Marginal costs of hospital-acquired conditions : information for priority-setting for patient safety programmes and research

Objective: To estimate the relative inpatient costs of hospital-acquired conditions. Methods: Patient level costs were estimated using computerized costing systems that log individual utilization of inpatient services and apply sophisticated cost estimates from the hospital's general ledger. Occurrence of hospital-acquired conditions was identified using an Australian ‘condition-onset' flag for diagnoses not present on admission. These were grouped to yield a comprehensive set of 144 categories of hospital-acquired conditions to summarize data coded with ICD-10. Standard linear regression techniques were used to identify the independent contribution of hospital-acquired conditions to costs, taking into account the case-mix of a sample of acute inpatients (n = 1,699,997) treated in Australian public hospitals in Victoria (2005/06) and Queensland (2006/07). Results: The most costly types of complications were post-procedure endocrine/metabolic disorders, adding AU$21,827 to the cost of an episode, followed by MRSA (AU$19,881) and enterocolitis due to Clostridium difficile (AU$19,743). Aggregate costs to the system, however, were highest for septicaemia (AU$41.4 million), complications of cardiac and vascular implants other than septicaemia (AU$28.7 million), acute lower respiratory infections, including influenza and pneumonia (AU$27.8 million) and UTI (AU$24.7 million). Hospital-acquired complications are estimated to add 17.3% to treatment costs in this sample. Conclusions: Patient safety efforts frequently focus on dramatic but rare complications with very serious patient harm. Previous studies of the costs of adverse events have provided information on ‘indicators’ of safety problems rather than the full range of hospital-acquired conditions. Adding a cost dimension to priority-setting could result in changes to the focus of patient safety programmes and research. Financial information should be combined with information on patient outcomes to allow for cost-utility evaluation of future interventions.

How different are complications that affect the older adult inpatient?

Objective: The incidence and cost of complications occurring in older and younger inpatients were compared. Design: Secondary analysis of hospital-recorded diagnosis and costs for multiday-stay inpatients in 68 public hospitals in two Australian states. Main outcome measures: A complication is defined as a hospital-acquired diagnosis that required additional treatment. The Australian Classification of Hospital-Acquired Diagnoses system is used to identify these complications. Results: Inpatients aged >70 years have a 10.9% complication rate, which is not substantially different from the 10.89% complication rate found in patients aged <70 years. Examination of the probability by single years, however, showed that the peak incidence associated with the neonatal period and childbirth is balanced by rates of up to 20% in patients >80 years. Examining the adult patient population (40–70 years), we found that while some common complications are not age specific (electrolyte disorders and cardiac arrhythmias), others (urinary tract and lower respiratory tract infections) are more common in the older adult inpatient. Conclusion: For inpatients aged >70 years, the risks of complications increase. The incidence of hospital-acquired diagnoses in older adults differs significantly from incidence rates found in younger cohorts. Urinary tract infection and alteration to mental state are more common in older adult inpatients. Surprisingly, these complexities do not result in additional costs when compared with costs for the same complications in younger adults. Greater awareness of these differing patterns will allow patient safety efforts for older patients to focus on complications with the highest incidence and cost.

Out-of-pocket expenditures for hospital care in Iran : who is at risk of incurring catastrophic payments?

Since the beginning of 1980s, the Iranian health care system has undergone several reforms designed to increase accessibility of health services. Notwithstanding these reforms, out-of-pocket payments which create a barrier to access health services contribute almost half of total health are financing in Iran. This study aimed to provide a greater understanding about the inequality and determinants of the out-of-pocket expenditure (OOPE) and the related catastrophic expenditure (CE) for hospital services in Iran using a nationwide survey data, the 2003 Utilisation of Health Services Survey (UHSS). The concentration index and the Heckman selection model were used to assess inequality and factors associated with these expenditures. Inequality analysis suggests that the CE is concentrated among households in lower socioeconomic levels. The results of the Heckman selection model indicate that factors such as length of stay, admission to a hospital owned by private sector or Ministry of Health and Medical Education, and living in remote areas are positively associated with higher OOPE. Results of the ordered-probit selection model demonstrate that length of stay, lower household wealth index, and admission to a private hospital are major factors contributing to the increase in the probability of CE. Also, we find that households living in East Azarbaijan, Kordestan and Sistan and Balochestan face a higher level of CE. Based on our findings, the current employer-sponsored health insurance system does not offer equal protection against hospital expenditure in Iran. It seems that a single universal health insurance scheme that covers health services for all Iranian—regardless of their employment status—can better protect households from catastrophic health spending.

Hospital care in Iran : an examination of national health system performance

This study examines hospital care system performance in Iran. We first briefly review hospital care delivery system in Iran. Then, the hospital care system in Iran has been investigated from financial, utilization, and quality perspectives. In particular, we examined the extent to which health care system in Iran protects people from the financial consequence of health care expenses and whether inpatient care distributed according to need. We also empirically analyzed the quality of hospital care in Iran using patient satisfaction information collected in a national health service survey. The Iranian health care system consists of unequal access to hospital care; mismatch between the distribution of services and inpatients' need; and high probability of financial catastrophe due to out-of-pocket payments for inpatient services. Our analysis indicates that the quality of hospital care among Iranian provinces favors patients residing in provinces with high numbers of hospital beds per capita such as Esfahan and Yazd. Patients living in provinces with low levels of accessibility to hospital care (e.g. Gilan, Kermanshah, Hamadan, Chahar Mahall and Bakhtiari, Khuzestan, and Sistan and Baluchestan) receive lower-quality services. These findings suggest that policymakers in Iran should work on several fronts including utilization, financing, and service quality to improve hospital care.

Using a theory of planned behaviour framework to explore hand hygiene beliefs at the ‘5 critical moments’ among Australian hospital-based nurses

Background Improving hand hygiene among health care workers (HCWs) is the single most effective intervention to reduce health care associated infections in hospitals. Understanding the cognitive determinants of hand hygiene decisions for HCWs with the greatest patient contact (nurses) is essential to improve compliance. The aim of this study was to explore hospital-based nurses’ beliefs associated with performing hand hygiene guided by the World Health Organization’s (WHO) 5 critical moments. Using the belief-base framework of the Theory of Planned Behaviour, we examined attitudinal, normative, and control beliefs underpinning nurses’ decisions to perform hand hygiene according to the recently implemented national guidelines. Methods Thematic content analysis of qualitative data from focus group discussions with hospital-based registered nurses from 5 wards across 3 hospitals in Queensland, Australia. Results Important advantages (protection of patient and self), disadvantages (time, hand damage), referents (supportive: patients, colleagues; unsupportive: some doctors), barriers (being too busy, emergency situations), and facilitators (accessibility of sinks/products, training, reminders) were identified. There was some equivocation regarding the relative importance of hand washing following contact with patient surroundings. Conclusions The belief base of the theory of planned behaviour provided a useful framework to explore systematically the underlying beliefs of nurses’ hand hygiene decisions according to the 5 critical moments, allowing comparisons with previous belief studies. A commitment to improve nurses’ hand hygiene practice across the 5 moments should focus on individual strategies to combat distraction from other duties, peer-based initiatives to foster a sense of shared responsibility, and management-driven solutions to tackle staffing and resource issues. Hand hygiene following touching a patient’s surroundings continues to be reported as the most neglected opportunity for compliance.

The ‘state of play’ in Australia: Early childhood educators and play-based learning

This article provides an overview of the Education Meets Play study that will investigate early childhood educators’ use of play-based learning, now mandatory under the National Quality Standard. By building on what can be gleaned about educators’ approaches to play-based learning prior to the implementation of the Early Years Learning Framework, the study will contribute to the evidence base concerning the implementation and effects of Australia’s early childhood education and care policy reform initiatives.

Valuation of hospital bed-days released by infection control programs: A comparison of methods

We performed a contingent valuation survey to elicit the opportunity cost of bed-days consumed by healthcare-associated infections in 11 European hospitals. The opportunity cost of a bed-day was significantly lower than the accounting cost; median values were i72 and i929, respectively (P ! .001). Accounting methods overestimate the opportunity cost of bed-days...

Current pre-hospital traumatic brain injury management in China

BACKGROUND Traumatic brain injury (TBI) is associated with mo st trauma-related deaths. Secondary brain injury is the leading cause of in-hospital deaths after traumatic brain injury. By early prevention and slowing of the initial pathophysiological mechanism of secondary brain injury, pre- hospital service can signifi cantly reduce case-fata lity rates of TBI. In China, the incidence of TBI is increasing and the proportion of severe TBI is much higher than that in other countries. The objective of this paper is to review the pre-hospital management of TBI in China. DATA SOURCES A literature search was conducted in January 2014 using the China National Knowledge Infrastructure (CNKI). Articles on the assessment and treatment of TBI in pre-hospital settings practiced by Chinese doctors were identified. The information on the assessment and treatment of hypoxemia, hypotension, and brain hern iation was extracted from the identifi ed articles. RESULTS Of the 471 articles identified, 65 met the selecti on criteria. The existing literature indicated that current practices of pre-hospital TBI management in China were sub-optimal and varied considerably across different regions. CONCLUSION Since pre-hospital care is the weakest part of Chinese emergency care, appropriate training programs on pre-hospital TBI management are urgently needed in China.

Secular and religious moral grounds resonating across state schools in Indonesia

This paper describes moral education in Indonesia, more particularly, how teachers have implemented the Character Education policy issued by the Ministry of Education and Culture (MOEC) in 2010. This policy required teachers to instil certain values in every lesson, including EFL lessons, to contribute towards building a shared national moral character. Drawing on Durkheim's distinction between secular and religious morality, this paper considers how state schools accommodated and promoted this ‘rational moral education' or secular morality (Durkheim, 1925) in government schools, and how it interacted with religious moral education. This paper uses Bernstein's concepts of pedagogic discourse, instructional and regulative discourses to analyse how teachers have recontextualised this policy in the micro pedagogic settings of their EFL classes. Three types of data were collected for this study: interviews, class observations and teachers' lesson plans. In this way, four EFL teachers working in state schools were interviewed on two occasions and three of their classes were observed. The first interview identified teachers' beliefs and perceptions regarding the Character Education policy. Their classroom and lesson plans were observed to augment this information. Then the final interview asked about the teacher's thinking behind their actions in the observed classes. Since character education was issued within the broader frame of school based curriculum that offered schools and teachers more choices to develop the local curriculum and its intent, the analysis will focus on what moral premises were evident in their school and classes, and how such morality was transmitted through the EFL lessons. The conclusion suggests that teachers' implementation of moral education in their classes was dominated by their school communities and the teachers' own preferred value of religiosity. Such value played out in the classes through both the regulative discourse and the instructional discourse.

The effect of feedback from pupil to teacher on assessment for leaning and visible learning: An ethnographic case study in a community school in England and the outcome in a state high school in Queensland, Australia

This study shows that there is positive regulatory effect of feedback from pupils to teachers on Assessment for Learning (AfL), classroom proactiveness, and on visible and progressive learning but not on behaviour. This research finding further articulates feedback from pupil to teacher as a paradigm shift from the classical paradigm of feedback from teacher to pupil. Here, the emphasis is geared towards pupils understanding of objectives built from previous knowledge. These are then feedback onto the teachers by the pupils in the form of discrete loops of cues and questions, where they are with their learning. This therefore enables them to move to the next level of understanding, and thus acquired independence, which in turn is reflected by their success in both formative and summative assessments. This study therefore shows that when feedback from pupil to teacher is used in combination with teacher to pupil feedback, AfL is ameliorated and hence, visible and accelerated learning occurs in a gender, nor subject non-dependent manner.

Medication Management of Adult Patients Admitted to Hospital with Epilepsy, Seizure or Convulsion

Background: An inpatient medication chart review at the Gold Coast Hospital identified shortcomings with the prescribing and monitoring of antiepileptic medications. Aim: To evaluate medication management of patients with epilepsy, seizure or convulsion; to map their transition through the health system; and to identify lifestyle behaviours that may lead to overt risks for seizure occurrence. Method: A retrospective observational audit of adult patients (16 years and over) admitted to hospital with a diagnosis of epilepsy, seizure or convulsion from 1 to 31 January 2012. Results: Majority of the 62 episodes of care investigated involved patients who were discharged directly from the ED (68%). Only 30% of all patients discharged from an inpatient unit received a discharge medication record from a pharmacist. Non-adherence with antiepileptic medications, alcohol and/ or recreational drug use and prescription medication misuse were identified as overt risks for seizure occurrence. Conclusion: Valuable insights were gained into the management of seizure patients. The role of the ED pharmacist was reviewed to focus on high-risk seizure patients. An increase in the provision of discharge medication records and patient education on the overt risks for seizure occurrence is needed.

Non-Therapeutic Medication Omissions: Incidence and Predictors at an Australian Hospital

Background: The inconsistent definition of non-therapeutic medication omissions, under-reporting, and a poor understanding of their associated factors hamper efforts to improve medication administration practices. Aim: To examine the incidence of non-therapeutic medication omissions among acutely ill medical and surgical adult patients; and to identify the patient-, drug- and system-related predictors of these omissions. Method: A medication chart audit of 288 acutely ill adult medical and surgical patients admitted to 4 target wards (2 surgical and 2 medical) at an Australian hospital. Patients admitted to these wards from December 2008 to November 2009, with at least one regularly prescribed medication, were eligible. The sample was stratified according to gender, season and ward. A medication chart audit identified medication omissions, and data were collected on gender, age, length of stay, comorbidities, medication history and clinical pharmacy review. Results: Of the 288 medication charts audited, 220 (75%) had one or more medication omissions. Of the 15 020 medication administration episodes, there were 1687 omissions, resulting in an omission rate per medication administration episode of 11%. Analgesics and aperients were the most frequently omitted medications, with failure to sign the medication record and patient refusal, the main reasons for omission. Female gender (p < 0.001) and the number of medication administration episodes (p < 0.001) were statistically significant predictors of non-therapeutic medication omissions. Conclusion: The high incidence of medication omissions suggests there is need for an agreed definition of medication omission and its inclusion as a reportable incident. Increasing medication reconciliation via implementation of the Medication Management Plan may also reduce the opportunity for error. J Pharm Pract Res 2011; 41: 188-91.

Evaluation of ANPR trials for traffic policing in Queensland. Report to the Queensland Police Service, State Traffic Support Branch

In response to the Travelsafe Committee Report No. 51 – report on the inquiry into Automatic Plate Recognition Technology – it was recommended that the Queensland Police Service continue to trial the deployment of ANPR technology for traffic enforcement work and to evaluate the road safety impacts and operational effectiveness of the technology. As such, the purpose of this report is to provide an independent evaluation of a trial of ANPR that was conducted by a project team within the State Traffic Support Branch of the Queensland Police Service (QPS) and provide recommendations as to the applicability and usability of the technology for use throughout Queensland...

Key beliefs of hospital nurses’ hand-hygiene behaviour: Protecting your peers and needing effective reminders

Issues addressed: Hand hygiene in hospitals is vital to limit the spread of infections. This study aimed to identify key beliefs underlying hospital nurses’ hand-hygiene decisions to consolidate strategies that encourage compliance. Methods: Informed by a theory of planned behaviour belief framework, nurses from 50 Australian hospitals (n = 797) responded to how likely behavioural beliefs (advantages and disadvantages), normative beliefs (important referents) and control beliefs (barriers) impacted on their hand-hygiene decisions following the introduction of a national ‘5 moments for hand hygiene’ initiative. Two weeks after completing the survey, they reported their hand-hygiene adherence. Stepwise regression analyses identified key beliefs that determined nurses’ hand-hygiene behaviour. Results: Reducing the chance of infection for co-workers influenced nurses’ hygiene behaviour, with lack of time and forgetfulness identified as barriers. Conclusions: Future efforts to improve hand hygiene should highlight the potential impact on colleagues and consider strategies to combat time constraints, as well as implementing workplace reminders to prompt greater hand-hygiene compliance. So what? Rather than emphasising the health of self and patients in efforts to encourage hand-hygiene practices, a focus on peer protection should be adopted and more effective workplace reminders should be implemented to combat forgetting.