Annual summary of selected activities in hospital maternity service.

Title from caption.

University Hospital South Dept. [and Health Service]

Homeopathic Hospital until 1922; then used as South Department of University Hospital 1922-1939; then North Hall (home of ROTC) in 1939. On verso: University Hospital. South Department.

Medicare : hospital use rates of aged enrollees by health service area, 1974-1977 /

"October 1981"--P. [4] of cover.

Hospital social service

Mode of access: Internet.

Evaluating a GP consultative psychiatric service in an Australian metropolitan hospital district

Objective: The aim was to develop a psychiatric assessment and advisory service for local general practitioners (GPs). Method: In July 2001, five full-time psychiatrists at Royal Brisbane ­Hospital each dedicated a 1-h appointment per week in their hospital private practice clinic to assess patients referred by local GPs. The 'Psych Opinion' clinic was advertised through the Division of General Practice Newsletter. After 12 months, the referrals to the clinic had been disappointing so two surveys were carried out: one to the GPs who had used the service and the other to those who had not referred. Results: Feedback from the GPs who had used the service showed a high level of satisfaction with the service. The second survey of the GPs who had not referred showed a strong endorsement of the concept but there was poor awareness of the service's existence. Conclusions: This model offers a way for public sector psychiatrists to provide timely assessments to local GPs without additional funding. There is strong support and willingness from the GPs to refer. However, the need to actively market the service both initially and on an ongoing basis is ­highlighted.

Proliferative diabetic retinopathy (R3) referrals from the digital diabetic retinopathy screening program:urgency of appointment in the hospital eye service achieved and needed?

DESIGN. Retrospective analysis PURPOSE. To assess the clinical characteristics and outcomes of patients identified with proliferative diabetic retinopathy (PDR) referred from the screening program to the hospital eye services (HES) METHODS. a retrospective analysis of urgently referred PDR cases to Birmingham Heartlands HES from august 2008 until July 2010 RESULTS. 130 urgent diabetic retinopathy referrals were made and reviewed. 103 (68% male, 80% type 2 diabetes) were referred for PDR with a mean age of 59 years, mean diabetes duration of 17.8years. 69% were on insulin treatment at the time of the screening, with mean HbA1c of 10.4% (range-5.7 to 16.5%). 65% of the patients were offered appointments at HES within two weeks after referral from the screening. 50.5% of the patients were seen in the HES within 2 weeks, 22 and 16 % were seen 2-4 and 4-8 weeks after referral respectively. 6 patients never attended ophthalmology examination during the two years of review. Of all the attendees, 56% were booked for pan retinal photocoagulation (PRP) & 9(9.3%) for macular laser respectively on their 1st HES visit. 75% of the patients were newly diagnosed PDR and 26 had previous PRP laser but lost to follow up. 63 patients ( 66%) received either PRP or macular laser treatment (85.7% of which is PRP). 63% of the PRP treatment was performed within a month of first HES attendance. Retinopathy grading discrepancy between the screening program and HES was noted in 20% (21 patients). CONCLUSIONS. This data suggests that the digital screening programme is appropriately identifying high risk patients with PDR with timely PRP laser treatment in the majority of patients but raises concern over patients lost to follow up (hence failsafe tracking of appointment attendance), and review of grading discrepancies between the ophthalmology and screening service.

Effectiveness of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual non-inferiority trial

OBJECTIVES: To compare the ability of ophthalmologists versus optometrists to correctly classify retinal lesions due to neovascular age-related macular degeneration (nAMD).

DESIGN: Randomised balanced incomplete block trial. Optometrists in the community and ophthalmologists in the Hospital Eye Service classified lesions from vignettes comprising clinical information, colour fundus photographs and optical coherence tomographic images. Participants' classifications were validated against experts' classifications (reference standard).

SETTING: Internet-based application.

PARTICIPANTS: Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care.

INTERVENTIONS: The trial emulated a conventional trial comparing optometrists' and ophthalmologists' decision-making, but vignettes, not patients, were assessed. Therefore, there were no interventions and the trial was virtual. Participants received training before assessing vignettes.

MAIN OUTCOME MEASURES: Primary outcome-correct classification of the activity status of a lesion based on a vignette, compared with a reference standard. Secondary outcomes-potentially sight-threatening errors, judgements about specific lesion components and participants' confidence in their decisions.

RESULTS: In total, 155 participants registered for the trial; 96 (48 in each group) completed all assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702/2016 (84.4%) and 1722/2016 (85.4%) correct classifications, respectively (OR 0.91, 95% CI 0.66 to 1.25; p=0.543). Optometrists' decision-making was non-inferior to ophthalmologists' with respect to the prespecified limit of 10% absolute difference (0.298 on the odds scale). Optometrists and ophthalmologists made similar numbers of sight-threatening errors (57/994 (5.7%) vs 62/994 (6.2%), OR 0.93, 95% CI 0.55 to 1.57; p=0.789). Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their classifications than optometrists.

CONCLUSIONS: Optometrists' ability to make nAMD retreatment decisions from vignettes is not inferior to ophthalmologists' ability. Shared care with optometrists monitoring quiescent nAMD lesions has the potential to reduce workload in hospitals.

TRIAL REGISTRATION NUMBER: ISRCTN07479761; pre-results registration.

Sensitization to indoor aeroallergens in children who attended the Allergy Service of the “Dr. José Eleuterio González” University Hospital of Monterrey, Mexico

Background: Indoor aeroallergens are the main cause of sensitization in children and represent a risk factor for the development of allergic diseases. Objective: Identify the major indoor aeroallergens most often sensitized to pediatric patients treated at the Allergy Service at the “Dr. José Eleuterio González” University Hospital of Monterrey Methods: We performed an observational and descriptive study where we reviewed reports of positive skin tests to the following common indoor aeroallergens: Dermatophagoides farinae (D. farinae), Dermatophagoides pteronyssinus (D. pteronyssinus), Canis familiaris (C. familiaris), Felis domesticus (F. domesticus), Blattella germanica (B. germanica) and Periplaneta americana (P. americana), found in patients under 16 years with symptoms of allergy, during the period of 2011-2012. Results: We performed 439 skin tests to aeroallergens in pediatric patients. Of these, 57.6% were male and 42.4% were female. Mean age was 6.3 years. The age groups were under 3 years: 17.8%, 3-5 years: 35%, 6-12 years: 36%, and 13-16 years: 11.2%. The main diagnoses were: allergic rhinitis (71.8%), asthma (16.6%), and atopic dermatitis (4.3%). In 57.9% of the cases, they had at least one positive skin test to any aeroallergen. The rate of sensitization to speciic aeroallergens was: D. Pteronyssinus 49.0%, D. farinae 44.6%, B. germanica 13.9%, P. Americana 10.9%, F. domesticus 10.7%, and C. familiaris 5.9%. Conclusion: Indoor aeroallergen sensitization can occur early in life, although it was more frequent in the preschooler and elementary school group. Dust house mites were the most commom cause of allergic sensitization.

Determinants of pre-hospital care non-usage for patients with emergency care needs [including commentary by Snooks H.]

Objective-To establish the demographic, health status and insurance determinants of pre-hospital ambulance non-usage for patients with emergency medical needs. Methods-Triage category, date of birth, sex, marital status, country of origin, method and time of arrival, ambulance insurance status, diagnosis, and disposal were collected for all patients who presented over a four month period (n=10 229) to the emergency department of a major provincial hospital. Data for patients with urgent (n=678) or critical care needs (n=332) who did not use pre-hospital care were analysed using Poisson regression. Results-Only a small percentage (6.6%) of the total sample were triaged as having urgent medical needs or critical care needs (3.2%). Predictors of usage for those with urgent care needs included age greater than 65 years (prevalence ratio (PR)=0.54; 95% confidence interval (CI)= 0.35 to 0.83), being admitted to intensive care or transferred to another hospital (PR=0.62; 95% CI=0.44 to 0.89) or ward (PR=0.72; 95% CI=0.56 to 0.93) and ambulance insurance status (PR=0.67; 95% CI=052 to 0.86). Sex, marital status, time of day and country of origin were not predictive of usage and non-usage. Predictors of usage for those with critical care needs included age 65 years or greater (PR=0.45; 95% CI=0.25 to 0.81) and a diagnosis of trauma (PR=0.49; 95% CI=0.26 to 0.92). A non-English speaking background was predictive of non-usage (PR=1.98; 95% CI=1.06 to 3.70). Sex, marital status, time of day, triage and ambulance insurance status were not predictive of non-usage. Conclusions-Socioeconomic and medical factors variously influence ambulance usage depending on the severity or urgency of the medical condition. Ambulance insurance status was less of an influence as severity of condition increased suggesting that, at a critical level of urgency, patients without insurance are willing to pay for a pre-hospital ambulance service.

How does ambulance service utilisation impact demand for Emergency Departments in Queensland, Australia?

Background: There are indications that pre-hospital emergency care and management of patients can help reduce the demand for hospital emergency departments (EDs). Ambulance services play a significant role at this stage of care. In 2003, the Queensland Government introduced a Community Ambulance Cover (CAC) levy in return for a free ambulance service at the point of access to all Queenslanders. This may have led to the impression in consumers of an entitlement to free ambulance services under any circumstances regardless of the urgency of the matter which may have in turn contributed to the crowding of EDs in Queensland. Objectives: This paper aims to answer the following questions: - How many patients arrive at hospital EDs by ambulance in Queensland, compared to other modes of arrival? - How has this changed over time, particularly after the CAC introduction in 2003? What percentage of ambulance arrivals are urgent ED patients? - Has the perceived free ambulance services created extra demand for EDs in Queensland, compared with other Australian jurisdictions that charge patients for ambulance services? Methods: We will secondary analyse the data from sources such as Queensland Ambulance Services, Department of Health and Australian Bureau of Statistics to answer the research questions. Findings and Conclusions Queensland has the highest utilization rate of ambulance services (about 18% in 2007-08) and the highest annual growth rate in demand for these services (7.7% on average since 2000-01), well above the population growth. On the other hand, the proportion of ED patients arriving by ambulance in Queensland has increased by about 4% annually. However, when compared with other states and territories with charge at the point of access, it seems that the growth in demand for EDs cannot be explained solely or mainly by CAC or ambulance utilisation in Queensland.

Evaluating the effect of a patient education brochure on patients’ expectations and satisfaction with emergency department service

Introduction: The purpose of this study was to assess the capacity of a written intervention, in this case a patient information brochure, to improve patient satisfaction during an Emergency Department (ED) visit. For the purpose of measuring the effect of the intervention the ED journey was conceptualised as a series of distinct areas of service comprising waiting time, service by the triage nurse, care from doctors and nurses and information giving Background of study: Research into patient satisfaction has become a widespread activity endorsed by both governments and hospital administrations. The literature on ED patient satisfaction has consistently indicated three primary areas of patient dissatisfaction: waiting time, nursing care and communication. Recent developments in the literature on patient satisfaction studies however have highlighted the relationship between patients. expectations of a service encounter and their consequent assessment of the experience as dissatisfying or satisfying. Disconfirmation theory posits that the degree to which expectations are confirmed will affect subsequent levels of satisfaction. The conceptual framework utilised in this study is Coye.s (2004) model of disconfirmation. Coye while reiterating satisfaction is a consequence of the degree expectations are either confirmed or disconfirmed also posits that expectations can be modified by interventions. Coye.s work conceptualises these interventions as intra encounter experiences (cues) which function to adjust expectations. Coye suggests some cues are unintended and may have a negative impact which also reinforces the value of planned cues intended to meet or exceed consumer expectations. Consequently the brochure can be characterized as a potentially positive cue, encouraging the patient to understand processes and to orient them in what can be a confronting environment. Only a limited number of studies have examined the effect of written interventions within an ED. No studies could be located which have tested the effect of ED interventions using a conceptual framework which relates the effect of the degree to which expectations are confirmed or disconfirmed in terms of satisfaction with services. Method: Two studies were conducted. Study One used qualitative methods to explore patients. expectations of the ED from the perspective of both patients and health care professionals. Study One was used in part to direct the development of the intervention (brochure) in Study Two. The brochure was an intervention designed to modify patients. expectations thus increasing their satisfaction with the provision of ED service. As there was no existing tools to measure ED patients. expectations and satisfaction a new tool was also developed based on the findings and the literature of Study One. Study Two used a non-randomised, quasi-experimental approach using a non-equivalent post-test only comparison group design used to investigate the effect of the patient education brochure (Stommel and Wills, 2004). The brochure was disseminated to one of two study groups (the intervention group). The effect of the brochure was assessed by comparing the data obtained from both the intervention and control group. These two groups consisted of 150 participants each. It was expected that any differences in the relevant domains selected for examination would indicate the effect of the brochure both on expectation and potentially satisfaction. Results: Study One revealed several areas of common ground between patients and nurses in terms of relevant content for the written intervention, including the need for information on the triage system and waiting times. Areas of difference were also found with patients emphasizing communication issues, whereas focus group members expressed concern that patients were often unable to assimilate verbal information. The findings suggested the potential utility of written material to reinforce verbal communication particularly in terms of the triage process and other ED protocols. This material was synthesized within the final version of the written intervention. Overall the results of Study Two indicated no significant differences between the two groups. The intervention group did indicate a significant number of participants who viewed the brochure of having changed their expectations. The effect of the brochure may have been obscured by a lack of parity between the two groups as the control group presented with statistically significantly higher levels of acuity and experienced significantly shorter waiting times. In terms of disconfirmation theory this would suggest expectations that had been met or exceeded. The results confirmed the correlation of expectations with satisfaction. Several domains also indicated age as a significant predictor with older patients tending to score higher satisfaction results. Other significant predictors of satisfaction established were waiting time and care from nurses, reinforcing the combination of efficient service and positive interpersonal experiences as being valued by patients. Conclusions: Information presented in written form appears to benefit a significant number of ED users in terms of orientation and explaining systems and procedures. The degree to which these effects may interact with other dimensions of satisfaction however is likely to be limited. Waiting time and interpersonal behaviours from staff also provide influential cues in determining satisfaction. Written material is likely to be one element in a series of coordinated strategies to improve patient satisfaction during periods of peak demand.

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.