Knowledge and attitudes of ED staff before and after implementation of the emergency nurse practitioner role

Introduction
The Emergency Nurse Practitioner (ENP) role was implemented in the Emergency Department (ED) at The Northern Hospital (TNH) in April 2004. Implementation of the ENP role occurred as part of a Department of Human Services funded project to establish the ENP model as an effective and sustainable model of care delivery in Victorian EDs.

Aim
The aim of this study was to examine the attitudes and knowledge of ED medical and nursing staff prior to, and following, implementation of the ENP role.

Methods
The design was a pre-test/post-test design and the Northern Emergency Nurse Practitioner Staff Survey was used for data collection. A total of 104 ED staff completed the pre-test survey and the post-test survey was completed by 79 ED staff.

Results
The attitudes and knowledge of ED medical and nursing staff changed significantly during implementation of the ENP role. Pre-test data indicated that staff were generally supportive of the role but had a poor understanding of the requirements for endorsement and how the role would function in clinical practice. Post-test data showed significant increases in support for the ENP role, a greater understanding of the requirements to become an ENP and increased understanding of the logistics and functions of an ENP.

Conclusion
The implementation of the Nurse Practitioner role within the emergency department of The Northern Hospital, Victoria Australia has been a positive experience for both medical and nursing staff.

Assessing cost-effectiveness of drug interventions for schizophrenia

Objective: To assess from a health sector perspective the incremental cost-effectiveness of eight drug treatment scenarios for established schizophrenia.

Method: Using a standardized methodology, costs and outcomes are modelled over the lifetime of prevalent cases of schizophrenia in Australia in 2000. A two-stage approach to assessment of health benefit is used. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted, using best available evidence. The robustness of results is tested using probabilistic uncertainty analysis. The second stage involves application of 'second filter' criteria (equity, strength of evidence, feasibility and acceptability) to allow broader concepts of benefit to be considered.

Results: Replacing oral typicals with risperidone or olanzapine has an incremental costeffectiveness ratio (ICER) of A$48 000 and A$92 000/DALY respectively. Switching from low-dose typicals to risperidone has an ICER of A$80 000. Giving risperidone to people experiencing side-effects on typicals is more cost-effective at A$20 000. Giving clozapine to people taking typicals, with the worst course of the disorder and either little or clear deterioration, is cost-effective at A$42 000 or A$23 000/DALY respectively. The least costeffective intervention is to replace risperidone with olanzapine at A$160 000/DALY.

Conclusions: Based on an A$50 000/DALY threshold, low-dose typical neuroleptics are indicated as the treatment of choice for established schizophrenia, with risperidone being reserved for those experiencing moderate to severe side-effects on typicals. The more expensive olanzapine should only be prescribed when risperidone is not clinically indicated. The high cost of risperidone and olanzapine relative to modest health gains underlie this conclusion. Earlier introduction of clozapine however, would be cost-effective. This work is limited by weaknesses in trials (lack of long-term efficacy data, quality of life and consumer satisfaction evidence) and the translation of effect size into a DALY change. Some stakeholders, including SANE Australia, argue the modest health gains reported in the literature do not adequately reflect perceptions by patients, clinicians and carers, of improved quality of life with these atypicals.

Discordance between lung function of Chinese university students of 20-year-old established norms

Objective: We examined the validity of the 20-year-old established Asian norms for pulmonary function in a contemporary cohort of Hong Kong Chinese university students. Design and participants: Pulmonary function testing was conducted in university students (n = 805). Setting: A university campus in Hong Kong. Measurements and results: Parameters recorded included gender, age, height, weight, standard lung function variables (ie, FEV1, FVC, and peak expiratory flow rate [PEFR]), and exhaled carbon monoxide (CO) level. Subjects completed a questionnaire on pulmonary health, smoking history, and their dietary and exercise habits within 3 months of the study. Data were compared with the established norms for lung function for Chinese persons from Hong Kong. On average, subjects were taller than those reported in the original cohort, on whom the established norms are based; however, FEV1, FVC, and PEFR were lower. As predicted, the exhaled CO level was higher in smokers. Those who exercised regularly had a higher FEV1 and FVC, and reported fewer respiratory complaints. Conclusions: Our findings support the idea that lung function norms not only differ across ethnic groups, but that they may be susceptible to change over a single generation within an ethnic group living in the same geographic region. Assuming the equivalence of our testing methods and those on which established norms are based, our findings shed further insight into the dynamic nature of lung function, and have implications regarding the definition of normal pulmonary function and its variance over the short term.

Medical treatment and the good death: an ethical analysis of euthanasia, physician assisted suicide, and the right to die

Frequent advances in medical technologies have brought fonh many innovative treatments that allow medical teams to treal many patients with grave illness and serious trauma who would have died only a few years earlier. These changes have given some patients a second chance at life, but for others. these new treatments have merely prolonged their dying. Instead of dying relatively painlessly, these unfortunate patients often suffer from painful tenninal illnesses or exist in a comatose state that robs them of their dignity, since they cannot survive without advanced and often dehumanizing forms of treatment. Due to many of these concerns, euthanasia has become a central issue in medical ethics. Additionally, the debate is impacted by those who believe that patients have the right make choices about the method and timing of their deaths. Euthanasia is defined as a deliberate act by a physician to hasten the death of a patient, whether through active methods such as an injection of morphine, or through the withdrawal of advanced forms of medical care, for reasons of mercy because of a medical condition that they have. This study explores the question of whether euthanasia is an ethical practice and, as determined by ethical theories and professional codes of ethics, whether the physician is allowed to provide the means to give the patient a path to a "good death," rather than one filled with physical and mental suffering. The paper also asks if there is a relevant moral difference between the active and passive forms of euthanasia and seeks to define requirements to ensure fully voluntary decision making through an evaluation of the factors necessary to produce fully informed consent. Additionally, the proper treatments for patients who suffer from painful terminal illnesses, those who exist in persistent vegetative states and infants born with many diverse medical problems are examined. The ultimate conclusions that are reached in the paper are that euthanasia is an ethical practice in certain specific circumstances for patients who have a very low quality of life due to pain, illness or serious mental deficits as a result of irreversible coma, persistent vegetative state or end-stage clinical dementia. This is defended by the fact that the rights of the patient to determine his or her own fate and to autonomously decide the way that he or she dies are paramount to all other factors in decisions of life and death. There are also circumstances where decisions can be made by health care teams in conjunction with the family to hasten the deaths of incompetent patients when continued existence is clearly not in their best interest, as is the case of infants who are born with serious physical anomalies, who are either 'born dying' or have no prospect for a life that is of a reasonable quality. I have rejected the distinction between active and passive methods of euthanasia and have instead chosen to focus on the intentions of the treating physician and the voluntary nature of the patient's request. When applied in equivalent circumstances, active and passive methods of euthanasia produce the same effects, and if the choice to hasten the death of the patient is ethical, then the use of either method can be accepted. The use of active methods of euthanasia and active forms of withdrawal of life support, such as the removal of a respirator are both conscious decisions to end the life of the patient and both bring death within a short period of time. It is false to maintain a distinction that believes that one is active killing. whereas the other form only allows nature to take it's course. Both are conscious choices to hasten the patient's death and should be evaluated as such. Additionally, through an examination of the Hippocratic Oath, and statements made by the American Medical Association and the American College of physicians, it can be shown that the ideals that the medical profession maintains and the respect for the interests of the patient that it holds allows the physician to give aid to patients who wish to choose death as an alternative to continued suffering. The physician is also allowed to and in some circumstances, is morally required, to help dying patients whether through active or passive forms of euthanasia or through assisted suicide. Euthanasia is a difficult topic to think about, but in the end, we should support the choice that respects the patient's autonomous choice or clear best interest and the respect that we have for their dignity and personal worth.

Measurement of the economic impact of visual impairment from age-related macular degeneration in Australia

The purpose of this report was to: (i) outline the potential value of health economic studies into age-related macular degeneration (AMD); (ii) provide an overview of health economic studies pertinent to AMD; and (iii) outline the basic frame work of cost-of-illness studies (a useful first step in applying economic methods). The detection and management of sensory loss in the elderly plays a key role in the Australian Government's Healthy Ageing Strategy. Age-related macular degeneration is currently the leading cause of blindness in elderly Australians. Although a large proportion of AMD cases remain untreatable, the introduction of photo­dynamic therapy provides a relatively expensive and possibly cost-effective innovation for others. Antioxidant therapy has also been proven effective in reducing progression of early to late disease. The discipline of economics can contribute to an understanding of AMD prevention and treatment through: (i) describing the current burden of disease; (ii) predicting the changes in the burden of disease over time, and (iii) evaluating the efficiency of different interventions. Cost-of-illness studies have been performed in many fields of medicine. Little work, however, has been done on describing the economic impact from AMD. A number of different economic evaluation methods can be used in judging the efficiency of possible interventions to reduce the disease burden of AMD. Although complementary in nature, each has specific uses and limitations. Studies of the economic impact of eye diseases are both feasible and necessary for informed health care decision-making.

Changing places : testing the relevance of educational research and teacher education

Frequent reviews of teacher education in recent times seem to indicate that those charged with the responsibility for teacher education have little understanding of the contemporary needs of teachers. Just how does educational research inform teachers in their day-to-day practice and how is its relevance tested? As an educational researcher Professor Shirley Grundy challenges her own notions of 'relevance' by returning from academia to the school system in Western Australia. This experience expanded her understanding of how conceptual frameworks and the realities of schools complemented each other. She reflects on the agenda for change faced by education systems and the ensuing transformation of curriculum planning, pedagogy, assessment and reporting procedures in some schools while not in others.

Her reference to Habermas' work relating to 'system' and 'lifeworld' provided her with an explanation for the social conditions of schooling, while her exploration of discourse theory provides some understanding of the practices related to the exercise of power in school settings. Interchanges such as that experienced by Grundy are to the mutual benefit of both parties.

Guidelines for treatment of osteoporosis in men

BACKGROUND: Osteoporosis is associated with significant morbidity and mortality in men. Published randomised controlled trials assessing the benefits of therapy in men with osteoporosis are limited, but those available need to be used to develop management guidelines.

OBJECTIVE: To present evidence based guidelines for the treatment of osteoporosis in men.

DISCUSSION: It is estimated that 30-60% of men presenting with spinal fractures have another illness contributing to their bone disease. Therefore assessment and treatment of coexisting medical conditions is a vital part of management of osteoporosis. While primary prevention of fractures remains crucial, treatment to ensure further fractures do not occur is equally important. Alendronate is the treatment of choice for men with osteoporosis and fractures, with cyclical etidronate an appropriate alternative and testosterone replacement therapy is indicated in hypogonadal men presenting with osteoporosis.

Procedural trained, procedural remain : the first report from 'A census of doctors who have been awarded the Graduate Diploma in Rural General Practice (GDRGP)'

Aims & rationale/Objectives : To document the practice of initial cohorts receiving the Graduate Diploma in Rural General Practice
Methods : With the co-operation of the National Rural Faculty (NRF) of Royal Australian College of General Practitioners (RACGP), a census by questionnaire was conducted on 279 graduates. The response rate was 70%.
Principal findings : The target doctors are young (65% < 40 years old). Under half (42.3%) have completed Advanced Rural Skills terms in >1 discipline. Of the total 272 posts recorded from 174 respondents, the most popular advanced skill is anaesthetics, followed by obstetrics. The ARSP increased confidence in 96.3% of respondents. Two thirds of doctors trained in a procedural skill remain practicing procedural General Practice.
Discussion : The GDRGP was the qualification developed to recognise competency gained as a result of a series of rural training initiatives begun within the RACGP Training Program in 1992. Its delivery has continued under the new GPET Training Program. Outcomes from the range of initiatives leading to the GDRGP are currently emerging in an environment which has seen significant changes within vocational training, and within the context of a rising focus on indemnity. Doctors who undertook this training have mostly retained procedural practice. In addition, RACGP rural initiatives successfully achieved increase confidence prior to rural work in advanced areas of practice, with >95% reporting an increase.
Implications : Changes within vocational training were accelerated without analysis of existing initiatives such as the GDRGP. Funding for the GDRGP was, as a result, withdrawn prematurely. These changes also saw the entrant of a second College with an interest in rural procedural practice. This research show that the GDRGP offers, and offered, a clear vocational pathway that will guide a doctor to a career as a rural doctor, and provide them with the advanced skills they need to practice confidently in the bush. It is important to capitalise on past success before deconstructing professional concepts of practice further.
Presentation type : Paper