Multiyear measurements of the oceanic and atmospheric boundary layers at the Brazil-Malvinas confluence region

This study analyzes and discusses data taken from oceanic and atmospheric measurements performed simultaneously at the Brazil-Malvinas Confluence (BMC) region in the southwestern Atlantic Ocean. This area is one of the most dynamical frontal regions of the world ocean. Data were collected during four research cruises in the region once a year in consecutive years between 2004 and 2007. Very few studies have addressed the importance of studying the air-sea coupling at the BMC region. Lateral temperature gradients at the study region were as high as 0.3 degrees C km(-1) at the surface and subsurface. In the oceanic boundary layer, the vertical temperature gradient reached 0.08 degrees C m(-1) at 500 m depth. Our results show that the marine atmospheric boundary layer (MABL) at the BMC region is modulated by the strong sea surface temperature (SST) gradients present at the sea surface. The mean MABL structure is thicker over the warmside of the BMC where Brazil Current (BC) waters predominate. The opposite occurs over the coldside of the confluence where waters from the Malvinas (Falkland) Current (MC) are found. The warmside of the confluence presented systematically higher MABL top height compared to the coldside. This type of modulation at the synoptic scale is consistent to what happens in other frontal regions of the world ocean, where the MABL adjusts itself to modifications along the SST gradients. Over warm waters at the BMC region, the MABL static instability and turbulence were increased while winds at the lower portion of the MABL were strong. Over the coldside of the BC/MC front an opposite behavior is found: the MABL is thinner and more stable. Our results suggest that the sea-level pressure (SLP) was also modulated locally, together with static stability vertical mixing mechanism, by the surface condition during all cruises. SST gradients at the BMC region modulate the synoptic atmospheric pressure gradient. Postfrontal and prefrontal conditions produce opposite thermal advections in the MABL that lead to different pressure intensification patterns across the confluence.

Kangaroo Mother Care in a Mozambican perinatal ward : a clinical case study

Kangaroo mother care (KMC) was first introduced in Mozambique in 1984. The aim of this study was to describe Mozambican mothers’ experiences of going through admission, passing from an intensive care ward to a nursery ward with their premature baby, undergoing KMC training before early discharge. A clinical case study was conducted, involving naturalistic observations and a face-to-face interview with 41 mothers participating to complete a questionnaire. Descriptive statistics and manifest content analysis were used in this study. The results show that the mothers were of low socio-economic standing and felt that they did not have enough information on KMC. The hierarchical organization within the hospital setting as well as communalistic behaviours influenced the mothers’ support of KMC, including information, communication, relationships and actions. The conclusion is that there is an important challenge for trained neonatal nurses to improve the guidelines for KMC and to empower mothers and their families to adopt KMC.

Operation of guardianship laws in the emergency ward

Enduring and workable legislative schemes typically include (a) a balanced approach to the rights and duties of all parties under their purview; and (b) consideration of all major consequences that may flow from the codification of underpinning doctrines. This column examines the 1999 amendments to the Guardianship and Administration Act 1986 (Vic) regulating patients’ consent to medical treatment focusing on their application in modern emergency departments. The legislation needs to reconcile the human rights principle that humane and appropriate treatment is a fundamental right of all those who suffer from ill health and disease, with the principle that all patients (including those with impaired, but not totally absent, decisional capacity) have an absolute right to refuse life-saving treatment. Consent and refusal of treatment provisions should be based on the notion of reasonableness, including recognition that the mental and emotional states experienced by physically ill people may, in the short term, adversely affect their decision-making capacity. Unless the consent legislation factors in the realities of modern emergency practice and resources, statutory thresholds for decisional competence, instead of affording protection, may result in much worse outcomes for vulnerable patients.

'Mother, teacher, adviser and missionary' : Matilda Ward in North Queensland, 1891–1917

This chapter focuses on Matilda Ward, a missionary at the Presbyterian mission of Mapoon, north Queensland, and the first paid woman missionary to work on an Aboriginal mission. It examines the factors that led to Ward’s employment on the mission, the role that she played in the life of the mission and the consequences of her actions for Indigenous mission residents. While Matilda Ward was unusual for her time, her experience points to broader shifts in missionary practice and attitudes to gender within the Australian churches, particularly through the development of women’s missionary societies.

Clinical outcomes associated with screening and referral for depression in an acute cardiac ward

Aim.  The aim of this paper is to describe the implementation of a depression screening and referral tool in two cardiac wards of a major metropolitan public hospital. The tool consisted of two sections: (1) screening for depression risk (Cardiac Depression Scale-5) and (2) consequential referral actions.

Background.  Prior research has shown that depression in patients with heart disease is associated with significantly impaired quality of life, decreased medication adherence, increased morbidity and increased use of healthcare services.

Design.  A prospective in-patient study design.

Method.  A consecutive sample of 202 patients admitted to either the cardiac medical (n = 145) or surgical (n = 57) wards of a major Melbourne metropolitan hospital were recruited into the study over an 18-week period.

Results.  Just over half (54%) of the patients were identified as ‘at risk’ of depression. Of these, 19% were assessed as moderate risk and 35% high risk. Of those patients, 91% had the risk score documented in their medical history, 90% had engaged in discussions with clinicians regarding their risk score, 85% had their risk score communicated formally to the medical team and 25% were formally referred for appropriate follow-up – significantly more than prior to implementation of the screening and referral tool.

Conclusions.  By providing a formalised mechanism for detecting depression, documented screening and referral rates improved for those with comorbid depression and heart disease affording an opportunity for early intervention. These findings support a move towards integrated approaches to screening of depression to become standard practice in the acute cardiac setting.

Relevance to clinical practice.  Such mechanisms also have the potential to initiate the development of new models of care that acknowledge the complexity of comorbid depression and heart disease and provide pathways from speciality to primary care which integrate the physical and psychosocial domains inclusive of screening, referral, systematic monitoring and streamlined behavioural and physical care.

Estimating the intensity of ward admission and its effect on emergency department access block

Emergency department access block is an urgent problem faced by many public hospitals today. When access block occurs, patients in need of acute care cannot access inpatient wards within an optimal time frame. A widely held belief is that access block is the end product of a long causal chain, which involves poor discharge planning, insufficient bed capacity, and inadequate admission intensity to the wards. This paper studies the last link of the causal chain-the effect of admission intensity on access block, using data from a metropolitan hospital in Australia. We applied several modern statistical methods to analyze the data. First, we modeled the admission events as a nonhomogeneous Poisson process and estimated time-varying admission intensity with penalized regression splines. Next, we established a functional linear model to investigate the effect of the time-varying admission intensity on emergency department access block. Finally, we used functional principal component analysis to explore the variation in the daily time-varying admission intensities. The analyses suggest that improving admission practice during off-peak hours may have most impact on reducing the number of ED access blocks.

Achieving eating independence in an acute stroke ward : Developing a collaborative care plan

Aim: This article outlines the development and implementation of a collaborative feeding care plan (FCP) for stroke patients in an acute stroke ward. The aim of this pilot study was to evaluate the impact of an ecological intervention to improve eating independence in an acute stroke ward environment. Methods: An action research approach comprising seven stages—determine the initial problem, develop the care plan, act, reflect and monitor progress, evaluate, reflect, and refine plan—was used to track environmental changes during the development and implementation of the FCP in an acute stroke ward in an Australian regional hospital. During the evaluation phase, six allied health staff completed a survey on the FCP. The staff also completed an observation assessment integrating the Eating Disability Scale, Functional Independence Measure and Canadian Occupational Performance Measure with 12 participants with acute stoke (participants with FCP=6; participants without FCP=6). Results: The FCP group showed significant improvements in upper limb independence (p=0.046), when comparing mean admission scores (3.5±0.97) with discharge scores (4.17±2.14). Clinically significant improvements in levels of collaboration between health professionals were also demonstrated. Conclusions: The changes in team collaboration and the patient’s upper limb independence indicate how environmental change can influence acute stroke patient outcomes. It is recommended that this study be expanded to further explore the effect of ecological interventions and change.

Interprofessional learning at work: what spatial theory can tell us about workplace learning in an acute care ward

It is widely recognized that every workplace potentially provides a rich source of learning. Studies focusing on health care contexts have shown that social interaction within and between professions is crucial in enabling professionals to learn through work, address problems and cope with challenges of clinical practice. While hospital environments are beginning to be understood in spatial terms, the links between space and interprofessional learning at work have not been explored. This paper draws on Lefebvre’s tri-partite theoretical framework of perceived, conceived and lived space to enrich understandings of interprofessional learning on an acute care ward in an Australian teaching hospital. Qualitative analysis was undertaken using data from observations of Registered Nurses at work and semi-structured interviews linked to observed events. The paper focuses on a ward round, the medical workroom and the Registrar’s room, comparing and contrasting the intended (conceived), practiced (perceived) and pedagogically experienced (lived) spatial dimensions. The paper concludes that spatial theory has much to offer understandings of interprofessional learning in work, and the features of work environments and daily practices that produce spaces that enable or constrain learning.

Nursing handover from ICU to cardiac ward: standardised tools to reduce safety risks

BACKGROUND: Standardising handover processes and content, and using context-specific checklists are proposed as solutions to mitigate risks for preventable errors and patient harm associated with clinical handovers. OBJECTIVES: Adapt existing tools to standardise nursing handover from the intensive care unit (ICU) to the cardiac ward and assess patient safety risks before and after pilot implementation. METHODS: A three-stage, pre-post interrupted time-series design was used. Data were collected using naturalistic observations and audio-recording of 40 handovers and focus groups with 11 nurses. In Stage 1, examination of existing practice using observation of 20 handovers and a focus group interview provided baseline data. In Stage 2, existing tools for high-risk handovers were adapted to create tools specific to ICU-to-ward handovers. The adapted tools were introduced to staff using principles from evidence-based frameworks for practice change. In Stage 3, observation of 20 handovers and a focus group with five nurses were used to verify the design of tools to standardise handover by ICU nurses transferring care of cardiac surgical patients to ward nurses. RESULTS: Stage 1 data revealed variable and unsafe ICU-to-ward handover practices: incomplete ward preparation; failure to check patient identity; handover located away from patients; and information gaps. Analyses informed adaptation of process, content and checklist tools to standardise handover in Stage 2. Compared with baseline data, Stage 3 observations revealed nurses used the tools consistently, ward readiness to receive patients (10% vs 95%), checking patient identity (0% vs 100%), delivery of handover at the bedside (25% vs 100%) and communication of complete information (40% vs 100%) improved. CONCLUSION: Clinician adoption of tools to standardise ICU-to-ward handover of cardiac surgical patients reduced handover variability and patient safety risks. The study outcomes provide context-specific tools to guide handover processes and delivery of verbal content, a safety checklist, and a risk recognition matrix.