Evaluation of an ambulatory nutrition support service for malnourished patients post hospital discharge

Introduction Malnutrition is common among hospitalised patients, with poor follow-up of nutrition support post-discharge. Published studies on the efficacy of ambulatory nutrition support (ANS) for malnourished patients post-discharge are scarce. The aims of this study were to evaluate the rate of dietetics follow-up of malnourished patients post-discharge, before (2008) and after (2010) implementation of a new ANS service, and to evaluate nutritional outcomes post-implementation. Materials and Methods Consecutive samples of 261 (2008) and 163 (2010) adult inpatients referred to dietetics and assessed as malnourished using Subjective Global Assessment (SGA) were enrolled. All subjects received inpatient nutrition intervention and dietetic outpatient clinic follow-up appointments. For the 2010 cohort, ANS was initiated to provide telephone follow-up and home visits for patients who failed to attend the outpatient clinic. Subjective Global Assessment, body weight, quality of life (EQ-5D VAS) and handgrip strength were measured at baseline and five months post-discharge. Paired t-test was used to compare pre- and post-intervention results. Results In 2008, only 15% of patients returned for follow-up with a dietitian within four months post-discharge. After implementation of ANS in 2010, the follow-up rate was 100%. Mean weight improved from 44.0 ± 8.5kg to 46.3 ± 9.6kg, EQ-5D VAS from 61.2 ± 19.8 to 71.6 ± 17.4 and handgrip strength from 15.1 ± 7.1 kg force to 17.5 ± 8.5 kg force; p<0.001 for all. Seventy-four percent of patients improved in SGA score. Conclusion Ambulatory nutrition support resulted in significant improvements in follow-up rate, nutritional status and quality of life of malnourished patients post-discharge.

Rethinking emergency management and climate adaptation policies

Emergency management and climate change adaptation will increasingly challenge all levels of government because of three main factors. First, Australia is extremely vulnerable to the impacts of climate change, particularly through the increasing frequency and/or intensity of disasters such as floods and bushfires. Second, the system of government that divides powers by function and level can often act as a barrier to a well-integrated response. Third, policymaking processes struggle to cope with such complex inter-jurisdictional issues. This paper discusses these factors and explores the nature of the challenge for Australian governments. Investigations into the 2009 Victorian bushfires, the 2011 Perth Hills bushfires, and the 2011 Brisbane floods offer an indication of the challenges ahead and it is argued that there is a need to: improve community engagement and communication; refocus attention on resilience; improve interagency communication and collaboration; and, develop institutional arrangements that support continual improvement and policy learning. These findings offer an opportunity for improving responses as well as a starting point for integrating disaster risk management and climate change adaptation policies. The paper is based on the preliminary findings of an NCCARF funded research project: The Right Tool for the Job – Achieving climate change adaptation outcomes through improved disaster management policies, planning and risk management strategies involving Griffith University and RMIT.

Review: "Health service frameworks for small rural and remote communities: issues and options" by J. Humphreys, S. Mathews-Cowey, F. Rolley 1996

This monograph is a welcome investigation of current issues in rural health service delivery in smaller communities. The underlying assumption is that existing health service frameworks for rural and remote communities with populations of less than 230 are simply- not appropriate for their needs. With this in mind, the authors identify the strengths and weaknesses of frameworks presently utilised, and offer viable alternatives. They have made information accessible to those who wish to improve the delivery of rural health care, and have provided a catalyst for further research and dialogue on rural health issues...

The interface of acute and aged care : the role of the nurse in a provincial area

Objective This study was to investigate issues that arose from pre-admission to post-discharge, for people in Toowoomba, Queensland over the age of 65 admitted to an acute facility. This paper concentrates on a significant concern that emerged from the large amount of data collected during this project, that is,the role of the nurse in the continuum of health care involving elderly people. Method The study involved a multi-site, multi-agency and multi-method (qualitative and quantitative) approach. Data was collected from regional service providers, the Department of Health and Aged Care (DHAC), the Australian Bureau of Statistics (ABS), Home and Community Care (HACC), the Aged Care Assessment Team (ACAT), elderly people who had been discharged from regional hospitals and their carers, residents of regional aged care facilities, area health professionals and elderly regional hospital inpatients. Results The data indicated that nurses in this provincial area currently play a limited role in preadmission planning, being mostly concerned with elective surgery, especially joint replacements. While nurses deliver the majority of care during hospitalisation, they do not appear to be cognizant of the needs of the elderly regarding post-acute discharge. Conclusion The recent introduction of the model of nurse case management in the acute sector appears to be a positive development that will streamline and optimise the health care of the elderly across the continuum in the Toowoomba area. The paper recommends some strategies, such as discharge liaison nurses based in Emergency Departments and the expansion of the nurse case management role, which would optimise care for the elderly person at the interface of care.

Effects of size of health service on scope of rural nursing practice

This paper presents the findings of an analysis of the activities of rural nurses from a national audit of the role and function of the rural nurse (Hegney, Pearson and McCarthy 1997). The results suggest that the size of the health service (defined by the number of acute beds) influences the activities of rural nurses. Further, the study reports on the differences of the context of practice between different size rural health services and the impact this has on the scope of rural nursing practice. The paper will conclude that the size of the health service is an outcome of rurality (small population densities, distance from larger health facilities, lack of on-site medical and allied health staff). It also notes that the size of the health service is a major contextual determinant of patient acuity and staff skill-mix in small rural hospitals, and therefore the scope of rural nursing practice.

Community night patrols in the Northern Territory : toward an improved performance and reporting framework

This Technical and Background Paper summarises the results of a Australian Government Attorney-General’s Department’s funded project. The project aimed to clarify the contribution of the community night patrol program in the Northern Territory (NT) to improving the community safety of Indigenous communities. The paper recommends an improved framework for monitoring performance and reporting. Community night patrols or similar services operate in many other areas of Australia and internationally. The paper concludes that the core business of community night patrols is (non-crisis) crime prevention not defacto policing. It also concludes that an unrecognised outcome of patrols is capturing and sharing local knowledge about community safety issues and solutions. Over time, community night patrols should focus on working with other services to reduce the need for repeat assistance to persons at risk and for risky incidents. The recently released Northern Territory Emergency Response Evaluation Report (2011) confirmed that communities and service providers surveyed largely support night patrols, but better data is required to more comprehensively assess their performance.

Quality demand in vaccination and how to improve service quality under Total Quality Control [论全面质量管理模式下预防接种工作的质量要求与改进对策]

Under the concept of Total Quality Control, based on their experience, the authors discussed potential demand for quality of immunization services and possible solutions to these demands. Abstract in Chinese 全面质量管理(total quality control,TQC)是在20世纪60年代由美国人V,Feigonbaum和J.unan先后提出的新的质量管理观念,众所周知的ISO9000族标准即建立在TQC理念下的质量管理标准,该标准已成为当今世界全球一致、最具权威的质量管理和质量保证的国际规则[1-2].21世纪是质量世纪,推行TQC,不断改进产品和服务质量,目前已成为我国各行各业在不断激烈的市场竞争下完善自我、保证生存和发展的重要手段.实施预防接种是预防和控制传染病,保护人群健康的重要措施,预防接种工作中,产品即预防接种服务,需方(顾客)为接受预防接种服务的广大人群,是产品的消费者.随社会的迅速发展,人们对健康需求的不断提高,对预防接种工作也提出了更高的质量要求.本文对TQC模式下顾客对预防接种服务的质量要求进行了综合分析,并对如何改进服务质量进行了初步探讨.

The development of chronic cough in children following presentation to a tertiary paediatric emergency department with acute respiratory illness : study protocol for a prospective cohort study

Background Acute respiratory illness, a leading cause of cough in children, accounts for a substantial proportion of childhood morbidity and mortality worldwide. In some children acute cough progresses to chronic cough (> 4 weeks duration), impacting on morbidity and decreasing quality of life. Despite the importance of chronic cough as a cause of substantial childhood morbidity and associated economic, family and social costs, data on the prevalence, predictors, aetiology and natural history of the symptom are scarce. This study aims to comprehensively describe the epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children presenting to a tertiary paediatric emergency department. Methods/design A prospective cohort study of children aged <15 years attending the Royal Children's Hospital Emergency Department, Brisbane, for a respiratory illness that includes parent reported cough (wet or dry) as a symptom. The primary objective is to determine the prevalence and predictors of chronic cough (>= 4 weeks duration) post presentation with acute respiratory illness. Demographic, epidemiological, risk factor, microbiological and clinical data are completed at enrolment. Subjects complete daily cough dairies and weekly follow-up contacts for 28(+/-3) days to ascertain cough persistence. Children who continue to cough for 28 days post enrolment are referred to a paediatric respiratory physician for review. Primary analysis will be the proportion of children with persistent cough at day 28(+/-3). Multivariate analyses will be performed to evaluate variables independently associated with chronic cough at day 28(+/-3). Discussion Our protocol will be the first to comprehensively describe the natural history, epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children. The results will contribute to studies leading to the development of evidence-based clinical guidelines to improve the early detection and management of chronic cough in children during and after acute respiratory illness.

Evidence for the safety and quality issues associated with the care of patients with cognitive impairment in acute care settings : a rapid review

The Australian Commission on Safety and Quality in Health Care commissioned this rapid review to identify recent evidence in relation to three key questions: 1. What is the current evidence of quality and safety issues regarding the hospital experience of people with cognitive impairment (dementia/delirium)? 2. What are the existing evidence-based pathways, best practice or guidelines for cognitive impairment in hospitals? 3. What are the key components of an ideal patient journey for a person with dementia and/or delirium? The purpose of this review is to identify best practice in caring for patients with cognitive impairment (CI) in acute hospital settings. CI refers to patients with dementia and delirium but can include other conditions. For the purposes of this report, ‘Hospitals’ is defined as acute care settings and includes care provided by acute care institutions in other settings (e.g. Multipurpose Services and Hospital in the Home). It does not include residential aged care settings nor palliative care services that are not part of a service provided by an acute care institution. Method Both peer-reviewed publications and the grey literature were comprehensively searched for recent (primarily post 2010) publications, reports and guidelines that addressed the three key questions. The literature was evaluated and graded according to the National Health and Medical Research Council (NHMRC) levels of criteria (see Evidence Summary – Appendix B). Results Thirty-one recent publications were retrieved in relation to quality and safety issues faced by people with CI in acute hospitals. The results indicate that CI is a common problem in hospitals (upwards of 30% - the rate increases with increasing patient age), although this is likely to be an underestimate, in part, due to numbers of patients without a formal dementia diagnosis. There is a large body of evidence showing that patients with CI have worse outcomes than patients without CI following hospitalisation including increased mortality, more complications, longer hospital stays, increased system costs as well as functional and cognitive decline. 4 To improve the care of patients with CI in hospital, best practice guidelines have been developed, of which sixteen recent guidelines/position statements/standards were identified in this review (Table 2). Four guidelines described standards or quality indicators for providing optimal care for the older person with CI in hospital, in general, while three focused on delirium diagnosis, prevention and management. The remaining guidelines/statements focused on specific issues in relation to the care of patients with CI in acute hospitals including hydration, nutrition, wandering and care in the Emergency Department (ED). A key message in several of the guidelines was that older patients should be assessed for CI at admission and this is particularly important in the case of delirium, which can indicate an emergency, in order to implement treatment. A second clear mess...

Giving voice to service providers who work with survivors of torture and trauma

Clinicians who support people from refugee and asylum seeking backgrounds are routinely exposed to stories of trauma as part of their work. Hearing these stories can be highly distressing for clinicians, but simultaneously provide opportunities for positive personal growth. Adopting a longitudinal qualitative design, we interviewed twelve service providers at two time points a year apart. We used a semistructured interview protocol and analyzed the data according to interpretative phenomenological analysis. Five superordinate and 19 constituent themes emerged from the analysis at Time 1 and Time 2. We found that participants were both positively and negatively affected by their work, and their experiences remained relatively stable across time. The participants highlighted the use of organizational and personal coping strategies to help minimize distress and maximize wellbeing. Adopting a broad repertoire of such strategies is not only advantageous for the service providers, but ultimately for those people they seek to assist.

Software as a service (SaaS) for small and medium enterprises (SMEs) : the role of intermediaries

Software as a Service (SaaS) is anticipated to provide significant benefits to small and medium enterprises (SMEs) due to ease of access to high-end applications, 7*24 availability, utility pricing, etc. However, underlying SaaS is the assumption that SMEs will directly interact with the SaaS vendor and use a self-service model. In practice, we see the rise of SaaS intermediaries who support SMEs with using SaaS. This paper reports on an empirical study of the role of intermediaries in terms of how they support SMEs in sourcing and leveraging SaaS for their business. The knowledge contributions of this paper are: (1) the identification and description of the role of SaaS intermediaries and (2) the specification of different roles of SaaS intermediaries, in particular a more basic role with technology orientation and operational alignment perspective and (3) a more added value role with customer orientation and strategic alignment perspective.

Service-oriented architecture integration within enterprise architecture : a-priori model

This paper proposes that critical realism can provide a useful theoretical foundation to study enterprise architecture (EA) evolution. Specifically it will investigate the practically relevant and academically challenging question of how EAs integrate the Service-oriented Architecture (SOA). Archer’s Morphogenetic theory is used as an analytical approach to distinguish the architectural conditions under which SOA is introduced, to study the relationships between these conditions and SOA introduction, and to reflect on EA evolution (elaborations) that then take place. The focus lies on the reasons why EA evolution takes place (or not) and what architectural changes happen. This paper uses the findings of a literature review to build an a-priori model informed by Archer’s theory to understand EA evolution in a field that often lacks a solid theoretical groundwork. The findings are threefold. First, EA can evolve on different levels (different integration outcomes). Second, the integration outcomes are classified into three levels: business architecture, information systems architecture and technology architecture. Third, the analytical separation using Archer’s theory is helpful in order to understand how these different integration outcomes are generated.

Patients perceptions of emergency department services : better specialised staff, convenient and available services

Many factors are identified as contributing to the high demand for emergency department (ED) care. Similarly, there have been many initiatives taken to minimise the impact that is placed on EDs. Many of these, however, do not consider the patient's opinions and motivations. The aim of this cross-sectional study was to understand patients’ perspectives and reasons behind their decision to present to EDs. 911 surveys were collected from patients presenting to eight QLD EDs in 2011. Based on the Principal Component Analysis technique, a six-item scale entitled "Best services at emergency departments" was extracted (α = 0.729) measuring patients' opinions and perspectives. Further, the independent t-tests were conducted between various groups of ED users. The results suggest that multiple users more likely viewed EDs as the best place for their conditions than the first-time users (Median 10.73 v 11.56, p<0.001). Moreover, patients who made the decision to present by themselves had a more favourable perception of the ED services than those for whom the decision was made or others were involved (Median 11.38 v 10.80, p=0.003). Method of arrival did not affect the respondents’ perception of ED (11.13 v 11.00, p=0.65). The results of this research indicate that patients’ perception of ED as the best and most appropriate place for attention to their medical conditions plays an important role in their decision to present and keep returning to ED. Understanding patients’ reasons and decisions enhances the success of planning and implementing alternative services to manage the demand for ED services.

Adding SUGAR : service user and carer collaboration in mental health nursing research

‘SUGAR: Service users and carers group advising on research’ is an exciting initiative established to develop collaborative working in mental health nursing research between mental health service users, carers, researchers and practitioners at City University London, UK. This paper will describe the background to SUGAR and how and why it was established; how the group operates; some of the achievements to date including researcher reflections; and case studies of how this collaboration influences our research. Written reflective narratives of service user and carer experiences of SUGAR were analysed using constant comparative methods by the members. Common themes are presented with illustrative quotes. The article highlights the benefits and possible limitations identified so far by members of SUGAR; outlines future plans and considers the findings in relation to literature on involvement and empowerment. This paper has been written by staff and members of SUGAR and is the first venture into collaborative writing of the group and reflects the shared ethos of collaborative working.