Emergency Health Services (EHS) : demand and service delivery models. monograph 3 : patients’ reasons and perceptions

Executive Summary Emergency health is a critical component of Australia’s health system and emergency departments (EDs) are increasingly congested from growing demand and blocked access to inpatient beds. The Emergency Health Services Queensland (EHSQ) study aims to identify the factors driving increased demand for emergency health and to evaluate strategies which may safely reduce the future demand growth. This monograph addresses the perspectives of users of both ambulance services and EDs. The research reported here aimed to identify the perspectives of users of emergency health services, both ambulance services and public hospital Emergency Departments and to identify the factors that they took into consideration when exercising their choice of location for acute health care. A cross-sectional survey design was used involving a survey of patients or their carers presenting to the EDs of a stratified sample of eight hospitals. A specific purpose questionnaire was developed based on a novel theoretical model which had been derived from analysis of the literature (Monograph 1). Two survey versions were developed: one for adult patients (self-complete); and one for children (to be completed by parents/guardians). The questionnaires measured perceptions of social support, health status, illness severity, self-efficacy; beliefs and attitudes towards ED and ambulance services; reasons for using these services, and actions taken prior to the service request. The survey was conducted at a stratified sample of eight hospitals representing major cities (four), inner regional (two) and outer regional and remote (two). Due to practical limitations, data were collected for ambulance and ED users within hospital EDs, while patients were waiting for or under treatment. A sample size quota was determined for each ED based on their 2009/10 presentation volumes. The data collection was conducted by four members of the research team and a group of eight interviewers between March and May 2011 (corresponding to autumn season). Of the total of 1608 patients in all eight emergency departments the interviewers were able to approach 1361 (85%) patients and seek their consent to participate in the study. In total, 911 valid surveys were available for analysis (response rate= 67%). These studies demonstrate that patients elected to attend hospital EDs in a considered fashion after weighing up alternatives and there is no evidence of deliberate or ill-informed misuse. • Patients attending ED have high levels of social support and self-efficacy that speak to the considered and purposeful nature of the exercise of choice. • About one third of patients have new conditions while two thirds have chronic illnesses • More than half the attendees (53.1%) had consulted a healthcare professional prior to making the decision. • The decision to seek urgent care at an ED was mostly constructed around the patient’s perception of the urgency and severity of their illness, reinforced by a strong perception that the hospital ED was the correct location for them (better specialised staff, better care for my condition, other options not as suitable). • 33% of the respondent held private hospital insurance but nevertheless attended a public hospital ED. Similarly patients exercised considered and rational judgements in their choice to seek help from the ambulance service. • The decision to call for ambulance assistance was based on a strong perception about the severity of the illness (too severe to use other means of transport) and that other options were not considered appropriate. • The decision also appeared influenced by a perception that the ambulance provided appropriate access to the ED which was considered most appropriate for their particular condition (too severe to go elsewhere, all facilities in one spot, better specialised and better care). • In 43.8% of cases a health care professional advised use of the ambulance. • Only a small number of people perceived that ambulance should be freely available regardless of severity or appropriateness. These findings confirm a growing understanding that the choice of professional emergency health care services is not made lightly but rather made by reasonable people exercising a judgement which is influenced by public awareness of the risks of acute health and which is most often informed by health professionals. It is also made on the basis of a rational weighing up of alternatives and a deliberate and considered choice to seek assistance from a service which the patient perceived was most appropriate to their needs at that time. These findings add weight to dispensing with public perceptions that ED and ambulance congestion is a result of inappropriate choice by patients. The challenge for health services is to better understand the patient’s needs and to design and validate services that meet those needs. The failure of our health system to do so should not be grounds for blaming the patient, claiming inappropriate patient choices.

Monitoring the levels of important nutrients in the food supply

A food supply that delivers energy-dense products with high levels of salt, saturated fats and trans fats, in large portion sizes, is a major cause of non-communicable diseases (NCDs). The highly processed foods produced by large food corporations are primary drivers of increases in consumption of these adverse nutrients. The objective of this paper is to present an approach to monitoring food composition that can both document the extent of the problem and underpin novel actions to address it. The monitoring approach seeks to systematically collect information on high-level contextual factors influencing food composition and assess the energy density, salt, saturated fat, trans fats and portion sizes of highly processed foods for sale in retail outlets (with a focus on supermarkets and quick-service restaurants). Regular surveys of food composition are proposed across geographies and over time using a pragmatic, standardized methodology. Surveys have already been undertaken in several high- and middle-income countries, and the trends have been valuable in informing policy approaches. The purpose of collecting data is not to exhaustively document the composition of all foods in the food supply in each country, but rather to provide information to support governments, industry and communities to develop and enact strategies to curb food-related NCDs.

Commentary on Nutrition and older Indigenous Australians : service delivery implications in remote communities. A narrative review

Indigenous Australians are the most socially and economically disadvantaged population group in Australia and have the poorest health status. The statistics describe and highlight the degree of sicknesses and disadvantage along with lower life expectancy, elevated mortality rate and increased risk of cardiovascular disease, cancer, diabetes, respiratory disease and kidney disease. While these statistics reflect poor health status and a high level of illness within Indigenous communities, it is known that individual, family and community behaviours play a key role in Indigenous health and wellbeing outcomes. These behavioural issues include use of tobacco, alcohol and other substances along with lack of physical activity and poor nutrition. The paper Nutrition and older Indigenous Australians: Service delivery implications in remote communities. A narrative view explores some of the issues specific to nutrition. Bronwyn Fredericks was invited to provide this commentary by the Editor of the Australasian Journal on Aging.

Learning processes in creative service teams : towards a dynamic systems theory

The fastest-growing segment of jobs in the creative sector are in those firms that provide creative services to other sectors (Hearn, Goldsmith, Bridgstock, Rodgers 2014, this volume; Cunningham 2014, this volume). There are also a large number of Creative Services (Architecture and Design, Advertising and Marketing, Software and Digital Content occupations) workers embedded in organizations in other industry sectors (Cunningham and Higgs 2009). Ben Goldsmith (2014, this volume) shows, for example, that the Financial Services sector is the largest employer of digital creative talent in Australia. But why should this be? We argue it is because ‘knowledge-based intangibles are increasingly the source of value creation and hence of sustainable competitive advantage (Mudambi 2008, 186). This value creation occurs primarily at the research and development (R and D) and the marketing ends of the supply chain. Both of these areas require strong creative capabilities in order to design for, and to persuade, consumers. It is no surprise that Jess Rodgers (2014, this volume), in a study of Australia’s Manufacturing sector, found designers and advertising and marketing occupations to be the most numerous creative occupations. Greg Hearn and Ruth Bridgstock (2013, forthcoming) suggest ‘the creative heart of the creative economy […] is the social and organisational routines that manage the generation of cultural novelty, both tacit and codified, internal and external, and [cultural novelty’s] combination with other knowledges […] produce and capture value’. 2 Moreover, the main “social and organisational routine” is usually a team (for example, Grabher 2002; 2004).

Innovations in dietary interventions : Use of a photographic food diary method and telephone linked computerized care in chronic disease

Access to dietetic care is important in chronic disease management and innovative technologies assists in this purpose. Photographic dietary records (PhDR) using mobile phones or cameras are valid and convenient for patients. Innovations in providing dietary interventions via telephone and computer can also inform dietetic practice. Three studies are presented. A mobile phone method was validated by comparing energy intake (EI) to a weighed food record and a measure of energy expenditure (EE) obtained using the doubly labelled water technique in 10 adults with T2 diabetes. The level of agreement between mean (±sd) energy intake mobile phone (8.2±1.7 MJ) and weighed record (8.5±1.6 MJ) was high (p=0.392), however EI/EE for both methods gave similar levels of under-reporting (0.69 and 0.72). All subjects preferred using the mobile phone vs. weighed record. Nineteen individuals with Parkinsons disease kept 3-day PhDRs on three occasions using point-and-shoot digital cameras over a 12 week period. The camera was rated as easy to use by 89%, keeping a PhDR was considered acceptable by 94% and none would rather use a “pen and paper” method. Eighty-three percent felt confident to use the camera again to record intake. An interactive, automated telephone system designed to coach people with T2 diabetes to adopt and maintain diabetes self-care behaviours, including nutrition, showed trends for improvements in total fat, saturated fat and vegetable intake of the intervention group compared to control participants over 6 months. Innovative technologies are acceptable to patients with chronic conditions and can be incorporated into dietetic care.

Perioperative medication management: expanding the role of the preadmission clinic pharmacist in a single centre, randomised controlled trial of collaborative prescribing

Objectives Current evidence to support non-medical prescribing is predominantly qualitative, with little evaluation of accuracy, safety and appropriateness. Our aim was to evaluate a new model of service for the Australia healthcare system, of inpatient medication prescribing by a pharmacist in an elective surgery preadmission clinic (PAC) against usual care, using an endorsed performance framework. Design Single centre, randomised controlled, two-arm trial. Setting Elective surgery PAC in a Brisbane-based tertiary hospital. Participants 400 adults scheduled for elective surgery were randomised to intervention or control. Intervention A pharmacist generated the inpatient medication chart to reflect the patient's regular medication, made a plan for medication perioperatively and prescribed venous thromboembolism (VTE) prophylaxis. In the control arm, the medication chart was generated by the Resident Medical Officers. Outcome measures Primary outcome was frequency of omissions and prescribing errors when compared against the medication history. The clinical significance of omissions was also analysed. Secondary outcome was appropriateness of VTE prophylaxis prescribing. Results There were significantly less unintended omissions of medications: 11 of 887 (1.2%) intervention orders compared with 383 of 1217 (31.5%) control (p<0.001). There were significantly less prescribing errors involving selection of drug, dose or frequency: 2 in 857 (0.2%) intervention orders compared with 51 in 807 (6.3%) control (p<0.001). Orders with at least one component of the prescription missing, incorrect or unclear occurred in 208 of 904 (23%) intervention orders and 445 of 1034 (43%) controls (p<0.001). VTE prophylaxis on admission to the ward was appropriate in 93% of intervention patients and 90% controls (p=0.29). Conclusions Medication charts in the intervention arm contained fewer clinically significant omissions, and prescribing errors, when compared with controls. There was no difference in appropriateness of VTE prophylaxis on admission between the two groups.

Can Business Continuity Management Create Reliability in Airports? (Issues from Theory into Practice)

The advances made within the aviation industry over the past several decades have significantly improved the availability, affordability and convenience of air travel and have been greatly beneficial in both social and economic terms. Air transport has developed into an irreplaceable service being relied on by millions of people each day and as such airports have become critical elements of national infrastructure to facilitate the movement of people and goods. As components of critical infrastructure (CI), airports are integral parts of a national economy supporting regional as well as national trade, commercial activity and employment. Therefore, any disruption or crisis which impacts the continuity of operations at airports can have significant negative consequences for the airport as a business, for the local economy and other nodes of transport infrastructure as well as for society. Due to the highly dynamic and volatile environment in which airports operate in, the aviation industry has faced many different challenges over the years ranging from terrorist attacks such as September 11, to health crises such as the SARS epidemic to system breakdowns such as the recent computer system outage at Virgin Blue Airlines in Australia. All these events have highlighted the vulnerability of airport systems to a range of disturbances as well as the gravity and widespread impact of any kind of discontinuity in airport functions. Such incidents thus emphasise the need for increasing resilience and reliability of airports and ensuring business continuity in the event of a crisis...

Defining food literacy and its components

Food literacy has emerged as a term to describe the everyday practicalities associated with healthy eating. The term is increasingly used in policy, practice, research and by the public; however, there is no shared understanding of its meaning. The purpose of this research was to develop a definition of food literacy which was informed by the identification of its components. This was considered from two perspectives: that of food experts which aimed to reflect the intention of existing policy and investment, and that of individuals, who could be considered experts in the everyday practicalities of food provisioning and consumption. Given that food literacy is likely to be highly contextual, this second study focused on disadvantaged young people living in an urban area who were responsible for feeding themselves. The Expert Study used a Delphi methodology (round one n = 43). The Young People’s Study used semi-structured, life-course interviews (n = 37). Constructivist Grounded Theory was used to analyse results. This included constant comparison of data within and between studies. From this, eleven components of food literacy were identified which fell into the domains of: planning and management; selection; preparation; and eating. These were used to develop a definition for the term “food literacy”.

A randomized controlled trial of self-management programme improves health-related outcomes of older people with heart failure

Aims This paper is a report on the effectiveness of a self-management programme based on the self-efficacy construct, in older people with heart failure. Background Heart failure is a major health problem worldwide, with high mortality and morbidity, making it a leading cause of hospitalization. Heart failure is associated with a complex set of symptoms that arise from problems in fluid and sodium retention. Hence, managing salt and fluid intake is important and can be enhanced by improving patients' self-efficacy in changing their behaviour. Design Randomized controlled trial. Methods Heart failure patients attending cardiac clinics in northern Taiwan from October 2006–May 2007 were randomly assigned to two groups: control (n = 46) and intervention (n = 47). The intervention group received a 12-week self-management programme that emphasized self-monitoring of salt/fluid intake and heart failure-related symptoms. Data were collected at baseline as well as 4 and 12 weeks later. Data analysis to test the hypotheses used repeated-measures anova models. Results Participants who received the intervention programme had significantly better self-efficacy for salt and fluid control, self-management behaviour and their heart failure-related symptoms were significantly lower than participants in the control group. However, the two groups did not differ significantly in health service use. Conclusion The self-management programme improved self-efficacy for salt and fluid control, self-management behaviours, and decreased heart failure-related symptoms in older Taiwanese outpatients with heart failure. Nursing interventions to improve health-related outcomes for patients with heart failure should emphasize self-efficacy in the self-management of their disease.

Conceptualizing the interplay of knowledge accumulation and integration capabilities in service innovation-based competitive strategy : a project-oriented firm context

While past knowledge-based approaches to service innovation have emphasized the role of integration of knowledge in the provisioning of solutions, these approaches fail to address complexities involved with knowledge integration in project-oriented context, specifically, how the firm’s capability to acquire new knowledge from clients and past project episodes influence the development of new service solutions. Adopting a dynamic capability framework and building on knowledge-based approaches to innovation, this paper presents a conceptual model that captures the interplay of learning capabilities and the knowledge integration capability in the service innovation-based competitive strategy. Implications to theory and directions for future research are discussed.

Australasian nutrition research for prevention and management of child obesity : innovation and progress in the last decade

The Food and Nutrition stream of Australasian Child and Adolescent Obesity Research Network (ACAORN) aims to improve the quality of dietary methodologies and the reporting of dietary intake within Australasian child obesity research (http://www.acaorn.org.au/streams/nutrition/). With 2012 marking ACAORN’s 10th anniversary, this commentary profiles a selection of child obesity nutrition research published over the last decade by Food and Nutrition Stream members. In addition, stream activities have included the development of an online selection guide to assist researchers in their selection of appropriate dietary intake methodologies (http://www.acaorn.org.au/streams/nutrition/dietary-intake/index.php). The quantity and quality of research to guide effective child obesity prevention and treatment has increased substantially over the last decade. ACAORN provides a successful case study of how research networks can provide a collegial atmosphere to foster and co-ordinate research efforts in an otherwise competitive environment.

The influence of food literacy on the everyday practicalities of meeting nutrition recommendations

Contemporary nutrition policies and plans call for focussing efforts to improve nutrition through a closer connection with food and the everyday practicalities of how people live and eat. Various words have been used to articulate what this might mean in practice. More recently, the term “food literacy” has emerged to explain this gap between the policy aims the (in)ability of people to know, understand and use food to meet nutrition recommendations. Despite its increasing use, there is no common understanding of this term or its components. Once established, food literacy could be measured in order to examine its association with nutritional outcomes. A Delphi study of 43 Australian food experts from diverse sectors and settings explored their understanding of the term “food literacy”, the likely components and possible relationship with nutrition. The three round Delphi study began with a semi-structured telephone interview and was followed by two online surveys. Constructivist grounded theory was used to analyse data, from which a conceptual model of the relationship between food literacy and nutrition was developed. The model was then tested and refined following a phenomenological study of 37 young people aged 16-25 years who were responsible for feeding themselves. They were interviewed about their food intake, day-to-day food decision making, the knowledge and skills used and their perceptions of someone who is “good with food”. Analysis from the Delphi study identified, eighty components of food literacy and these were grouped into eight domains: 1)access, 2)planning and management, 3)selection, 4)knowing where food comes from, 5)preparation, 6)eating, 7)nutrition and 8)food related language. When these were compared to results of the Young People’s study it was found that while specific components of food literacy were largely contextual, the importance of all eight domains continued to be relevant. The results of these qualitative studies have set the boundaries and scope of meaning of food literacy and will be used to inform the development of measurable variables to be tested in a quantitative cross-sectional study. This prospective study will examine the relationship between food literacy and nutrition. This research is useful in guiding government strategy and investment, and informing the planning, implementation and evaluation of interventions by practitioners.

Urban Food Security, Urban Resilience and Climate Change

The growing importance of logistics in increasingly globalised production and consumption systems strengthens the case for explicit consideration of the climate risks that may impact on the operation of ports in the future, as well as the formulation of adaptation responses that act to enhance their resilience. Within a logistics chain, seaports are functional nodes of significant strategic importance, and are considered as critical gateways linking local and national supply chains to global markets. However, they are more likely to be exposed to vagaries of climate-related extreme events due to their coastal locations. As such, they need to be adaptive and respond to the projected impacts of climate change, in particular extreme weather events. These impacts are especially important in the logistics context as they could result in varying degrees of business interruption; including business closure in the worst case scenario. Since trans-shipment of freight for both the import and export of goods and raw materials has a significant impact on Australia’s sustained economic growth it was considered important to undertake a study of port functional assets, to assess their vulnerability to climate change, to model the potential impacts of climate-related extreme events, and to highlight possible adaptation responses.

The Impacts of Climate Change on Australia’s Food Production and Export

The global food system is undergoing unprecedented change. With population increases, demands for food globally will continue to rise at the same time that agricultural environments are compromised through urban encroachment, climate change and environmental degradation. Australia has long identified itself as an agricultural exporting nation—but what will its capacity be in feeding an increasing global population as it also comes to terms with extreme climatic events such as the floods, fires and droughts, and reduced water availability, experienced in recent decades? This chapter traces the history of Australian agricultural exports and evaluates its food production and export capacity against scientific predictions of climate change impacts. With the federal government forecasting declines in the production of wheat, beef, dairy and sugar, Australia’s key export commodities may well be compromised. Calls to produce more food using new technologies are likely to generate significant environmental problems. Yet, a radical reconfiguration of Australian agriculture which incorporates alternative approaches, such as agro-ecology, is rarely considered by government and industry.

Climate Change and the Resilience of Commodity Food Production in Australia

The current view of Australian state and national governments about the effects of climate change on agriculture is that farmers – through the adoption of mitigation and adaptation strategies – will remain resilient, and agricultural production will continue to expand. The assumption is that neoliberalism will provide the best ‘free market’ options for climate change mitigation and adaptation in farming. In contrast, we argue that neoliberalism will increase the move towards productivis (‘high-tech’) agriculture – the very system that has caused major environmental damage to the Australian continent. High-tech farming is highly dependent upon access to water and fossil fuels, both of which would appear to be the main limits to production in future decades. Productivist agriculture is a system highly reliant upon fertilizers and fuels that are derived from the petrochemical industry, and are currently increasing in cost as the price of oil increases.