Major Australian Hospital Research Articles

Cancellation of operations on the day of intended surgery at a major Australian referral hospital

Cancellation of operations on the day of intended surgery at a major Australian referral hospital

Cancellation of operations on the day of intended surgery at a major Australian referral hospital

To establish the rate of and reasons for cancellations of surgery on the scheduled day in an Australian hospital. Prospective survey. Major metropolitan tertiary hospital, 13 May to 15 November 2002. Proportion of operations cancelled on the day of surgery, obtained each day from the operating theatre list and a separate list of additions and cancellations compiled on the day; reasons for cancellations from the cancellation list, extended or confirmed, as necessary, by questioning of bookings and ward staff, or members of the surgical team; estimated and actual duration of each operation and patient information from hospital clinical records. 7913 theatre sessions were scheduled by 133 surgeons in the study period; 941 of these (11.9%) were cancelled on the day, including 724 of 5472 (13.2%) elective procedures on working weekdays. Main reasons for cancellation were: no theatre time due to over-run of previous surgery (18.7%); no postoperative bed (18.1%); cancelled by patient (17.5%); and change in patient clinical status (17.1%). Procedural reasons (including patient not ready, no surgeon, list error, administrative cause, and communication failure) totalled 21.0%. Ear, nose and throat surgery experienced the most cancellations (19.6%), followed by cardiothoracic surgery (15.8%). There were five major reasons of similar magnitude for on-the-day surgery cancellations. We estimated that 60% of cancellations of elective procedures were potentially avoidable. Change of one factor leading to cancellation (eg, provision of more postoperative beds) is not likely to lead to improvement unless the other major factors are also tackled.

Evidence-based Practice Needs Evidence-based Implementation

Clinical pathways have been designed to provide an effective interface between evidence and practice in healthcare. Strong evidence supports the assertion that when clinical pathways are utilized they improve outcomes. However, published evidence measuring the uptake of clinical pathways by health professionals remains sparse. This article presents a study evaluating the degree of documented compliance with the clinical pathway chart used for patients diagnosed with an acute myocardial infarction (AMI) in a major Australian regional hospital. The relationships between compliance and demographic and illness were also examined. Data were collected from 124 records with the result that the level of documented compliance was 16.5%. Clients with private health insurance had significantly higher documented compliance with the clinical pathway than those with no private health insurance. There were also significant variations in documented compliance according to the type of AMI recorded. Recommendations to improve compliance with clinical pathways are included along with recommendations for future research.

Ambulatory Blood Pressure, Microalbuminuria, And Autonomic Neuropathy In Adolescents With Type 1 Diabetes

OBJECTIVE—To examine the relationship between 24‐h blood pressure (BP) measurements, urinary albumin excretion rates, and autonomic neuropathy (AN) in adolescents with type 1 diabetes. RESEARCH DESIGN AND METHODS—A total of 31 patients with microalbuminuria (MA), 20 patients with intermittent MA (I‐MA) and 11 patients with persistent MA (P‐MA) were identified from the diabetes clinics at two major Australian tertiary care pediatric hospitals. Two control groups were used, one consisted of 19 age‐, sex‐, and diabetes duration‐matched adolescents with normoalbuminuria (NA), and the other consisted of 46 age and sex‐matched nondiabetic control subjects. A medical history and physical examination were followed by a series of noninvasive tests of cardiovascular and pupillary autonomic function and then by 24‐h ambulatory blood pressure monitoring (ABPM). RESULTS—ABPM showed an incremental increase in all BP parameters from nondiabetic control subjects through subjects with NA. A parallel incremental increase in diurnal and nocturnal ambulatory heart rates was also evident. Subjects with MA had significantly reduced pupillary adaptation to darkness compared with nondiabetic subjects and subjects with NA. The above results paralleled an incremental increase in HbA(1c) levels in adolescents with type 1 diabetes from subjects with NA to subjects with P‐MA. CONCLUSIONS—Higher 24‐h BP values and evidence of subclinical signs of AN are present before P‐MA develops and may have important implications for timing the introduction of treatments designed to prevent or retard the microvascular complications of type 1 diabetes in adolescents.

Ambulatory blood pressure, microalbuminuria, and autonomic neuropathy in adolescents with type 1 diabetes.

To examine the relationship between 24-h blood pressure (BP) measurements, urinary albumin excretion rates, and autonomic neuropathy (AN) in adolescents with type 1 diabetes. A total of 31 patients with microalbuminuria (MA), 20 patients with intermittent MA (I-MA) and 11 patients with persistent MA (P-MA) were identified from the diabetes clinics at two major Australian tertiary care pediatric hospitals. Two control groups were used; one consisted of 19 age-, sex-, and diabetes duration-matched adolescents with normoalbuminuria (NA), and the other consisted of 46 age- and sex-matched nondiabetic control subjects. A medical history and physical examination were followed by a series of noninvasive tests of cardiovascular and pupillary autonomic function and then by 24-h ambulatory blood pressure monitoring (ABPM). ABPM showed an incremental increase in all BP parameters from nondiabetic control subjects through subjects with NA. A parallel incremental increase in diurnal and nocturnal ambulatory heart rates was also evident. Subjects with MA had significantly reduced pupillary adaptation to darkness compared with nondiabetic subjects and subjects with NA. The above results paralleled an incremental increase in HbAlc levels in adolescents with type 1 diabetes from subjects with NA to subjects with P-MA. Higher 24-h BP values and evidence of subclinical signs of AN are present before P-MA develops and may have important implications for timing the introduction of treatments designed to prevent or retard the microvascular complications of type 1 diabetes in adolescents.

Perceptions and practice of universal blood and body fluid precautions by registered nurses at a major Sydney teaching hospital.

Guidelines for universal blood and body fluid precautions (UBBFP) designed to protect health care workers from occupational exposure to blood borne pathogens have been developed by the US Centers for Disease Control. These guidelines have been adopted by the New South Wales Department of Health and all major Australian hospitals. To determine the degree of understanding and utilization of UBBFP by Australian nurses, 192 nurses were asked about UBBFP, recent occupational exposures and understanding of hepatitis B transmission. Seventy-three per cent of nurses stated they 'used UBBFP at all times', yet only 58% of these nurses stated they always used gloves when 'handling blood or blood equipment' and just 85% reported always using 'gloves to clean up urine and faeces'. Overall 146 (76%) nurses experienced 230 occupational exposures (168 mucocutaneous, 48 percutaneous) in the previous 6 months. These were more common in men (P=0.024) and in operating theatres (95% of nurses) and high dependency units (88%). Percutaneous exposures were significantly more frequent in nurses who stated they did not wear gloves when handling blood/blood equipment (P=0.036), whereas mucocutaneous exposures were significantly more frequent among nurses who stated they do not adhere to UBBFP at all times (P=0.005). Eighty-three per cent of nurses experiencing exposures did not report all of them. In this study knowledge and adoption of UBBFP translated directly into lower risk for an occupational exposure. It is concluded that educational strategies to improve understanding and adoption of UBBFP by nurses are required.

Human resource management in hospitals: a contested arena for jurisdiction.

During the past 10 years, financial pressures on health service providers have led to a quest for more efficient service delivery and many consequential changes to the organisation and utilisation of staff. This study investigated the organisational responses to such pressures by four major South Australian hospitals and the level of involvement of hospital human resource staff in the staffing issues associated with strategic planning. With one exception, there was little contribution from qualified human resource professionals to staffing decisions involving medical and nursing personnel and little value was placed on their potential input by other professional groups. If, as suggested by writers on strategic human resource management, human resource practice is moving toward a more strategic approach, then there is a large credibility gap for human resource staff to overcome within the South Australian health service.

Human papillomavirus deoxyribonucleic acid as a prognostic indicator in early-stage cervical cancer: A possible role for type 18

OBJECTIVE: Our purpose was to determine the prognostic significance of human papillomarivus deoxyribonucleic acid in cervical cancers. STUDY DESIGN: The polymerase chain reaction was used to detect human papillomavirus deoxyribonucleic acid types 6, 11, 16, 18, 31, 33, 52, or 58 in tumors from 148 patients (equal numbers of whom were disease free or had relapses) surgically treated for stage IIB or IIA cancers in a major Australian hospital. Cox regression modeling was used to assess the effect of human papillomavirus status on tumor recurrence, taking into account patient age, clinical stage, histologic node status, and type of tumor. RESULTS: Seventy of 74 (95%) of the recurring tumors and 62 of 74 (84%) of the nonrecurring tumors were human papillomavirus deoxyribonucleic acid positive. The rates of positivity of types 16 and 18 were 64% versus 31% in the recurrers and 65% versus 14% in the nonrecurrers. Human papillomavirus type 18 positivity was associated with a greater risk of recurrence than was type 16 positivity (hazard ratio 1.8; p = 0.03). Clinical stage, nodal metastasis, and young age (≤ 35 years) also had adverse effects on relapse (hazard ratio for each approximately 2). CONCLUSION: Human papillomavirus type 16 positivity is a risk factor for tumor recurrence in surgically treated cervical cancer.

Hand — Washing in a neonatal intensive care unit: Comparative effectiveness of chlorhexidine gluconate 4% w/v and triclosan 1% w/v

o 1. To evaluate the effects of triclosan on the methicillinresistant Staphylococcus aureus (MRSA) rates in a neonatal intensive care nursery. 2. To measure the amount of skin damage caused by handwashing with triclosan. A seven-week controlled prospective study between two hospital wards using different hand wash products, combined with clinical information on MRSA rates during the previous 10 months. All neonates and nursing staff in the intensive care and special care nurseries of a major metropolitan Australian hospital. The average weekly ‘new case’ MRSA rate was reduced from 3.4 per cent to 0.14 per cent (p>0.0001) in the experimental ward whilst no significant changes occurred in the control ward. Staff reported less skin damage and a higher rate of acceptance with the trial product. Results from the seven-week trial support wider use of the product and more extensive follow-up evaluation.

Quality assurance and clinical indicators in emergency medicine

Quality assurance and clinical indicators in emergency medicine

Measuring and modifying hospital drug use

Various methods are available to quantitate medicinal drug use in hospitals. These represent a hierarchy of clinical specificity, complexity and cost of acquisition. Similarly, various strategies and methods are available to modify prescribing patterns. The objectives of this study are to illustrate these processes of measurement of drug use and modification of prescribing patterns using specific examples derived from practice at three major Australian teaching hospitals over 15 years. Methods to measure and modify drug usage in the three hospitals are outlined and 12 examples are presented by specific drug or drug category. Each example includes details of the methods used to detect inappropriate drug use (pharmacy purchases, pharmacy issues, prescription analysis, clinical record review, performance and outcome assessment), the intervention strategies used (re-educative, persuasive, facilitative, power), the methods employed to alter drug prescribing and the relative effectiveness and cost-efficiency of the interventions. Readily available, relatively cheap quantitative methods provide significant information and an efficient basis for planning definitive studies, and substantial modification of prescription patterns is possible through the strategic use of limited manpower and resources.

Observation wards in Australian hospitals

Observation wards have not been discussed in the Australian literature. In the United Kingdom, the few published reports suggest that they are an essential part of the function of emergency departments. This paper presents the results of a survey of 44 major Australian hospitals regarding their use of observation wards. Half the hospitals that were surveyed had such wards but variations existed in the way that they functioned. Nearly half the remaining hospitals wanted to establish an observation ward. Our concept of observation wards is discussed.