Quality of child abuse information in emergency department injury surveillance data : linking hospital and child welfare data

Emergency departments (EDs) are often the first point of contact with an abused child. Despite legal mandate, the reporting of definite or suspected abusive injury to child safety authorities by ED clinicians varies due to a number of factors including training, access to child safety professionals, departmental culture and a fear of ‘getting it wrong’. This study examined the quality of documentation and coding of child abuse captured by ED based injury surveillance data and ED medical records in the state of Queensland and the concordance of these data with child welfare records. A retrospective medical record review was used to examine the clinical documentation of almost 1000 injured children included in the Queensland Injury Surveillance Unit database (QISU) from 10 hospitals in urban and rural centres. Independent experts re-coded the records based on their review of the notes. A data linkage methodology was then used to link these records with records in the state government’s child welfare database. Cases were sampled from three sub-groups according to the surveillance intent codes: Maltreatment by parent, Undetermined and Unintentional injury. Only 0.1% of cases coded as unintentional injury were recoded to maltreatment by parent, while 1.2% of cases coded as maltreatment by parent were reclassified as unintentional and 5% of cases where the intent was undetermined by the triage nurse were recoded as maltreatment by parent. Quality of documentation varied across type of hospital (tertiary referral centre, children’s, urban, regional and remote). Concordance of health data with child welfare data varied across patient subgroups. Outcomes from this research will guide initiatives to improve the quality of intentional child injury surveillance systems.

Paediatric spinal deformity research at the Mater Children's Hospital, Brisbane, Australia.

The Paediatric Spine Research group was formed in 2002 to perform high quality research into the prevention and management of spinal deformity, with an emphasis on scoliosis. The group has successfully built collaborative bridges between the scientific and research expertise at QUT, and the clinical skills and experience of the spinal orthopaedic surgeons at the Mater Children’s Hospital in Brisbane. Clinical and biomechanical research is now possible as a result of the development of detailed databases of patients who have innovative and unique surgical interventions for spinal deformity such as thoracoscopic scoliosis correction, thoracoscopic staple insertion for juvenile idiopathic scoliosis and minimally invasive growing rods. The Mater in Brisbane provides these unique datasets of spinal deformity surgery patients, whose procedures are not being performed anywhere else in the Southern Hemisphere. The most detailed is a database of thoracoscopic scoliosis correction surgery which now contains 180 patients with electronic collections of X-Rays, photographs and patient questionnaires. With ethics approval, a subset of these patients has had CT scans, and a further subset have had MRI scans with and without a compressive load to simulate the erect standing position. This database has to date contributed to 17 international refereed journal papers, a further 7 journal papers either under review or in final preparation, 53 national conference presentations and 35 international conference presentations. Major findings from selected journal publications will be presented. It is anticipated that as the surgical databases grow they will continue to provide invaluable clinical data which will feed into clinically relevant projects driven by both medical and engineering researchers whose findings will benefit spinal deformity patients and scientific knowledge worldwide.

Measuring falls events in acute hospitals-A comparison of three reporting methods to identify missing data in the hospital reporting system

OBJECTIVES: To compare three different methods of falls reporting and examine the characteristics of the data missing from the hospital incident reporting system. DESIGN: Fourteen-month prospective observational study nested within a randomized controlled trial. SETTING: Rehabilitation, stroke, medical, surgical, and orthopedic wards in Perth and Brisbane, Australia. PARTICIPANTS: Fallers (n5153) who were part of a larger trial (1,206 participants, mean age 75.1 � 11.0). MEASUREMENTS: Three falls events reporting measures: participants’ self-report of fall events, fall events reported in participants’ case notes, and falls events reported through the hospital reporting systems. RESULTS: The three reporting systems identified 245 falls events in total. Participants’ case notes captured 226 (92.2%) falls events, hospital incident reporting systems captured 185 (75.5%) falls events, and participant selfreport captured 147 (60.2%) falls events. Falls events were significantly less likely to be recorded in hospital reporting systems when a participant sustained a subsequent fall, (P5.01) or when the fall occurred in the morning shift (P5.01) or afternoon shift (P5.01). CONCLUSION: Falls data missing from hospital incident report systems are not missing completely at random and therefore will introduce bias in some analyses if the factor investigated is related to whether the data ismissing.Multimodal approaches to collecting falls data are preferable to relying on a single source alone.

Using routinely collected hospital data for child maltreatment surveillance : issues, methods and patterns

Background: International data on child maltreatment are largely derived from child protection agencies, and predominantly report only substantiated cases of child maltreatment. This approach underestimates the incidence of maltreatment and makes inter-jurisdictional comparisons difficult. There has been a growing recognition of the importance of health professionals in identifying, documenting and reporting suspected child maltreatment. This study aimed to describe the issues around case identification using coded morbidity data, outline methods for selecting and grouping relevant codes, and illustrate patterns of maltreatment identified. Methods: A comprehensive review of the ICD-10-AM classification system was undertaken, including review of index terms, a free text search of tabular volumes, and a review of coding standards pertaining to child maltreatment coding. Identified codes were further categorised into maltreatment types including physical abuse, sexual abuse, emotional or psychological abuse, and neglect. Using these code groupings, one year of Australian hospitalisation data for children under 18 years of age was examined to quantify the proportion of patients identified and to explore the characteristics of cases assigned maltreatment-related codes. Results: Less than 0.5% of children hospitalised in Australia between 2005 and 2006 had a maltreatment code assigned, almost 4% of children with a principal diagnosis of a mental and behavioural disorder and over 1% of children with an injury or poisoning as the principal diagnosis had a maltreatment code assigned. The patterns of children assigned with definitive T74 codes varied by sex and age group. For males selected as having a maltreatment-related presentation, physical abuse was most commonly coded (62.6% of maltreatment cases) while for females selected as having a maltreatment-related presentation, sexual abuse was the most commonly assigned form of maltreatment (52.9% of maltreatment cases). Conclusion: This study has demonstrated that hospital data could provide valuable information for routine monitoring and surveillance of child maltreatment, even in the absence of population-based linked data sources. With national and international calls for a public health response to child maltreatment, better understanding of, investment in and utilisation of our core national routinely collected data sources will enhance the evidence-base needed to support an appropriate response to children at risk.

Reliability of routinely collected hospital data for child maltreatment surveillance

Background: Internationally, research on child maltreatment-related injuries has been hampered by a lack of available routinely collected health data to identify cases, examine causes, identify risk factors and explore health outcomes. Routinely collected hospital separation data coded using the International Classification of Diseases and Related Health Problems (ICD) system provide an internationally standardised data source for classifying and aggregating diseases, injuries, causes of injuries and related health conditions for statistical purposes. However, there has been limited research to examine the reliability of these data for child maltreatment surveillance purposes. This study examined the reliability of coding of child maltreatment in Queensland, Australia. Methods: A retrospective medical record review and recoding methodology was used to assess the reliability of coding of child maltreatment. A stratified sample of hospitals across Queensland was selected for this study, and a stratified random sample of cases was selected from within those hospitals. Results: In 3.6% of cases the coders disagreed on whether any maltreatment code could be assigned (definite or possible) versus no maltreatment being assigned (unintentional injury), giving a sensitivity of 0.982 and specificity of 0.948. The review of these cases where discrepancies existed revealed that all cases had some indications of risk documented in the records. 15.5% of cases originally assigned a definite or possible maltreatment code, were recoded to a more or less definite strata. In terms of the number and type of maltreatment codes assigned, the auditor assigned a greater number of maltreatment types based on the medical documentation than the original coder assigned (22% of the auditor coded cases had more than one maltreatment type assigned compared to only 6% of the original coded data). The maltreatment types which were the most ‘under-coded’ by the original coder were psychological abuse and neglect. Cases coded with a sexual abuse code showed the highest level of reliability. Conclusion: Given the increasing international attention being given to improving the uniformity of reporting of child-maltreatment related injuries and the emphasis on the better utilisation of routinely collected health data, this study provides an estimate of the reliability of maltreatment-specific ICD-10-AM codes assigned in an inpatient setting.

Linking ambulance, emergency department and hospital admissions data : understanding the emergency journey

Objective: to assess the accuracy of data linkage across the spectrum of emergency care in the absence of a unique patient identifier, and to use the linked data to examine service delivery outcomes in an emergency department setting. Design: automated data linkage and manual data linkage were compared to determine their relative accuracy. Data were extracted from three separate health information systems: ambulance, ED and hospital inpatients, then linked to provide information about the emergency journey of each patient. The linking was done manually through physical review of records and automatically using a data linking tool (Health Data Integration) developed by the CSIRO. Match rate and quality of the linking were compared. Setting: 10, 835 patient presentations to a large, regional teaching hospital ED over a two month period (August-September 2007). Results: comparison of the manual and automated linkage outcomes for each pair of linked datasets demonstrated a sensitivity of between 95% and 99%; a specificity of between 75% and 99%; and a positive predictive value of between 88% and 95%. Conclusions: Our results indicate that automated linking provides a sound basis for health service analysis, even in the absence of a unique patient identifier. The use of an automated linking tool yields accurate data suitable for planning and service delivery purposes and enables the data to be linked regularly to examine service delivery outcomes.

Evaluation of financial incentives as a quality improvement strategy in the public hospital context : clinician attitudes, design variables, and economic costs

In 2008, a three-year pilot ‘pay for performance’ (P4P) program, known as ‘Clinical Practice Improvement Payment’ (CPIP) was introduced into Queensland Health (QHealth). QHealth is a large public health sector provider of acute, community, and public health services in Queensland, Australia. The organisation has recently embarked on a significant reform agenda including a review of existing funding arrangements (Duckett et al., 2008). Partly in response to this reform agenda, a casemix funding model has been implemented to reconnect health care funding with outcomes. CPIP was conceptualised as a performance-based scheme that rewarded quality with financial incentives. This is the first time such a scheme has been implemented into the public health sector in Australia with a focus on rewarding quality, and it is unique in that it has a large state-wide focus and includes 15 Districts. CPIP initially targeted five acute and community clinical areas including Mental Health, Discharge Medication, Emergency Department, Chronic Obstructive Pulmonary Disease, and Stroke. The CPIP scheme was designed around key concepts including the identification of clinical indicators that met the set criteria of: high disease burden, a well defined single diagnostic group or intervention, significant variations in clinical outcomes and/or practices, a good evidence, and clinician control and support (Ward, Daniels, Walker & Duckett, 2007). This evaluative research targeted Phase One of implementation of the CPIP scheme from January 2008 to March 2009. A formative evaluation utilising a mixed methodology and complementarity analysis was undertaken. The research involved three research questions and aimed to determine the knowledge, understanding, and attitudes of clinicians; identify improvements to the design, administration, and monitoring of CPIP; and determine the financial and economic costs of the scheme. Three key studies were undertaken to ascertain responses to the key research questions. Firstly, a survey of clinicians was undertaken to examine levels of knowledge and understanding and their attitudes to the scheme. Secondly, the study sought to apply Statistical Process Control (SPC) to the process indicators to assess if this enhanced the scheme and a third study examined a simple economic cost analysis. The CPIP Survey of clinicians elicited 192 clinician respondents. Over 70% of these respondents were supportive of the continuation of the CPIP scheme. This finding was also supported by the results of a quantitative altitude survey that identified positive attitudes in 6 of the 7 domains-including impact, awareness and understanding and clinical relevance, all being scored positive across the combined respondent group. SPC as a trending tool may play an important role in the early identification of indicator weakness for the CPIP scheme. This evaluative research study supports a previously identified need in the literature for a phased introduction of Pay for Performance (P4P) type programs. It further highlights the value of undertaking a formal risk assessment of clinician, management, and systemic levels of literacy and competency with measurement and monitoring of quality prior to a phased implementation. This phasing can then be guided by a P4P Design Variable Matrix which provides a selection of program design options such as indicator target and payment mechanisms. It became evident that a clear process is required to standardise how clinical indicators evolve over time and direct movement towards more rigorous ‘pay for performance’ targets and the development of an optimal funding model. Use of this matrix will enable the scheme to mature and build the literacy and competency of clinicians and the organisation as implementation progresses. Furthermore, the research identified that CPIP created a spotlight on clinical indicators and incentive payments of over five million from a potential ten million was secured across the five clinical areas in the first 15 months of the scheme. This indicates that quality was rewarded in the new QHealth funding model, and despite issues being identified with the payment mechanism, funding was distributed. The economic model used identified a relative low cost of reporting (under $8,000) as opposed to funds secured of over $300,000 for mental health as an example. Movement to a full cost effectiveness study of CPIP is supported. Overall the introduction of the CPIP scheme into QHealth has been a positive and effective strategy for engaging clinicians in quality and has been the catalyst for the identification and monitoring of valuable clinical process indicators. This research has highlighted that clinicians are supportive of the scheme in general; however, there are some significant risks that include the functioning of the CPIP payment mechanism. Given clinician support for the use of a pay–for-performance methodology in QHealth, the CPIP scheme has the potential to be a powerful addition to a multi-faceted suite of quality improvement initiatives within QHealth.

Pre-Admission and Post-Hospital Management of Heart Failure in Patients not Enrolled in Specialist Programs

Aim: To review the management of heart failure in patients not enrolled in specialist multidisciplinary programs. Method: A prospective clinical audit of patients admitted to hospital with either a current or past diagnosis of heart failure and not enrolled in a specialist heart failure program or under the direct care of the cardiology unit. Results: 81 eligible patients were enrolled (1 August to 1 October 2008). The median age was 81 9.4 years and 48% were male. Most patients (63%) were in New York Heart Association Class II or Class III heart failure. On discharge, 59% of patients were prescribed angiotensin converting enzyme inhibitors and 43% were prescribed beta-blockers. During hospitalisation, 8.6% of patients with a past diagnosis of heart failure were started on an angiotensin converting enzyme inhibitor and 4.9% on a beta-blocker. There was evidence of suboptimal dosage on admission and discharge for angiotensin converting enzyme inhibitors (19% and 7.4%) and beta-blockers (29% and 17%). The results compared well with international reports regarding the under-treatment of heart failure. Conclusion: The demonstrated practice gap provides excellent opportunities for the involvement of pharmacists to improve the continuation of care for heart failure patients discharged from hospital in the areas of medication management review, dose titration and monitoring.

Effects of wearing a pressure redistribution belt while lying in a hospital bed

Bedsores (ulcers) are caused by multiple factors which include, but are not limited to; pressure, shear force, friction, temperature, age and medication. Specialised support services, such as specialised mattresses, sheepskin coverings etc., are thought to decrease or relieve pressure, resulting in a lowering of pressure ulcer incidence [3]. The primary aim of this study was to compare the upper/central body pressure distribution between normal lying in a hospital bed versus the use of a pressure redistribution belt. The study involved 16 healthy voluntary subjects lying on a hospital bed with and without wearing the belt. Results showed that the use of a pressure redistribution belt results in reduced pressure peaks and prevents the pressure from increasing over time.

Measuring National Accessibility to Cardiac Services using Geographic Information Systems

The Cardiac Access-Remoteness Index of Australia (Cardiac ARIA) used geographic information systems (GIS) to model population level, road network accessibility to cardiac services before and after a cardiac event for all (20,387) population localities in Australia., The index ranged from 1A (access to all cardiac services within 1 h driving time) to 8E (limited or no access). The methodology derived an objective geographic measure of accessibility to required cardiac services across Australia. Approximately 71% of the 2006 Australian population had very good access to acute hospital services and services after hospital discharge. This GIS model could be applied to other regions or health conditions where spatially enabled data were available.

Validation of de-identified record linkage to ascertain hospital admissions in a cohort study

Background Cohort studies can provide valuable evidence of cause and effect relationships but are subject to loss of participants over time, limiting the validity of findings. Computerised record linkage offers a passive and ongoing method of obtaining health outcomes from existing routinely collected data sources. However, the quality of record linkage is reliant upon the availability and accuracy of common identifying variables. We sought to develop and validate a method for linking a cohort study to a state-wide hospital admissions dataset with limited availability of unique identifying variables. Methods A sample of 2000 participants from a cohort study (n = 41 514) was linked to a state-wide hospitalisations dataset in Victoria, Australia using the national health insurance (Medicare) number and demographic data as identifying variables. Availability of the health insurance number was limited in both datasets; therefore linkage was undertaken both with and without use of this number and agreement tested between both algorithms. Sensitivity was calculated for a sub-sample of 101 participants with a hospital admission confirmed by medical record review. Results Of the 2000 study participants, 85% were found to have a record in the hospitalisations dataset when the national health insurance number and sex were used as linkage variables and 92% when demographic details only were used. When agreement between the two methods was tested the disagreement fraction was 9%, mainly due to "false positive" links when demographic details only were used. A final algorithm that used multiple combinations of identifying variables resulted in a match proportion of 87%. Sensitivity of this final linkage was 95%. Conclusions High quality record linkage of cohort data with a hospitalisations dataset that has limited identifiers can be achieved using combinations of a national health insurance number and demographic data as identifying variables.

Investigation of decision making issues in the use of current clinical information systems

Clinical information systems have become important tools in contemporary clinical patient care. However, there is a question of whether the current clinical information systems are able to effectively support clinicians in decision making processes. We conducted a survey to identify some of the decision making issues related to the use of existing clinical information systems. The survey was conducted among the end users of the cardiac surgery unit, quality and safety unit, intensive care unit and clinical costing unit at The Prince Charles Hospital (TPCH). Based on the survey results and reviewed literature, it was identified that support from the current information systems for decision-making is limited. Also, survey results showed that the majority of respondents considered lack in data integration to be one of the major issues followed by other issues such as limited access to various databases, lack of time and lack in efficient reporting and analysis tools. Furthermore, respondents pointed out that data quality is an issue and the three major data quality issues being faced are lack of data completeness, lack in consistency and lack in data accuracy. Conclusion: Current clinical information systems support for the decision-making processes in Cardiac Surgery in this institution is limited and this could be addressed by integrating isolated clinical information systems.

Hospital utilisation among people born in refugee-source countries : an analysis of hospital admissions, Victoria, 1998–2004

Objective: To investigate whether hospital utilisation and health outcomes in Victoria differ between people born in refugee-source countries and those born in Australia. Design and setting: Analysis of a statewide hospital discharge dataset for the 6 financial years from 1 July 1998 to 30 June 2004. Hospital admissions of people born in eight countries for which the majority of entrants to Australia arrived as refugees were included in the analysis. Main outcome measures: Age-standardised rates and rate ratios for: total hospital admissions; emergency admissions; surgical admissions; total days in hospital; discharge at own risk; hospital deaths; admissions due to infectious and parasitic diseases; and admissions due to mental and behavioural disorders. Results: In 2003–04, compared with the Australia-born Victorian population, people born in refugee-source countries had lower rates of surgical admission (rate ratio [RR], 0.85; 95% CI, 0.81–0.88), total days in hospital (RR, 0.74; 95% CI, 0.73–0.75), and admission due to mental and behavioural disorders (RR, 0.70; 95% CI, 0.65–0.76). Over the 6-year period, rates of total days in hospital and rates of admission due to mental and behavioural disorders for people born in refugee-source countries increased towards Australian-born averages, while rates of total admissions, emergency admissions, and admissions due to infectious and parasitic diseases increased above the Australian-born averages. Conclusions: Use of hospital services among people born in refugee-source countries is not higher than that of the Australian-born population and shows a trend towards Australian-born averages. Our findings indicate that the Refugee and Humanitarian Program does not currently place a burden on the Australian hospital system.

Managing intravenous medications in the non-hospital setting: An ethnographic investigation

Little published information exists about the issues involved in conducting complex intravenous medication therapy in patients' homes. An ethnographic study of a local hospital-in-the-home program in the Australian Capital Territory explored this phenomenon to identify those factors that had an impact on the use of medicine in the home environment. This article focuses on one of the three themes identified in the study-Clinical Practice. Within this theme, topics related to the organization and management of intravenous medications, geography and diversity of patient caseload, and communication in the practice setting are discussed. These findings have important implications for policy development and establishment of a research agenda for hospital-in-the-home services.