Cardiovascular alterations and management

This chapter reviews the support of cardiovascular function in the face of
many compromises to the system. It focuses on two of the most prevalent and fatal diseases affecting the heart: coronary heart disease and heart failure. These diseases are also a common comorbidity in elderly patients admitted to critical care units. The first section on coronary heart disease reviews the pathophysiological concepts of myocardial ischaemia and associated complications, with detailed consideration of the clinical implications, assessment and associated management. Heart failure is discussed in terms of the body’s compensatory mechanisms and the clinical sequelae and associated clinical features of heart failure. Nursing and medical management is outlined including the management of acute exacerbations of heart failure. Finally, other cardiovascular disorders commonly managed in critical care units are reviewed, ranging from other forms of heart failure to hypertensive emergencies and aortic aneurysms. The case study presented at the end of the chapter highlights the key aspects of the management of coronary heart disease and heart failure in patients admitted to critical care units.

Occupational stress and job satisfaction in media personnel assigned to the Iraq War (2003)

This paper investigates occupational stressors amongst media personnel assigned to work on covering the Iraq War via interviews with 54 journalists from the BBC and Reuters, who worked in Iraq between February and April 2003. A range of stressors were identified that could be categorized into three main themes, control over the situation, support from management and grief from the death of colleagues. Journalists not embedded with military units were more likely to report negative physical and emotional health outcomes. The study concludes that hazardous work environments do not, by themselves, cause stress and poor job satisfaction. Rather, organizational factors, the imbalance between the ability to make decisions about how to carry out their job effectively and the perceived rewards of working in such environments appear to have a greater impact on work related stress.

A landscape-scale, applied fire management experiment promotes recovery of a population of the threatened Gouldian Finch, Erythrura gouldiae, in Australia's tropical savannas

Fire is an integral part of savanna ecology and changes in fire patterns are linked to biodiversity loss in savannas worldwide. In Australia, changed fire regimes are implicated in the contemporary declines of small mammals, riparian species, obligate-seeding plants and grass seed-eating birds. Translating this knowledge into management to recover threatened species has proved elusive. We report here on a landscape-scale experiment carried out by the Australian Wildlife Conservancy (AWC) on Mornington Wildlife Sanctuary in northwest Australia. The experiment was designed to understand the response of a key savanna bird guild to fire, and to use that information to manage fire with the aim of recovering a threatened species population. We compared condition indices among three seed-eating bird species-one endangered (Gouldian finch) and two non-threatened (long-tailed finch and double-barred finch)-from two large areas (> 2,830 km2) with initial contrasting fire regimes ('extreme': frequent, extensive, intense fire; versus 'benign': less frequent, smaller, lower intensity fires). Populations of all three species living with the extreme fire regime had condition indices that differed from their counterparts living with the benign fire regime, including higher haematocrit levels in some seasons (suggesting higher levels of activity required to find food), different seasonal haematocrit profiles, higher fat scores in the early wet season (suggesting greater food uncertainty), and then lower muscle scores later in the wet season (suggesting prolonged food deprivation). Gouldian finches also showed seasonally increasing stress hormone concentrations with the extreme fire regime. Cumulatively, these patterns indicated greater nutritional stress over many months for seed-eating birds exposed to extreme fire regimes. We tested these relationships by monitoring finch condition over the following years, as AWC implemented fire management to produce the 'benign' fire regime throughout the property. The condition indices of finch populations originally living with the extreme fire regime shifted to resemble those of their counterparts living with the benign fire regime. This research supports the hypothesis that fire regimes affect food resources for savanna seed-eating birds, with this impact mediated through a range of grass species utilised by the birds over different seasons, and that fire management can effectively moderate that impact. This work provides a rare example of applied research supporting the recovery of a population of a threatened species.

Data management challenges in analysis and synthesis in the ecosystem sciences

Open-data has created an unprecedented opportunity with new challenges for ecosystem scientists. Skills in data management are essential to acquire, manage, publish, access and re-use data. These skills span many disciplines and require trans-disciplinary collaboration. Science synthesis centres support analysis and synthesis through collaborative 'Working Groups' where domain specialists work together to synthesise existing information to provide insight into critical problems. The Australian Centre for Ecological Analysis and Synthesis (ACEAS) served a wide range of stakeholders, from scientists to policy-makers to managers. This paper investigates the level of sophistication in data management in the ecosystem science community through the lens of the ACEAS experience, and identifies the important factors required to enable us to benefit from this new data-world and produce innovative science. ACEAS promoted the analysis and synthesis of data to solve transdisciplinary questions, and promoted the publication of the synthesised data. To do so, it provided support in many of the key skillsets required. Analysis and synthesis in multi-disciplinary and multi-organisational teams, and publishing data were new for most. Data were difficult to discover and access, and to make ready for analysis, largely due to lack of metadata. Data use and publication were hampered by concerns about data ownership and a desire for data citation. A web portal was created to visualise geospatial datasets to maximise data interpretation. By the end of the experience there was a significant increase in appreciation of the importance of a Data Management Plan. It is extremely doubtful that the work would have occurred or data delivered without the support of the Synthesis centre, as few of the participants had the necessary networks or skills. It is argued that participation in the Centre provided an important learning opportunity, and has resulted in improved knowledge and understanding of good data management practices.

Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: a systematic review and meta-synthesis of qualitative studies

INTRODUCTION: Despite the availability of evidence-based guidelines for the management of low back pain that contain consistent messages, large evidence-practice gaps in primary care remain.

OBJECTIVES: To perform a systematic review and meta-synthesis of qualitative studies that have explored primary care clinicians' perceptions and beliefs about guidelines for low back pain, including perceived enablers and barriers to guideline adherence.

METHODS: Studies investigatingperceptions and beliefs about low back pain guidelines were included if participants were primary care clinicians and qualitative methods had been used for both data collection and analysis. We searched major databases up to July 2014. Pairs of reviewers independently screened titles and abstracts, extracted data, appraised method quality using the CASP checklist, conducted thematic analysis and synthesized the results in narrative format.

RESULTS: Seventeen studies, with a total of 705 participants, were included. We identified three key emergent themes and eight subthemes: (1) guideline implementation and adherence beliefs and perceptions; (2) maintaining the patient-clinician relationship with imaging referrals; (3) barriers to guideline implementation. Clinicians believed that guidelines were categorical, prescriptive and constrained professional practice; however popular clinical practices superseded the guidelines. Imaging referrals were used to manage consultations and to obtain definitive diagnoses. Clinicians' perceptions reflected a lack of content knowledge and understanding of how guidelines are developed.

DISCUSSION: Addressing misconceptions and other barriers to uptake of evidence-based guidelines for managing low back pain is needed to improve knowledge transfer and close the evidence-practice gap in the treatment of this common condition.

Intensive case management for high-risk patients with first-episode psychosis: service model and outcomes

Background : The first episode of psychosis is a crucial period when early intervention can alter the trajectory of the young person's ongoing mental health and general functioning. After an investigation into completed suicides in the Early Psychosis Prevention and Intervention Centre (EPPIC) programme, the intensive case management subprogramme was developed in 2003 to provide assertive outreach to young people having a first episode of psychosis who are at high risk owing to risk to self or others, disengagement, or suboptimal recovery. We report intensive case management model development, characterise the target cohort, and report on outcomes compared with EPPIC treatment as usual.

Methods : Inclusion criteria, staff support, referral pathways, clinical review processes, models of engagement and care, and risk management protocols are described. We compared 120 consecutive referrals with 50 EPPIC treatment as usual patients (age 15–24 years) in a naturalistic stratified quasi-experimental real-world design. Key performance indicators of service use plus engagement and suicide attempts were compared between EPPIC treatment as usual and intensive case management, and psychosocial and clinical measures were compared between intensive case management referral and discharge.

Findings : Referrals were predominately unemployed males with low levels of functioning and educational attainment. They were characterised by a family history of mental illness, migration and early separation, with substantial trauma, history of violence, and forensic attention. Intensive case management improved psychopathology and psychosocial outcomes in high-risk patients and reduced risk ratings, admissions, bed days, and crisis contacts.

Interpretation : Characterisation of intensive case management patients validated the clinical research focus and identified a first episode of psychosis high-risk subgroup. In a real-world study, implementation of an intensive case management stream within a well-established first episode of psychosis service showed significant improvement in key service outcomes. Further analysis is needed to determine cost savings and effects on psychosocial outcomes. Targeting intensive case management services to high-risk patients with unmet needs should reduce the distress associated with pathways to care for patients, their families, and the community.

Communicating about the management of medications as patients move across transition points of care: an observation and interview study

RATIONALE, AIMS AND OBJECTIVES: As patients move across transition points, effective medication management is critical for patient safety. The aims of this study were to examine how health professionals, patients and family members communicate about managing medications as patients moved across transition points of care and to identify possible sources of communication failure.

METHOD: A descriptive approach was used involving observations and interviews. The emergency departments and medical wards of two hospitals were involved. Observations focused on how health professionals managed medications during interactions with other health professionals, patients and family members, as patients moved across clinical settings. Follow-up interviews with participants were also undertaken. Thematic analysis was completed of transcribed data, and descriptive statistics were used to analyse characteristics of communication failure.

RESULTS: Three key themes were identified: environmental challenges, interprofessional relationships, and patient and family beliefs and responsibilities. As patients moved between environments, insufficient tracking occurred about medication changes. Before hospital admission, patients participated in self-care medication activities, which did not always involve exemplary behaviours or match the medications that doctors prescribed. During observations, 432 instances of communication failure (42.8%) were detected, which related to purpose, content, audience and occasion of the communication.

CONCLUSIONS: Extensive challenges exist involving the management of medications at transition points of care. Bedside handovers and ward rounds can be utilized as patient counselling opportunities about changes in the medication regimen. Greater attention is needed on how patients in the community make medication-related decisions.

Sedimentary factors are key predictors of carbon storage in SE Australian saltmarshes

Although coastal vegetated ecosystems are widely recognised as important sites of long-term carbon (C) storage, substantial spatial variability exists in quantifications of these ‘blue C’ stocks. To better understand the factors behind this variability we investigate the relative importance of geomorphic and vegetation attributes to variability in the belowground C stocks of saltmarshes in New South Wales (NSW), southeast Australia. Based on the analysis of over 140 sediment cores, we report mean C stocks in the surface metre of sediments (mean ± SE = 164.45 ± 8.74 Mg C ha−1) comparable to global datasets. Depth-integrated stocks (0–100 cm) were more than two times higher in fluvial (226.09 ± 12.37 Mg C ha−1) relative to marine (104.54 ± 7.11) geomorphic sites, but did not vary overall between rush and non-rush vegetation structures. More specifically, sediment grain size was a key predictor of C density, which we attribute to the enhanced C preservation capacity of fine sediments and/or the input of stable allochthonous C to predominantly fine-grained, fluvial sites. Although C density decreased significantly with sediment depth in both geomorphic settings, the importance of deep C varied substantially between study sites. Despite modest spatial coverage, NSW saltmarshes currently hold approximately 1.2 million tonnes of C in the surface metre of sediment, although more C may have been returned to the atmosphere through habitat loss over the past approximately 200 years. Our findings highlight the suitability of using sedimentary classification to predict blue C hotspots for targeted conservation and management activities to reverse this trend.

Sound the alarm: health and safety risks associated with alarm response for salaried and retained metropolitan firefighters

Responding to an emergency alarm poses a significant risk to firefighters' health and safety, particularly to cardiovascular health, physical and psychological stress, and fatigue. These risks have been largely categorised for salaried firefighters working 'on station'. Less is known about the factors that contribute to these risks for the vast number of non-salaried personnel who serve in retained roles, often deploying from home. The present study investigated the alarm response procedure for Australian metropolitan fire fighters, identifying common and divergent sources of risk for salaried and retained staff. There were significant differences in procedure between the two workgroups and this resulted in differences in risk profile between groups. Sleep and fatigue, actual response to the alarm stimulus, work-life balance and trauma emerged as sources of risk experienced differently by salaried and retained firefighters. Key findings included reports of fatigue in both groups, but particularly in the case of retained firefighters who manage primary employment as well as their retained position. This also translated into a poor sense of work-life balance. Both groups reported light sleep, insufficient sleep or fragmented sleep as a result of alarm response. In the case of salaried firefighters, this was associated with being woken on station when other appliances are called. There were risks from physical and psychological responses to the alarm stimulus, and reports of sleep inertia when driving soon after waking. The findings of this study highlight the common and divergent risks for these workgroups, and could be used in the ongoing management of firefighters' health and safety.

Engaging patients, clinicians and health funders in weight management: the Counterweight Programme

Background. The Counterweight Programme provides an evidence based and effective approach for weight management in routine primary care. Uptake of the programme has been variable for practices and patients.

Aim. To explore key barriers and facilitators of practice and patient engagement in the Counterweight Programme and to describe key strategies used to address barriers in the wider implementation of this weight management programme in UK primary care.

Methods. All seven weight management advisers participated in a focus group. In-depth interviews were conducted with purposeful samples of GPs (n = 7) and practice nurses (n = 15) from 11 practices out of the 65 participating in the programme. A total of 37 patients participated through a mixture of in-depth interviews (n = 18) and three focus groups. Interviews and focus groups were analysed for key themes that emerged.

Results. Engagement of practice staff was influenced by clinicians’ beliefs and attitudes, factors relating to the way the programme was initiated and implemented, the programme content and organizational/contextual factors. Patient engagement was influenced by practice endorsement of the programme, clear understanding of programme goals, structured proactive follow-up and perception of positive outcomes.

Conclusions. Having a clear understanding of programme goals and expectations, enhancing self-efficacy in weight management and providing proactive follow-up is important for engaging both practices and patients. The widespread integration of weight management programmes into routine primary care is likely to require supportive public policy.

Explaining the variation in the management of lifestyle risk factors in primary health care: a multilevel cross sectional study

Background

Despite evidence for the effectiveness of interventions to modify lifestyle behaviours in the primary health care (PHC) setting, assessment and intervention for these behaviours remains low in routine practice. Little is known about the relative importance of various determinants of practice.

This study aimed to examine the relative importance of provider characteristics and attitudes, patient characteristics and consultation factors in determining the rate of assessment and intervention for lifestyle risk factors in PHC.

Methods

A prospective audit of assessment and intervention for lifestyle risk factors was undertaken by PHC nurses and allied health providers (n = 57) for all patients seen (n = 732) over a two week period. Providers completed a survey to assess key attitudes related to addressing lifestyle issues. Multi-level logistic regression analysis of patient audit records was undertaken. Associations between variables from both data sources were examined, together with the variance explained by patient and consultation (level 1) and provider (level 2) factors.

Results

There was significant variance between providers in the assessment and intervention for lifestyle risk factors. The consultation type and reason for the visit were the most important in explaining the variation in assessment practices, however these factors along with patient and provider variables accounted for less than 20% of the variance. In contrast, multi-level models showed that provider factors were most important in explaining the variance in intervention practices, in particular, the location of the team in which providers worked (urban or rural) and provider perceptions of their effectiveness and accessibility of support services. After controlling for provider variables, patients' socio-economic status, the reason for the visit and providers' perceptions of the 'appropriateness' of addressing risk factors in the consultation were all significantly associated with providing optimal intervention. Together, measured patient consultation and provider variables accounted for most (80%) of the variation in intervention practices between providers.

Conclusion

The findings highlight the importance of provider factors such as beliefs and attitudes, team location and work context in understanding variations in the provision of lifestyle intervention in PHC. Further studies of this type are required to identify variables that improve the proportion of variance explained in assessment practices.

Should I and Can I?: a mixed methods study of clinician beliefs and attitudes in the management of lifestyle risk factors in primary health care

Background
Primary health care (PHC) clinicians have an important role to play in addressing lifestyle risk factors for chronic diseases. However they intervene only rarely, despite the opportunities that arise within their routine clinical practice. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about this for PHC clinicians working outside general practice. The aim of this study was to explore the beliefs and attitudes of PHC clinicians about incorporating lifestyle risk factor management into their routine care and to examine whether these varied according to their self reported level of risk factor management.

Methods
A cross sectional survey was undertaken with PHC clinicians (n = 59) in three community health teams. Clinicians' beliefs and attitudes were also explored through qualitative interviews with a purposeful sample of 22 clinicians from the teams. Mixed methods analysis was used to compare beliefs and attitudes for those with high and low levels of self reported risk factor management.

Results
Role congruence, perceived client acceptability, beliefs about capabilities, perceived effectiveness and clinicians' own lifestyle were key themes related to risk factor management practices. Those reporting high levels of risk factor screening and intervention had different beliefs and attitudes to those PHC clinicians who reported lower levels.

Conclusion
PHC clinicians' level of involvement in risk factor management reflects their beliefs and attitudes about it. This provides insights into ways of intervening to improve the integration of behavioural risk factor management into routine practice.

Winning the Accreditation Game: The Library as Key Player and Hidden Gold Mine

Libraries are a central hub of information resources supporting college and university curricula. Several library strategies, cross-campus collaborations, and philosophical considerations of electronic and print offerings led to successful accreditations in business and engineering programs.

O processo de aprendizagem organizacional no âmbito de programas de qualidade

As constantes mudanças no ambiente exigem das empresas uma capacidade de adaptação para a sobrevivência, aliada à necessidade de expandir a capacidade criativa. Desta forma, existe a necessidade de identificar como as organizações aprendem e como é possível oportunizar essa aprendizagem. A presente dissertação tem por objetivo identificar e analisar se e como ocorrem os processos de Aprendizagem Organizacional no âmbito de programas de qualidade premiados pelo Programa Gaúcho de Qualidade e Produtividade (PGQP). Os elementos referenciais de Aprendizagem Organizacional (AO) identificados na literatura associados com o atendimento aos critérios exigidos pelo PGQP, permitiram esta análise. Foi realizada uma pesquisa em duas empresas que receberam o Troféu Prata nesse programa. A pesquisa caracterizou-se como um estudo de caso múltiplo, envolvendo na coleta de dados entrevistas e os relatórios do PGQP de 1999 até 2002. Foram realizadas entrevistas semiestruturadas com vinte e oito executivos das diversas áreas, coordenadores da qualidade e analistas envolvidos nos principais processos da empresa. O resultado dos levantamentos efetuados e a identificação de ocorrência de Aprendizagem Organizacional envolvem os critérios: liderança, planejamento estratégico, foco no cliente e no mercado, informação e análise, gestão de pessoas, gestão de processos, e resultados da organização. Constatou-se que existem diferentes processos de AO nas empresas que possuem programas de qualidade. Identificou-se que é fator relevante para a ocorrência de que as metodologias aplicadas provoquem o questionamento dos insights e que sejam sistemáticas e entendidas por toda a organização. Na maioria dos temas avaliados nos critérios do PGQP, o processo de aprendizagem pressupõe tempo para que seus resultados sejam identificados. As empresas que incentivam a troca de conhecimento e possuem pessoal qualificado tendem a assumir características de aprendizagem organizacional com maior facilidade. Assim, esse estudo contribui para a busca da eficácia no s processos de mudança das empresas, no caso, os programas de qualidade.

Pop-management: grandes empresas de consultoria no Brasil

Nesta pesquisa, investigamos e analisamos as empresas de consultoria no Brasil e seu papel na divulgação e legitimação de novas idéias e práticas de gestão empresarial. As empresas de consultoria fazem parte do campo do management, junto com a mídia de negócios, os gurus empresariais e as escolas de Administração. Participaram do estudo 4 grandes empresas de consultoria. A pesquisa compreendeu 3 frentes: (1) uma investigação sobre o tema junto às publicações acadêmicas e revistas de negócios, (2) entrevistas com sócios e pessoas-chave de grandes empresas de consultoria e (3) análise de projetos típicos implementados por estas empresas. Concluímos que as consultorias vivem dilemas complexos de atuação junto aos clientes. Especulamos ainda que tais organizações constituem elementos de reprodução e adaptação (limitada) de expertise estrangeira e são agentes influentes de difusão da cultura do management.