Perth Hospital Research Articles

The economic benefits of increased levels of nursing care in the hospital setting

To assess the economic impact of increased nursing hours of care on health outcomes in adult teaching hospitals in Perth, Western Australia. Advancing technology and increased availability of treatment interventions are increasing demand for health care while the downturn in world economies has increased demand for greater efficiency. Nurse managers must balance nurse staffing to optimize care and provide efficiencies. This longitudinal study involved the retrospective analysis of a cohort of multi-day stay patients admitted to adult teaching hospitals. Hospital morbidity and staffing data from September 2000 until June 2004, obtained in 2010 from a previous study, were used to analyse nursing-sensitive outcomes pre- and post-implementation of the Nurse Hours per Patient Day staffing method, which remains in place today. The cost of the intervention comprised increased nursing hours following implementation of the staffing method. The number of nursing-sensitive outcomes was 1357 less than expected post-implementation and included 155 fewer 'failure to rescue' events. The 1202 other nursing-sensitive outcomes prevented were 'surgical wound infection', 'pulmonary failure', 'ulcer, gastritis', 'upper gastrointestinal bleed', and 'cardiac arrest'. One outcome, pneumonia, showed an increase of 493. Analysis of life years gained was based on the failure to rescue events prevented and the total life years gained was 1088. The cost per life year gained was AUD$8907. The implementation of the Nurse Hours per Patient Day staffing method was cost-effective when compared with thresholds of interventions commonly accepted in Australia.

Changing trends in venous thromboembolism‐related imaging in Western Australian teaching hospitals, 2002–2010

To determine trends in referral for venous thromboembolism (VTE) imaging in Western Australian teaching hospitals. Retrospective audit of the WA picture archiving and communication system, PathWest Laboratory Medicine records, the hospital morbidity database at the four adult teaching hospitals in Perth, WA, and the WA death registry. All patients referred for VTE-related imaging, and all hospital separations for pulmonary embolism (PE) during 2002-2010. Number of referrals for computed tomography pulmonary angiography (CTPA), ventilation-perfusion lung scintigraphy, leg ultrasound and plasma D-dimer assay; hospital separations for PE and deaths from PE. Referrals for VTE-related imaging increased by 34%, while PE-related imaging increased by 65% during the study period, owing entirely to referrals for CTPA, which increased by more than 500%. The number of hospital separations for PE increased by 45% over the same period and the prevalence of PE among referred patients fell from 22.1% in 2002 to 19.5% in 2010. There was no fall in the death rate from PE in WA during the study period (P = 0.19). The number of D-dimer tests performed in the same hospitals increased by 42% over the study period. The increased number of referrals for PE-related imaging resulted in more diagnoses but no reduction in deaths from PE in WA. Widespread D-dimer testing did not reduce referrals for imaging and is likely to have resulted in increased referrals. Increased imaging leads to overdiagnosis of clinically insignificant PE, and alternative strategies are required to reduce PE death rates.

Approaching Families for Organ Donation—Intensivists’ Perspectives

In Australia the initial approach to families for organ donation is almost always undertaken by intensivists. There is, however, a paucity of literature on intensivists' views on this approach and how their approach compares with recommendations in published literature on this subject. This study consisted of a survey of the views of intensive care consultants and senior intensive care registrars in the four major teaching hospitals in Perth, Western Australia, on how they approached families for organ donation. The study also includes a review of recently published literature on approaching families for organ donation. The survey results indicate that most intensive care consultants felt adequately trained to approach families for organ donation, but almost half of the group surveyed would prefer a collaborative approach with either a donor co-ordinator or a colleague with additional training on this subject. Despite recommendations in the literature and from the Australian and New Zealand Intensive Care Society to determine the registration status of potential donors on the Australian Organ Donation Registry prior to discussions with families, this was not always undertaken. In addition, the benefits of organ donation were not always discussed with families, nor were the reasons for refusal of consent sensitively explored.

Does accumulating exposure to illicit drugs bring forward the age at onset in schizophrenia?

Whilst cannabis has been associated with an earlier age at onset in schizophrenia, the impact of amphetamine and/or cocaine plus cannabis consumption on age at onset remains unclear. The present study was designed to test the hypothesis that consumption of amphetamine and/or cocaine in addition to cannabis would lead to an earlier age at onset of schizophrenia than that seen for cannabis consumption alone. A secondary objective was to determine what kind of effect additional substance use exerted (e.g. additive, multiplicative). Patients with a diagnosis of schizophrenia were recruited from consecutive admissions to the inpatient and outpatient services of a large psychiatric hospital in Perth, Australia and 167 participants were assessed using the Diagnostic Interview for Psychosis, which included detailed inquiry into illicit drug use in the 12 months prior to the onset of psychiatric symptoms. Participants were categorized into four groups: no illicit substance use (n = 65), cannabis use (n = 68), cannabis plus amphetamine use (n = 25), and cocaine plus cannabis/cocaine plus cannabis plus amphetamine use (n = 9). Analysis of variance was performed to detect trends, and linear regression used to analyze the consumption of each additional substance as a predictor of age at onset. We observed a linear trend for mean age at onset: 23.34 (SD = 6.91) years for no illicit substance use, 22.51 (SD = 5.27) years for cannabis use, 20.84 (SD = 3.48) years for cannabis plus amphetamine use, and 19.56 (SD = 3.54) years for cocaine plus cannabis/cocaine plus cannabis plus amphetamine use; the variation in the means between groups was statistically significant: F(1,163) = 5.66, p = 0.008, Cohen's d = 0.38. For the consumption of each additional substance, age at onset was earlier by 1.2 years: R (2) = 0.034, F(1,165) = 5.72, p = 0.018. Whilst preliminary, these findings suggest that additional consumption of each substance predicted an earlier age at onset by approximately 1 additional year.

Total Laparoscopic Hysterectomy – New Endoneedle for Ligation of Uterine Vessels and Vault Closure

To show that two challenges in TLH - uterine vessel haemostasis and vault closure - can be overcome by the use of a new laparoscopic endoneedle. This paper uses slides and videos of operations to present the results of the study. Operations were performed in a major private teaching hospital in Perth, Australia. 20 private patients who underwent TLH had their uterine arteries ligated with the endoneedle using 1 vicryl suture before bipolar and division. The vaginal vault was closed with the endoneedle using 1 monocryl suture. 20 private patients with fully informed financial and operative consent. There were no interventions. The study revealed that the uterine suture provided better haemostasis than when only an energy-sealing device was used. The suture on the uterine pedicle provided a clear lateral landmark for ureteric safety. The vaginal vault was closed with single bite or figure of 8 sutures. No vault dehiscence was encountered. The use of the new laparoscopic endoneedle provides the GYN performing TLH with a new tool to tackle the uterine pedicle and vault suturing. Numerous laparoscopic workshops have a suturing component, as this is a challenging task for GYNs. It is hoped that this new tool will lead to more GYNs undertaking TLH, thereby spreading the benefits of MIS.

Clusters according to patient need in a long-stay inpatient population with schizophrenia: does executive dysfunction underpin needs-directed care?

To identify the external validators of patient clusters according to need in a long-stay inpatient population with schizophrenia. We recruited without exclusion 112 in-patients with chronic schizophrenia in a long-stay rehabilitation facility of a major psychiatric hospital in Perth, Western Australia. Case managers completed a number of measures for participants, including The Camberwell Assessment of Need-Short Appraisal Schedule, which evaluates health and social needs. Latent class analysis according to patient need was performed to identify clusters within the cohort. One way analysis of variance was used to identify the external validators of these clusters, using variables obtained from the additional study measures (Social Behaviour Schedule, Global Assessment of Function, Basic Everyday Living Skills, Behaviour Rating Inventory of Executive Function-Adult version). Three distinct needs-based clusters with different external profiles were identified. A "low unmet needs" group (n = 50) with relatively intact executive function, with the least problematic behaviour and most independent functioning; a "high unmet need (drug abstinent)" group (n = 43) with greatest executive dysfunction, most problematic behaviour and least independent function; a "high unmet need (drug using)" group (n = 19), with less severe executive dysfunction, and intermediate relative to the other groups on measures of social behaviour and independent functioning. The clinical heterogeneity we have identified, which may well be explained by executive dysfunction, suggests further exploration of appropriate assessment and streams of care for those in the rehabilitation setting is warranted.

Can father inclusive practice reduce paternal postnatal anxiety? A repeated measures cohort study using the hospital anxiety and depression scale

BackgroundPerinatal research on anxiety and depression has primarily focused on mothers. We have limited knowledge of fathers’ anxiety during the perinatal period yet there is evidence that the parenting capacity of a person can be compromised by anxiety and depression. The purpose of this paper is to identify the impact of a father inclusive intervention on perinatal anxiety and depression. The prime focus of the intervention was to provide education and support to fathers of breastfeeding partners with the aim of increasing both initiation and duration of breastfeeding.MethodsA repeated measures cohort study was conducted during a RCT that was implemented across eight public maternity hospitals in Perth, Western Australia between May 2008 and June 2009. A baseline questionnaire which included the Hospital Anxiety and Depression Scale (HADS) was administered to all participants on the first night of their hospital based antenatal education program and was repeated at six weeks postnatal. SPSS version 17 was used for reporting descriptive results.ResultsThe mean anxiety levels at baseline for the fathers in the intervention group (n=289) and control group (n=244) were 4.58 and 4.22 respectively. At 6 weeks postnatal (only matched pairs), intervention and control group were 3.93 and 3.79. More intervention group fathers self-rated less anxiety compared to the fathers in the control group from baseline to post test (p=0.048). Depression scores for intervention fathers at baseline (mean =1.09) and at six weeks (mean=1.09) were very similar to fathers in the control group at baseline (mean=1.11) and at six weeks (mean =1.07) with no significant changes.ConclusionsBoth intervention and control group fathers experienced some anxiety prior to the birth of their baby, but this was rapidly reduced at six weeks. Paternal anxiety is common to new fathers and providing them with information and strategies for problem-solving can increase their knowledge and potentially lower the risk of postnatal anxiety.Trial registration(Australian New Zealand Clinical Trials Registry ACTRN12609000667213)

Maintaining emotional wellbeing in the intensive care unit: A grounded theory study from the perspective of experienced nurses

This Grounded Theory study developed a substantive theory to explore and explain the experienced nurse’s perspective of maintaining emotional wellbeing in the Intensive Care Unit (ICU). Data were collected by recorded interviews of 15 experienced ICU registered nurses from an ICU of a metropolitan hospital in Perth, Western Australia. Emotional wellbeing was described by the participants as feelings of satisfaction and happiness, derived from the delivery of best care to patients and their families. This formed the context of the study. The core problem shared by ICU nurses was the Inability to Protect Self from Distress. Distress was described as feelings of grief, sadness, frustration and anger in response to caring for patients who were critically ill, and their families.Conditions were also identified that impacted the nurse's ability to protect self from distress: Best care; Autonomy; Teamwork; and Previous nursing and life experience. The Basic Social and Psychological Process used by nurses to protect themselves from distress, and therefore maintain their emotional wellbeing was called Protecting Self from Distress. The process was described under three phases: Delivering best care, Validating care episodes, and Distancing self from distress. The process described how nurses protected self from distress, including strategies to overcome or promote the conditions that impacted nurse wellbeing. Nurses maintain their emotional wellbeing through the delivery of best care. Best care referred to giving the best care possible given the nature of critical illness and limitations of critical care.Understanding the conditions that impacted nurse wellbeing provides valuable insight into factors that help or hinder the delivery of best care. The substantive theory outlined processes that enabled nurses to maintain their emotional wellbeing and succeed in providing best care to patients and families in the ICU. Minimising threats to the delivery of best care will promote nurse satisfaction, happiness, enhance wellbeing and may contribute to higher retention rates. The satisfaction and happiness enjoyed by nurses was found to be the reason the group in this study remained nursing in ICU.

Emergency department overcrowding, mortality and the 4‐hour rule in Western Australia

To assess whether emergency department (ED) overcrowding was reduced after the introduction of the 4-hour rule in Western Australia and whether any changes in overcrowding were associated with significant changes in patient mortality rates. Quasi-experimental intervention study using dependent pretest and post-test samples. Hospital and patient data were obtained for three tertiary hospitals and three secondary hospitals in Perth, WA, for 2007-08to 2010-11. Mortality rates; overcrowding rates. No change was shown in mortality from 2007-08to 2010-11for the secondary hospitals and from 2007-08to 2009-10for the tertiary hospitals. ED overcrowding (as measured by 8-hour access block) at the tertiary hospitals improved dramatically, falling from above 40% in July 2009to around 10% by early 2011, and presentations increased by 10%, while the mortality rate fell significantly (by 13%; 95% CI, 7%-18%; P<0.001) from 1.12% to 0.98% between 2009-10and 2010-11. Monthly mortality rates decreased significantly in two of the three tertiary hospitals concurrently with decreased access block and an increased proportion of patients admitted in under 4hours. Introduction of the 4-hour rule in WA led to a reversal of overcrowding in three tertiary hospital EDs that coincided with a significant fall in the overall mortality rate in tertiary hospital data combined and in two of the three individual hospitals. No reduction in adjusted mortality rates was shown in three secondary hospitals where the improvement in overcrowding was minimal.

Women’s Perceptions of Contributory Factors for Successful Vaginal Birth After Cesarean

BACKGROUND:In July 2008, a new midwife-led “Next Birth After Cesarean” (NBAC) service was launched at King Edward Memorial Hospital (KEMH) in Perth, Western Australia. Midwives from the NBAC service provide antenatal care, evidence-based information about birth choices, tailored birth preparation classes, and assistance with developing birth plans to pregnant women who have had a previous cesarean birth.OBJECTIVE:To determine the contributory factors that women who were cared for by the NBAC service and experienced a vaginal birth after cesarean (VBAC) perceived to be associated with achieving their desired mode of birth.METHODS:A qualitative descriptive approach was used for this study in which semistructured interviews were conducted with 13 participant women who have achieved a VBAC and were analyzed using a modified “constant comparison” technique.FINDINGS:Two key themes reflecting personal and professional factors comprising eight subthemes emerged from analysis of interview data.CONCLUSIONS:These findings offer a unique perspective on the phenomenon of achieving a VBAC and provide maternity care practitioners and policy makers around the world with valuable insights into how the care environment might be enhanced for women who would prefer a vaginal birth after their previous cesarean section.

Very Early Poststroke Aphasia Therapy: A Pilot Randomized Controlled Efficacy Trial

Early stroke rehabilitation has shown benefits over spontaneous recovery. Insufficient evidence exists to determine the benefits of early aphasia intervention. We hypothesized that daily aphasia therapy would show better communication outcomes than usual care (UC) in early poststroke recovery. This prospective, randomized, single-blinded, controlled trial was conducted in three acute-care hospitals in Perth, Australia, each with over 200 stroke admissions annually. Patients with acute stroke causing moderate to severe aphasia were recruited at a median of three-days (range: 0-10 days) to receive daily aphasia therapy or usual care therapy. Individually tailored, impairment-based intervention was provided for the acute hospital stay or intervention phase (median: 19 days; range: 5-76). Primary outcome measures were the aphasia quotient and functional communication profile at acute hospital discharge or four-weeks poststroke, whichever came first. A random-number generator and sealed envelopes were used to randomize participants. Assessments were completed by a blinded assessor. Fifty-nine participants were recruited, with six withdrawals (10%) and seven deaths (12%) at six-months. Ninety percent had ischemic strokes, with 56·5% experiencing a total anterior circulation stroke. The group mean (± SD) age was 69·1 (± 13·9) years. Six participants (18·75%) in the daily aphasia therapy group did not complete the minimum (150 min) therapy required for this study. The daily aphasia therapy intervention phase mean therapy session time was 45 min (range: 30-80) and the total mean amount of therapy for the daily aphasia therapy participants was 331 min (range: 30-1415). Four (15%) participants in the usual care group received therapy. The collective total therapy provided to these participants was 295 min over seven sessions. Usual care participants received an average of 10·5 min of therapy per week during the intervention phase. At the primary end point, a generalized estimating equations model demonstrated that after controlling for initial aphasia severity, participants receiving daily aphasia therapy scored 15·1 more points (P = 0·010) on the aphasia quotient and 11·3 more points (P = 0·004) on the functional communication profile than those receiving usual care therapy. Daily aphasia therapy in very early stroke recovery improved communication outcomes in people with moderate to severe aphasia.

Single Surgeon Laparoscopy

To demonstrate the possibility of a single surgeon performing complex laparoscopy operations, even laparoscopic hysterectomy, without the need for a surgical or pelvic assistant. This presentation uses slides and videos of operations. Operations were performed in two private hospitals in Perth, Australia, using mechanical uterine and camera positioners. The operations included total laparoscopic hysterectomies and complex laparoscopic procedures. The author performs approximately ten of these operations each week. 10 private patients, with fully informed financial and operative consent, each week over approximately the last five years. No surgical or pelvic assistants were required at any time during the procedures. The use of the mechanical uterine and camera positioners was successful in each operation and no surgical or pelvic assistants were required. This experience shows that single surgeon laparoscopy is possible with the use of mechanical uterine and camera positioners. This method eliminates positioning variabilities due to human fatigue, liberating valuable nursing and medical human resources for other tasks.

Further psychometric testing of an instrument to measure emotional care in hospital

This paper describes further testing of the instrument Patient Evaluation of Emotional Care during Hospitalisation. In 2005, a questionnaire was developed that could be completed by patients to evaluate the quality of emotional care received during their time in hospital. This questionnaire was tested at an acute care private hospital in Perth, Western Australia, with encouraging estimates of reliability and validity. The purpose of this study was to further test this questionnaire in a larger sample of inpatients at a public hospital in the same state. Psychometric evaluation. A hospital-wide survey of 13 wards of a public hospital was conducted. Two hundred and fifty-one patients completed the questionnaire. Psychometric testing of the Patient Evaluation of Emotional Care during Hospitalisation demonstrated acceptable internal consistency reliability. Confirmatory factor analysis substantiated the four sub-scales as follows: Level of Security, Level of Knowing, Level of Personal Value and Level of Connection. The Level of Connection sub-scale was assessed for the first time in this study. This sub-scale had the lowest mean score of all the sub-scales across the hospital as well as in each of the wards surveyed. Qualitative data substantiated, from the patients’ perspective, a lack of connection with hospital staff. Further psychometric testing of the Patient Evaluation of Emotional Care during Hospitalisation instrument has confirmed its psychometric properties and usefulness as an instrument to measure emotional care during hospitalisation. The Patient Evaluation of Emotional Care during Hospitalisation is a reliable and valid tool with which the emotional care of patients in hospital can be measured and the effectiveness of interventions assessed.

A retrospective survey of the safety of trivalent influenza vaccine among adults working in healthcare settings in south metropolitan Perth, Western Australia, in 2010

In Australia, annual vaccination with trivalent influenza vaccine (TIV) is recommended for healthcare providers. Each year, an influenza vaccination program is run in south metropolitan area hospitals in Perth, Western Australia. In 2010, a survey to examine side effects following vaccination and subsequent significant respiratory illnesses during the influenza season was undertaken. A total of 2245 individuals vaccinated in the area-wide hospital vaccination program responded, representing 50% of consenting recipients. Data linkage was performed to ascertain additional information such as brand details. Side effects within 48h of receipt of the influenza vaccine were reported by 387 (17.2%). Only 30 respondents (1.3%) had to seek health advice following a side effect temporally related to influenza vaccination and 10 (0.4%) required treatment. Recipients who received Fluvax® (364, 18.0%; CSL Biotherapies) were more likely to report side effects than those who received another brand (23, 10.2%; OR 1.94, 95% CI 1.24–3.03, P=0.004). The difference in the side effect profiles was largely confined to systemic effects. Most respondents (1621, 72.2%) did not require time off work for a respiratory illness during the subsequent influenza season. Overall, the influenza vaccine was demonstrated to be safe among this large sample of predominantly healthcare workers. A higher rate of adverse events, albeit primarily mild, was reported among recipients of Fluvax® in 2010.

Major trauma deaths at Perth secondary hospitals

Some major trauma (Injury Severity Score [ISS] >15) patients transported to a secondary hospital in Perth do not survive. We sought to describe this cohort and assess preventability. A cohort study from a previously developed cohort of trauma deaths in Western Australia from 1 July 1997 to 30 June 2006. A preformatted data sheet was used to collect a range of descriptive, time, physiological, and autopsy data. Trauma scores were calculated. Preventability was assessed using three approaches, based on ISS, Trauma Revised Injury Severity Score (TRISS) and individual case review. There were 74 major trauma deaths, mean age 55.6 ± 26.3 years (range 3-95). Thirty-seven (50%) were motor vehicle crashes. The mean Revised Trauma Score was 3.84 ± 3.09 (0-7.84), median ISS 31 (interquartile range [IQR] 25-51), median TRISS 0.127 (IQR 0.031-0.772) and median time to death was 80 min (IQR 20 min-10 h 8 min). Severe head and chest injuries were the most common. Almost half (36, 48.6%) were receiving CPR on arrival to the hospital. The crude proportion of potentially preventable deaths, based on ISS, TRISS and case review, were 16.2%, 32.4% and 6.7%, respectively. However, these were predominantly elderly patients and a decision against resuscitation was recorded in 54%. The proportion of potentially preventable major trauma deaths at Perth secondary hospitals is low. The most notable group were the elderly after falls, and trauma system efforts should be focused on this group. Primary prevention of major trauma represents the biggest opportunity for improvements in trauma survival.

A comparison of metropolitan vs rural major trauma in Western Australia

BackgroundMetropolitan and rural Western Australia (WA) major trauma transport times are extremely different. We compared outcomes from these different systems of care. MethodsMajor trauma (Injury Severity Score, ISS>15) data from the Royal Flying Doctor Service (RFDS) and Trauma Registries, 1 July 1997–30 June 2006. Two groups were studied: Metro (metropolitan major trauma transported directly to a tertiary hospital), and Rural (rural major trauma transferred by the RFDS to a tertiary hospital in Perth). The primary endpoint was death. We used logistic regression and multiple imputation. Results3333 major trauma patients were identified (mean age 40.1±22.6 yrs; Metro=2005, Rural=1328). The rural patients were younger, had a larger proportion of motor vehicle crashes, and higher median ISS (25 vs 24, p<0.001). Mean times to definitive care were 59min versus 11.6h, respectively (p<0.0001). After adjusting for age, injury severity and the effect of time with the initial rural deaths, there was a significantly increased risk of death (OR 2.60, 95% CI 1.05–6.53, p=0.039) in the Rural group. For those rural patients who reached Perth, the adjusted OR for death was 1.10 (95% CI 0.66–1.84, p=0.708). ConclusionThere is more than double the risk of major trauma death in rural and remote WA. However, if a major trauma patient survives to be retrieved to Perth by the RFDS, then mortality outcomes are equivalent to the metropolitan area.

A multi-faceted intervention to implement guideline care and improve quality of care for older people who present to the emergency department with falls

BackgroundGuidelines recommend that older people should receive multi-factorial interventions following an injurious fall however there is limited evidence that this is routine practice. We aimed to improve the delivery of evidence based care to patients presenting to the Emergency Department (ED) following a fall.MethodsA prospective before and after study was undertaken in the ED of a medium-sized hospital in Perth, Western Australia. Participants comprised 313 community-dwelling patients, aged 65 years and older, presenting to ED as a result of a fall. A multi-faceted strategy to change practice was implemented and included a referral pathway, audit and feedback and additional falls specialist staff. Key measures to show improvements comprised the proportion of patients reviewed by allied health, proportion of patients referred for guideline care, quality of care index, all determined by record extraction.ResultsAllied health staff increased the proportion of patients being reviewed from 62.7% in the before period to 89% after the intervention (P < 0.001). Before the intervention a referral for comprehensive guideline care occurred for only 6/177 (3.4%) of patients, afterwards for 28/136 (20.6%) (difference = 17.2%, 95% CI 11-23%). Average quality of care index (max score 100) increased from 18.6 (95% CI: 16.7-20.4) to 32.6 (28.6-36.6).ConclusionsA multi-faceted change strategy was associated with an improvement in allied health in ED prioritizing the review of ED fallers as well as subsequent referral for comprehensive geriatric care. The processes of multi-disciplinary care also improved, indicating improved care received by the patient.

The effectiveness of health promotion materials and activities on breastfeeding outcomes

To determine the effect of mothers receiving health promotion material and education antenatally and/or postnatally on breastfeeding outcomes in Perth, Western Australia. A 12-month longitudinal study was conducted in two public maternity hospitals in Perth, Western Australia, between 2002 and 2003. Data were collected on a consecutive sample 587 mothers. The results showed that mothers who received an individual consultation or were involved in a discussion on breastfeeding antenatally with hospital staff were approximately 55% less likely to cease fully breastfeeding (HR 0.44; 95% CI 0.24-0.88) before 6 months, and 50% less likely to cease any breastfeeding before 12 months postnatally (HR 0.51; 95% CI 0.28-0.92). In the postnatal period, mothers who received instruction on positioning and attachment of the infant to the breast while in hospital were approximately 30% less likely to cease fully breastfeeding before 6 months (HR 0.66; 95% CI 0.45-0.99). The results of this study suggest a positive association between receiving individualized breastfeeding information in both the antenatal and postnatal period, and breastfeeding outcomes.

A qualitative exploration of nurse's perception of Critical Outreach Service: A before and after study

Critical Care Outreach Services (CCOS) have been reported to streamline the transfer of patients from the intensive care unit (ICU) to the wards and provide a follow-up service supporting ward staff to provide optimum care for patients discharged from ICU. The aim of this study was to explore the perceptions of nursing staff before and after the introduction of a CCOS at three adult teaching hospitals in Perth, Western Australia. Exploratory focus groups were conducted with registered nurses (RNs) at each of the participating hospitals prior to and 6 months after the introduction of a CCOS. Framework analysis was used to analyse the transcribed data using a thematic approach with themes developed from the narratives of the participants. Inexperienced RNs in particular voiced positive comments about the CCOS. The role was seen as a senior nurse who was an additional resource for less experienced staff as they educated them on complex procedures that were not common on the general wards. The RNs reported that apprehensions about the role that they had pre-implementation were not borne out in practice and that they believed that the CCOS had positive effects on patient outcomes. The CCOS improved communication processes between members of the multidisciplinary team and units within the hospital, which subsequently enhanced the ward transition process for critically ill patients and ward nursing staff.

Total Laparoscopic Hysterectomy (TLH) – Technique To Demystify the Procedure

Study Objective: 600,000 hysterectomies are performed in the USA each year. Yet only 10% have been performed laparoscopically each year over the last ten years. Here we present a technique combining bipolar energy and dissecting scissors with a unique Australian designed vaginal delineator. This paper uses slides and movies to present our technique of performing TLH. Design: This paper uses slides and movies to present our technique of performing TLH. Setting: Operations were performed in a major private teaching hospital in Perth, Australia. This technique has been used to perform over 2000 TLH cases. Patients: Private patients with informed financial and operative consent. Intervention: No conversion to open hysterectomy was required using this technique and instrumentation in patients chosen for TLH. Measurements and Main Results: All TLH operations were successfully concluded using this technique and instrumentation. Conclusion: The technique demystifies TLH for GYNs contemplating commencing the procedure. The advantages of MIS operations can be extended to benefit patients requiring a hysterectomy.