitioners admitted failing to report suspicions, though they were mostly cognisant of their responsibility to report suspected cases of abuse and neglect. Only the belief that the suspected abuse was a single incident and unlikely to happen again predicted non-reporting (X2 [1, N =89] =7.60, p

General practice in Australia 2020: "robust and ready" or "rudderless and reeling"?

The future role and structure of Australian general practice remains uncertain, despite a decade of seemingly constant change following the release of the National Health Strategy papers. Some of the suggested change strategies (such as rural Practice Incentive Payments and practice accreditation) have been implemented; others (such as general practitioner involvement with area health authorities in delivering national goals and targets for communities) still await attention. An overarching vision for our health care system in 2020 and general practice's role within it are still to be clearly enunciated. Australia is at variance with other Western countries, such as the United Kingdom, Canada and New Zealand, which have spent significant time refocusing their health systems to deal with an ageing population with an increased burden of chronic disease. Health bureaucrats and governments need to invest strategically in operational primary care now. This will require the active commitment of general practice's national bodies to articulate and actively promote a shared vision for Australian general practice.

An audit of structured diabetes care in a rural general practice

Objective: To assess the impact of structured diabetes care in a rural general practice. Design and setting: A cohort study of structured diabetes care (care plans, multidisciplinary involvement and regular patient recall) in a large general practice in a medium-sized Australian rural town. Medical care followed each doctor's usual practice. Participants: The first 404 consecutive patients with type 2 diabetes who consented to take part in the program were evaluated 24 months after enrolment in July 2002 to December 2003. Main outcome measures: Change in cardiovascular disease risk factors (waist circumference, body mass index, serum lipid levels, blood pressure); change in indicators of risks associated with poorly controlled diabetes (glycated haemoglobin [HbA1(c]) concentration, foot lesions, clinically significant hypoglycaemia); change in 5-year cardiovascular disease risk. Results: Women had a lower 5-year risk of a cardiovascular event at enrolment than men. Structured care was associated with statistically significant reductions in mean cardiovascular disease risk factors (waist circumference, -2.6 cm; blood pressure [systolic, -3 mmHg; diastolic -7 mmHg]; and serum lipid levels [total cholesterol, -0.5 mmol/L; HDL cholesterol, 0.02 mmol/L; LDL cholesterol, -0.4 mmol/L; triglycerides, -0.3 mmol/L]); and improvements in indicators of diabetic control (proportion with severe hypoglycaemic events, -2.2%; proportion with foot lesions, -14%). The greatest improvements in risk factors occurred in patients with the highest calculated cardiovascular risk. There was a statistically significant increase in the proportion of patients with ideal blood pressure (systolic,

Deregulation, competition policy and intra-professional contests in medical education

This paper investigates how government policy directions embracing deregulation and market liberalism, together with significant pre-existing tensions within the Australian medical profession, produced ground breaking change in the funding and delivery of medical education for general practitioners. From an initial view between and within the medical profession, and government, about the goal of improving the standards of general practice education and training, segments of the general practice community, particularly those located in rural and remote settings, displayed increasingly vocal concerns about the approach and solutions proffered by the predominantly urban-influenced Royal Australian College of General Practitioners (RACGP). The extent of dissatisfaction culminated in the establishment of the Australian College of Rural and Remote Medicine (ACRRM) in 1997 and the development of an alternative curriculum for general practice. This paper focuses on two decades of changes in general practice training and how competition policy acted as a justificatory mechanism for putting general practice education out to competitive tender against a background of significant intra-professional conflict. The government's interest in increasing efficiency and deregulating the 'closed shop' practices of professions, as expressed through national competition policy, ultimately exposed the existing antagonisms within the profession to public view and allowed the government some influence on the sacred cow of professional training. Government policy has acted as a mechanism of resolution for long standing grievances of the rural GPs and propelled professional training towards an open competition model. The findings have implications for future research looking at the unanticipated outcomes of competition and internal markets.

Optical in-fiber Bragg grating sensor systems for medical applications

Two in-fiber Bragg grating (FBG) temperature sensor systems for medical applications are demonstrated: (1) an FBG flow-directed thermodilution catheter based on interferometric detection of wavelength shift that is used for cardiac monitoring; and (2) an FBG sensor system with a tunable Fabry-Perot filter for in vivo temperature profiling in nuclear magnetic resonance (NMR) machines. Preliminary results show that the FBG sensor is in good agreement with electrical sensors that are widely used in practice. A field test shows that the FBG sensor system is suitable for in situ temperature profiling in NMR machines for medical applications.

Gender and general practice: the single-handed woman General Practitioner

This research examines women GPs' careers, how they run their practices and how they reconcile professional and domestic lives. It looks at the particular experiences of women GPs who practise alone, and at the pressures in past practice experience which have led them to do so. It is argued that many of the problems of group practice which can be identified are attributable to gender. For example, one reason given for entering general practice is a desire to be able to provide the full range of medical care and not to specialise. Women GPs, however, may find themselves seeing more women patients for "women's problems" and children than they would freely choose. Women have not entered general practice in order to specialise in these areas of medicine. Indeed, if they had wanted to specialise in obstetrics, gynaecology or paediatrics they would have had difficulty advancing very far in these male-dominated areas of hospital hierarchy. Other gender related problems exist for women in general practice and practising single-handedly is one strategy that women GPs have used to counter the problems of working in male-dominated practices and partnerships. However, the twenty-four hour commitment of single-handed practice may bring further pressures in reconciling this with responsibility for home life. Out-of-hours cover, which can be viewed as the link between professional and domestic life, where the one intrudes into the other, is also examined in terms of the gender issues it raises. The interaction of gender and ethnicity is also considered for the 11 Asian women GPs in the study. Interviews were conducted with 29 single-handed women GPs in the Midlands. In addition, some cases were studied in greater depth by being observed in their surgeries and on home visits for a day each. A qualitative/feminist approach to analysis has been employed.

Drug information in general practice pharmacy

The drug information sources currently available to general practice pharmacists have been identified. The use of and attitudes to these sources were assessed as well as the perceived information needs of practising pharmacists. The special requirements of women pharmacists and pharmacists working part-time were studied. The relationship of the medical representative as an information source for pharmacists was evaluated. Participation in continuing education programmes as a vital means of ensuring current information awareness and knowledge for the practising profession has been considered. Investigations were mainly pursued by questionnaire survey, while computer facilities were used for the processing and the analyses of data. The desirability of collated and evaluated information from one or more independent authoritative sources has been discussed. The increasing advisory role of the general practice pharmacist and the needs of the patient and potential customer have been discussed, with projections for the pharmacist's future health care contribution.