Queensland Public Hospitals Research Articles

How registered nurses balance limited resources in order to maintain competence: a grounded theory study

BackgroundNurses have limited time outside of work for continuing professional development. Consequently, strategies need to be explored to enable them to better maintain their competence. This article describes recent research investigating if nursing behaviours in the use of mobile technologies could be leveraged to better facilitate mobile learning. It addresses a gap in the existing literature around how nurses resource their own professional development and learning in the absence of appropriate learning resources in the workplace.MethodsThe research employed a classic grounded theory methodology which was conducted with 27 registered nurses from Public and Private Hospitals in Queensland and external postgraduate nursing students from Victoria, South Australia and the Northern Territory enrolled at the University of Southern Queensland.ResultsThe Theory of Economising Learning describes how nurses maintain competence with limited resources. Unfavourable staffing levels and a fast-paced workplace mean that nurses rarely prioritise their professional learning while at work. Instead, it requires the nurse to contribute personal resources including time and money.Though the research revealed nurses were unconcerned about using mobile technologies, they were concerned about maintaining competence with limited resources. To counter this, nurses economised their learning by balancing personal resources against their motivation to maintain competence. The process of economising learning begins and ends with the development of the nurse’s personal curriculum in response to what they identify as being the most significant knowledge deficits at work that jeopardise their competence. A learning opportunity that addresses the knowledge deficit is sought. Nurses balance the opportunity to address the deficit against the cost of personal resources, to decide if they will engage with the opportunity and update their personal curriculum accordingly.ConclusionsIt is suggested that workplaces need to create reasonable expectations within nurses to address knowledge deficits and provide the resources, including time, to allow them to do so without personal cost. It is also necessary for workplaces to moderate the flow of learning opportunities so as not to overwhelm and demotivate the nurses. Currently, nurses use several strategies to optimise their learning using mobile technologies which could be leveraged in the workplace.

Can Administrative Health Data Improve the Gold Standard? Evidence from a Model of the Progression of Myocardial Infarction.

Background: Myocardial infarction (MI), remains one of the leading causes of death and disability globally but publications on the progression of MI using data from the real world are limited. Multistate models have been widely used to estimate transition rates between disease states to evaluate the cost-effectiveness of healthcare interventions. We apply a Bayesian multistate hidden Markov model to investigate the progression of MI using a longitudinal dataset from Queensland, Australia. Objective: To apply a new model to investigate the progression of myocardial infarction (MI) and to show the potential to use administrative data for economic evaluation and modeling disease progression. Methods: The cohort includes 135,399 patients admitted to public hospitals in Queensland, Australia, in 2010 treatment of cardiovascular diseases. Any subsequent hospitalizations of these patients were followed until 2015. This study focused on the sub-cohort of 8705 patients hospitalized for MI. We apply a Bayesian multistate hidden Markov model to estimate transition rates between health states of MI patients and adjust for delayed enrolment biases and misclassification errors. We also estimate the association between age, sex, and ethnicity with the progression of MI. Results: On average, the risk of developing Non-ST segment elevation myocardial infarction (NSTEMI) was 8.7%, and ST-segment elevation myocardial infarction (STEMI) was 4.3%. The risk varied with age, sex, and ethnicity. The progression rates to STEMI or NSTEMI were higher among males, Indigenous, or elderly patients. For example, the risk of STEMI among males was 4.35%, while the corresponding figure for females was 3.71%. After adjustment for misclassification, the probability of STEMI increased by 1.2%, while NSTEMI increased by 1.4%. Conclusions: This study shows that administrative health data were useful to estimate factors determining the risk of MI and the progression of this health condition. It also shows that misclassification may cause the incidence of MI to be under-estimated.

Australian nurses' suggestions for the management of violence in the workplace: 'The people who make the policy are not the people on the floor'.

To ascertain nurses' perceptions about, and suggestions for, management solutions to workplace violence perpetrated by patients. Violence towards nurses from patients in the workplace is high in Australia. There is a need for good management responses, and experienced nurses can provide logistical suggestions about effective strategies. This study uses an exploratory qualitative design. Focus group interviews were undertaken with 23 nurses working in a regional public hospital in Queensland, Australia. The COREQ research reporting checklist was followed, and the qualitative data were transcribed and thematically analysed manually and byNVivo. Policy implementation, training, staff movement, seclusion, debriefing and a full reporting cycle were identified as central themes. Workplace violence management happens before, during and after a violent event. Weak processes undermine management; staff training on de-escalation is needed. Affected staff need freedom to move from the ward. Better medical orders should be in place before an event. A full debriefing and feedback cycle are required, along with easier reporting processes. Nursing management can reduce violence by ensuring better institutional support, consistent follow-up and complete feedback procedures. Legal support, follow-up mechanisms and staff training in de-escalation are key points.

Survival of advanced melanoma patients treated with immunotherapy and targeted therapy: A real-world study.

We aimed to examine the survival outcomes plus patient and treatment characteristics of advanced melanoma patients treated with first-line immunotherapy (IT), targeted therapy (TT), and chemotherapy (CTH) and compare findings with information from pivotal trials for each therapy. We retrospectively reviewed the use of systematic IT, TT and CTH therapies in melanoma patients in four Queensland public hospitals. We estimated median duration of overall survival (OS) and survival rates (6months, 1, and 2 years) using Kaplan-Meier methods. We compared our findings to those of clinical trials. Five hundred three patients who met the inclusion criteria were divided into three groups based on the first-line treatment: IT 232; TT 157; and CTH 114. OS was 18 months with IT (95% CI 13, 22); 12 months with TT (95% CI 8, 15); and 5months with CTH (95% CI 5, 6). The demographic characteristics, treatment protocols, and durations for IT and TT were generally consistent with trials but fewer patients in our study had subsequent therapy than in the trials. The OS in our study was slightly lower than the OS reported in trials. The OS of novel cancer therapy in the real world was lower than seen in trials but is expected given these are patients who have a poorer prognosis. A future study could investigate the impact of prognostic factors on survival in the longer term. This study provides evidence that we can use routinely collected real-world data to evaluate the effectiveness of checkpoint and kinase inhibitors in patients with advanced melanoma.

Understanding the impact and causes of 'failure to attend' on continuity of care for patients with chronic conditions.

To understand the impact and causes of 'Failure to Attend' (FTA) labelling, of patients with chronic conditions. Nurse navigators are registered nurses employed by public hospitals in Queensland, Australia, to coordinate the care of patients with multiple chronic conditions, who frequently miss hospital appointments. The role of the nurse navigator is to improve care management of these patients. Evidence for this is measured through improvement in patient self-management of their conditions, a reduction in preventable hospital admissions and compliance with attendance at outpatient clinics. Failure to attend (FTA) is one measure of hospital utilisation, identifying outpatient appointments that are cancelled or not attended. The cohort for this study was patients with multiple chronic conditions, and nurse navigators coordinating their care. Data describing the concept of FTA were thematically analysed twelve months into this three year evaluation. Although the patient is blamed for failing to attend appointments, the reasons appear to be a mixture of systems error/miscommunication between the patient and the health services or social reasons impacting on patient's capacity to attend. Themes emerging from the data were: access barriers; failure to recognise personal stigma of FTA; and bridging the gap. The nurse navigators demonstrate their pivotal role in engaging with outpatient services to reduce FTAs whilst helping patients to become confident in dealing with multiple appointments. There are many reasons why a patient is unable to attend a scheduled appointment. The phrase 'Failure to Attend' has distinctly negative connotations and can lead to a sense of blame and shame for those with complex chronic needs. We propose the use of the neutral phrase "appointment did not proceed" to replace FTA. This article advocates for further consideration of collaborative models that engage the patient in their care journey and for consideration of the language used within the outpatient acute hospital setting, proposing the term 'appointment did not proceed.'

An Australian State-Based Cohort Study of Autoimmune Encephalitis Cases Detailing Clinical Presentation, Investigation Results, and Response to Therapy.

Introduction: Autoimmune encephalitis is a disorder associated with antibodies directed against central nervous system proteins with variable clinical features. This study aims to add to knowledge of the disease by reporting the details of a cohort of patients with autoimmune encephalitis in Queensland, Australia.Methodology: We surveyed patients with autoimmune encephalitis diagnosed and managed through public hospitals in Queensland, Australia between 2010 and the end of 2019. Cases were identified via case detection through a centralized diagnostic neuroimmunology laboratory (Division of Immunology, HSQ Pathology Queensland Central Laboratory, Brisbane, Queensland, Australia) and a survey of neurologists. Data including demographic details, clinical presentation, investigation results, treatments including immune therapy and outcomes was collected.Results: Sixty cases of antibody positive autoimmune encephalitis were identified. Twenty-eight were of anti-NMDA-receptor encephalitis with other cases associated with antibodies against LGi1, Caspr2, glycine receptor, DPPX, GABAB receptor, IgLON5, GFAP, and SOX1. The number of diagnosed cases, especially of anti-NMDA-receptor encephalitis has markedly increased over the period 2017 to 2019. Clinical presentations were marked by heterogeneous symptom complexes and prolonged hospital admissions. Imaging studies were largely normal or non-specific. There was a response to immune therapy and a low mortality rate. Most cases affected by this disorder were left with ongoing symptoms associated with mild disability.Conclusion: Autoimmune encephalitis in Queensland, Australia is an increasingly common but complex clinical entity marked by heterogeneous presentations, response to immune therapy and outcome results marked by low mortality and incomplete recovery.

A cascade of interventions: A classification tree analysis of the determinants of primary cesareans in Australian public hospitals.

Both globally and in Australia, there has been a sharp rise in cesarean births (CB). Commonly, this rise has been attributed to the changing epidemiology of women giving birth. A significant body of knowledge exists on the risk factors associated with a greater need for cesarean. Yet, we have little information on the reasons recorded by clinicians as to why cesareans are provided. This study aimed to explore the drivers of primary cesareans in Australian public hospitals. Using a linked administrative data set, the frequency and percent of mothers' characteristics were compared between those who had a cesarean birth and those who had a vaginal birth (n=98967) with no history of previous cesareans in Queensland public hospitals between July 1, 2012, and June 30, 2015. The top 10 reasons recorded by clinicians for a primary cesarean were reported. Using a machine-learning algorithm, two decision trees were built to determine factors driving primary cesarean birth. "Labour and delivery complicated by fetal heart rate anomaly" (23%) and "primary inadequate contractions" (22.8%) were the top two reasons for a primary cesarean birth. The most common characteristics among mothers who had fetal heart rate anomalies were as follows: artificial rupture of membranes (39%), oxytocin (32%), no obstruction of labor (42%), and epidural (52%). For women who had primary inadequate contractions, the most common characteristics were as follows: epidural (33%), oxytocin (49%), artificial rupture of membranes (45%), and fetal stress (56%). Efforts should be made by health practitioners during the antenatal period to maximize the use of preventative measures that minimize the need for medical interventions.

Aggregate efficiency of industry and its groups: the case of Queensland public hospitals

In this paper, we explore the efficiency of different groups of hospitals in Queensland, Australia, focusing on teaching and non-teaching hospitals, by adapting the most recent developments on statistical analysis of aggregate efficiency. We focus on the two approaches: the bootstrap approach proposed by Simar and Zelenyuk (J Appl Econ 22(7):1367–1394, 2007) and the central limit theorems recently developed by Simar and Zelenyuk (Oper Res 66(1):137–149, 2018), (Eur J Oper Res, 2020). To adapt these developments, we extend the central limit theorems to the context where there are several sub-groups in the population. Using real data on Queensland public hospitals, we found that teaching hospitals are significantly less efficient than non-teaching hospitals when benchmarking is done with respect to the constant returns to scale frontier, but are significantly more efficient when benchmarking with respect to the variable returns to scale frontier.

Allied health primary contact services: results of a 2-year follow-up study of clinical effectiveness, safety, wait times and impact on medical specialist out-patient waitlists.

Objective Long specialist out-patient waitlists are common in public health facilities, but not all patients require consultation with a medical specialist. Studies of single allied health primary contact services have shown they provide timely, appropriate care and reduce demand on medical specialist out-patient waitlists. This study evaluated the collective benefits across multiple allied health primary contact services and models to determine their clinical effectiveness, safety, timeliness of care and impact on medical specialist out-patient waitlists. Method Using a prospective observational study design, data were collected and analysed for patients attending 47 allied health primary contact services in Queensland public hospitals over a 2-year period. Outcomes reported are global status, adverse events, wait times and impact on medical specialist out-patient waitlists. Results In all, 10634 patients were managed in and discharged from the allied health services. Most adult patients (80%) who attended at least two consultations reported an improvement in health status. No adverse events were attributed to the model of care. Approximately 68%, 44% and 90% of urgent, semi-urgent and non-urgent out-patients respectively were seen within clinically recommended time frames. Between 35% and 89% of patients were removed from out-patient waitlists without medical specialist consultation across the service models. Conclusions Allied health primary contact services provide safe, effective and timely care. The impact on medical specialist out-patient waitlists varied depending on service model and pathway characteristics. What is known about this topic? Most studies of allied health primary contact services have focused on the management of patients on orthopaedic specialist out-patient waitlists by a physiotherapist. These studies of either individual services or groups of services with the same model cite benefits, including reduced waiting times, high levels of patient and referrer satisfaction, improved conversion to surgery, cost-effectiveness and more effective utilisation of medical specialists. What does this paper add? This paper highlights that, collectively, allied health primary contact services are safe, effective and provide timely care. The proportion of patients independently managed and removed from various medical specialist out-patient waitlists and the services involved are reported, demonstrating the variety of service models. This study reports outcomes for primary contact services for which there is a dearth of published literature, including dietician services for patients on gastroenterology waitlists, speech pathology and audiology services for patients on ear, nose and throat waitlists, occupational therapy hand services for patients on orthopaedic waitlists and physiotherapy led pelvic-health services for patients on gynaecology waitlists. Possibilities for efficiency gains are identified and discussed. What are the implications for practitioners? Health service managers should consider allied health primary contact services as a viable option to increase specialist out-patient capacity. Service model characteristics that maximise impact on medical specialist out-patient waitlist management are highlighted to inform resource allocation.

A multisite longitudinal evaluation of patient characteristics associated with a poor response to non-surgical multidisciplinary management of low back pain in an advanced practice physiotherapist-led tertiary service

BackgroundNon-surgical multidisciplinary management is often the first pathway of care for patients with chronic low back pain (LBP). This study explores if patient characteristics recorded at the initial service examination have an association with a poor response to this pathway of care in an advanced practice physiotherapist-led tertiary service.MethodsTwo hundred and forty nine patients undergoing non-surgical multidisciplinary management for their LBP across 8 tertiary public hospitals in Queensland, Australia participated in this prospective longitudinal study. Generalised linear models (logistic family) examined the relationship between patient characteristics and a poor response at 6 months follow-up using a Global Rating of Change measure.ResultsOverall 79 of the 178 (44%) patients completing the Global Rating of Change measure (28.5% loss to follow-up) reported a poor outcome. Patient characteristics retained in the final model associated with a poor response included lower Formal Education Level (ie did not complete school) (Odds Ratio (OR (95% confidence interval)) (2.67 (1.17–6.09), p = 0.02) and higher self-reported back disability (measured with the Oswestry Disability Index) (OR 1.33 (1.01–1.77) per 10/100 point score increase, p = 0.046).ConclusionsA low level of formal education and high level of self-reported back disability may be associated with a poor response to non-surgical multidisciplinary management of LBP in tertiary care. Patients with these characteristics may need greater assistance with regard to their comprehension of health information, and judicious monitoring of their response to facilitate timely alternative care if no benefits are attained.

Laboratory surveillance of paediatric Clostridium difficile infections in healthcare and community settings in Australia, from 2013 to at present

Background: Clostridium difficile is a common antimicrobial-resistant bacterium in healthcare and community settings. C. difficile colonises the gastrointestinal tract and proliferates as a result of the disruption to microbiota from antimicrobial exposure. Increasing rates of hospital and community-acquired C. difficile infections (CA-CDI) in children have been recorded in many parts of the world, however, research in Australia has been limited. The C. difficile Antimicrobial Resistance Surveillance (CDARS) study is a longitudinal investigation of both the molecular epidemiology and antimicrobial resistance phenotype of C. difficile isolated in Australia since 2013. Here we report the molecular characterization of C. difficile isolated from paediatric patients during this period. Methods & Materials: C. difficile isolates (or PCR positive stool samples) were sent from 10 laboratories (one private and one public laboratory) across five states in Australia. Isolates were characterized by PCR for toxin genes and ribotyping. Results: Of the 1542 isolates recovered throughout the study period (August–September 2013–February–March 2018), 127 (8.2%) were from paediatric patients with ages ranging from <1 to 17 years. Overall, 88.2% of isolates (n = 112) were toxigenic (A+B+CDT−, n = 104; A+B+CDT+, n = 6; A−B+CDT−, n = 2). A total of 38 different RTs were identified of which two were novel. The most common RTs isolated were toxigenic RTs 014/020, 002, 046 and 056. Interestingly, RT 027 was isolated from an 11-year-old patient in a public hospital in Queensland. Conclusion: The presence of highly diverse strains in paediatric patients from both hospitals and community-based healthcare establishments suggests the possibility of patients acquiring infections from sources/reservoirs external to the hospital contributing to the rise in CA-CDIs in Australia in recent years. The presence of toxigenic strains, especially the well-established (in both humans and animals) RT 014/020, and the strain commonly found in the Asia-Pacific region, RT 017, is of interest. Additional whole genome sequencing studies will enhance our understanding of the significance of isolating C. difficile from young children (primarily toxigenic strains that are commonly found in other sources/reservoirs such as the environment, food, animals and the elderly).

Analysis of health administration data to inform health service planning for paediatric palliative care

BackgroundHealth service planning in paediatric palliative care is complex, with the diverse geographical and demographic characteristics adding to the challenge of developing services across different nations. Accurate and reliable data...

Red flags and gut feelings—Midwives’ perceptions of domestic and family violence screening and detection in a maternity department

BackgroundDomestic and family violence (DFV) is known to escalate during pregnancy. Routine screening for DFV in maternity departments is a widely acceptable practice according to staff and women. This study is part of a 3-year follow-up of an organisational intervention evaluation and aimed to identify clinicians’ perceptions of current practices, as well as barriers and enablers to DFV antenatal screening. MethodSemi-structured interviews were conducted with ten midwives about conducting DFV screening within the maternity department of a large tertiary public hospital in Queensland, Australia. Interview transcripts were read and thematically analysed by two independent researchers. ResultsFour main themes emerged from the data: uncertainty despite education and training; fear of opening Pandora’s Box; working with ‘red flags’ and ‘gut feelings’; and it’s all about the relationship. ConclusionAlthough clinicians identified the importance of guidelines for managing DFV and knowledge of resources and services, confidence varied. Ongoing, formal, mandatory training in the area of DFV was highlighted. Managing partner presence in the room, building rapport with the woman, and time constraints continue to be challenging barriers to DFV detection. Routine screening, continuity of care, and staff knowledge and experience were major enablers to successful detection and response.

Complications of cardiac implantable electronic device placement in public and private hospitals.

Few safety data exist comparing clinical outcomes in Australian public and private hospitals. We hypothesised that differences could exist between public and private hospitals due to differences in acuity and patient-level co-morbidities. To report comparative complications of cardiac implantable electronic device (CIED) placement in public and private hospitals. We conducted an observational cohort study of outcomes of patients aged >18 years from 2010 to 2015 undergoing a new permanent pacemaker (PPM), implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy pacemaker or defibrillator (CRT-D/P) implant in NSW and Queensland public and private hospitals. The primary endpoint was major CIED-related complications occurring in-hospital or within 90 days of discharge. The independent effect of hospital sector was determined using multiple logistic regression, adjusting for covariates, including age, sex, co-morbidities and procedural acuity. A total of 32 364 new CIED implants (PPM 23 845, ICD 5361 and CRT-D/P 3158) were included (49% in private hospitals). Overall, 8.0% of private hospital procedures and 9.6% public hospital procedures experienced at least one complication. After adjustment, the overall risk of CIED complications was similar in private and public hospitals (OR: 0.92, 95% CI: 0.84-1.00, P = 0.06). In analysis of individual complications, adjusted all-cause in-hospital mortality was higher in private hospitals, (OR: 1.49, 95% CI: 1.03-2.16, P = 0.036) primarily driven by an excess mortality in acute cases. The adjusted risk of in-hospital generator operation (OR: 0.53, 95% CI: 0.30-0.94, P = 0.03) and post-discharge infection (OR: 0.61, 95% CI: 0.46-0.81, P < 0.001) was lower in private hospitals. These data identify important similarities and differences in safety outcomes of CIED implantation between Australian public and private hospitals.

After-hours emergency department care: Does time or day of arrival affect survival?

To determine whether after-hours presentation to EDs is associated with differences in 7-day and 30-day mortality. The influence of patient case-mix and workforce staffing differences are also explored. We conducted a retrospective observational study of 3.7 million ED episodes across 30 public hospitals in Queensland, Australia during May 2013-September 2015 using routinely collected hospital data linked to hospital staffing data and the death registry. Episodes were categorised as within/after-hours using time of presentation. Staffing was derived from payroll records and explored by defining 11 staffing ratios. Weekend presentation was slightly more associated (7-day mortality odds ratio 1.05, 95% confidence interval [CI] 1.01-1.10) or no more associated (30-day mortality odds ratio 1.01, 95% CI 0.98-1.03) with death than weekday presentation. When weeknights are included in the 'after-hours' period, odds ratios are smaller, so that after-hours presentation is no more associated (7-day mortality odds ratio 1.03, 95% CI 0.99-1.08) or less associated (30-day mortality odds ratio 0.95, 95% CI 0.93-0.97) with death. No significant after-hours patient case-mix differences were observed between weekday and weekend presentations for 7-day mortality. In other combinations of outcome and after-hours definition, some differences (especially measures relating to severity of presenting condition) were found. Staffing ratios were not strongly associated with any within/after-hours differences in ED mortality. After-hours presentation on the weekend to an ED is associated with higher 7-day mortality even after controlling for case-mix.

Bortezomib use and outcomes for the treatment of multiple myeloma.

The public subsidy in Australia of bortezomib (Velcade) for untreated non-transplant multiple myeloma patients was based on the VISTA trial. To ascertain the health outcomes of bortezomib in 'real world' transplant-ineligible elderly patients, compared to trial data. Patient and treatment data were extracted from an oncology information system, laboratory information system and medical chart audits for three Queensland public hospitals. We identified 74 patients; the median age was 75 years. Our cohort comprised 47% patients who were International Staging System stage III, 45% at stage II and 8% at stage I. Patients who had comorbidities, such as cardiac disease (41%), pulmonary disease (14%), diabetes (22%), peripheral neuropathy (14%) and other comorbidities (41%) at baseline were included. The common regimens prescribed were VMP, CVD and VD, and most patients (n = 73) received bortezomib on a once-weekly or twice-a-week basis. The overall response rate was 81%. Half (53%) of the patients did not complete their planned therapy due to toxicity (30%), suboptimal response or disease progression (15%), or death on treatment (8%). Overall survival was 40.7 months and progression free survival was 17.7 months. Our patients were older, had worse disease characteristics and more comorbidities than patients in the VISTA trial. While response rates were similar, survival outcomes appeared worse. Bortezomib-based treatment in the real world setting still carries a high risk of toxicity in the elderly population.

Outcome of angioembolization for blunt renal trauma in haemodynamically unstable patients: 10-year analysis of Queensland public hospitals.

The aim of the study was to evaluate whether angioembolization is an appropriate alternative method for the management of blunt renal trauma in haemodynamically unstable patients. A retrospective analysis was conducted from 2002 to 2012 at three tertiary trauma hospitals in the state of Queensland. Patients who had blunt renal trauma and underwent renal angioembolization or had a trauma nephrectomy were identified using patient records and operating theatre and interventional radiology databases. The inclusion criteria were - haemodynamically unstable patients with blunt renal trauma treated with angioembolization, above the age of 16 years. Patients who underwent angioembolization for other causes such as: penetrating renal trauma, post-procedure, renal tumours, renal angiomyolipomas or arteriovenous malformations were excluded. Patients below the age of 16 were also excluded. Post-embolization renal function, blood pressure, morbidity and mortality were analysed using the paired t2 test. A total of 668 renal trauma patients were identified during this period. Sixteen patients underwent angioembolization for blunt renal trauma. Post-procedure renal function normalized without any hypertension with the median follow up being 4 months. Four patients had post-embolization complications including a urinoma, two devascularized kidneys and one ureteric stricture requiring nephrectomy. There was no mortality. Selective angioembolization, where feasible, is an alternative method in the management of haemodynamically stable patients with blunt renal trauma maximizing nephron sparing and producing acceptable long-term outcomes with avoidance of the morbidity of trauma nephrectomy. This is the first study that we know of in Australia analysing the outcome of angioembolization for blunt renal trauma.

Developing a sociocultural framework of compliance: an exploration of factors related to the use of early warning systems among acute care clinicians.

BackgroundEarly warning systems (EWS) are most effective when clinicians monitor patients’ vital signs and comply with the recommended escalation of care protocols once deterioration is recognised.ObjectivesTo explore sociocultural factors influencing acute care clinicians’ compliance with an early warning system commonly used in Queensland public hospitals in Australia.MethodsThis interpretative qualitative study utilised inductive thematic analysis to analyse data collected from semi-structured interviews conducted with 30 acute care clinicians from Queensland, Australia.ResultsThis study identified that individuals and teams approached compliance with EWS in the context of 1) the use of EWS for patient monitoring; and 2) the use of EWS for the escalation of patient care. Individual and team compliance with monitoring and escalation processes is facilitated by intra and inter-professional factors such as acceptance and support, clear instruction, inter-disciplinary collaboration and good communication. Noncompliance with EWS can be attributed to intra and inter-professional hierarchy and poor communication.ConclusionsThe overarching organisational context including the hospital’s embedded quality improvement and administrative protocols (training, resources and staffing) impact hospital-wide culture and influence clinicians’ and teams’ compliance or non-compliance with early warning system’s monitoring and escalation processes. Successful adoption of EWS relies on effective and meaningful interactions among multidisciplinary staff.

Protocol and establishment of a Queensland renal biopsy registry in Australia

BackgroundRenal biopsy is often required to obtain information for diagnosis, management and prognosis of kidney disease that can be broadly classified into acute kidney injury (AKI) and chronic kidney disease (CKD). The most common conditions identified on renal biopsy are glomerulonephritis and tubulo-interstitial disorders. There is a paucity of information on management strategies and therapeutic outcomes in AKI and CKD patients. A renal biopsy registry will provide information on biopsy-proven kidney disorders to improve disease understanding and tracking, healthcare planning, patient care and outcomes.MethodsA registry of patients, that includes biopsy-proven kidney disease, was established through the collaboration of nephrologists from Queensland Hospital and Health Services and pathologists from Pathology Queensland services. The registry is in keeping with directions of the Advancing Kidney Care 2026 Collaborative, established in September 2018 as a Queensland Health initiative. Phase 1 of the registry entailed retrospective acquisition of data from all adult native kidney biopsies performed in Queensland, Australia, from 2002 to 2018. Data were also linked with the existing CKD.QLD patient registry. From 2019 onwards, phase 2 of the registry involves prospective collection of all incident consenting patients referred to Queensland public hospitals and having a renal biopsy. Annual reports on patient outcomes will be generated and disseminated.DiscussionEstablishment of the Queensland Renal Biopsy Registry (QRBR) aims to provide a profile of patients with biopsy-proven kidney disease that will lead to better understanding of clinico-pathological association and facilitate future research. It is expected to improve patient care and outcomes.

Patient Deterioration in Australian Regional and Rural Hospitals: Is the Queensland Adult Deterioration Detection System the Criterion Standard?

This study compares the efficiency of six early warning systems (EWSs) to determine whether the EWS used in most public hospitals in Queensland, Australia, The Queensland Adult Deterioration Detection System (Q-ADDS), is best suited for use in small regional and rural hospitals. In this retrospective case-control study, patients who experienced an in-hospital severe adverse event (index patients) for a 3.5-year period were demographically and diagnostically matched with patients who had uneventful hospital stays (control patients). The EWS efficiency was based on the area under the receiver operator characteristic curve (AUROC) and the number of false and true alerts generated by each EWS. The incidence of severe adverse events was 1.2% of in-hospital patients, and 2500 sets of vital signs were collected from 159 index and 172 control patients. The EWSs were only able to identify approximately half of the index patients. The AUROC was 0.666 to 0.801 and the EWS generated 2.4 to 7.6 false alerts to every true alert per 1000 admissions. The National Early Warning Score had the best ratio of false to true alerts (2.4:1) but was only able to identify 40.8% of deteriorating patients. The Q-ADDS identified 46.5% of the deteriorating patients and had a false to true alert ratio of 3.2:1. When compared with the National Early Warning Score, systems with higher AUROCs (0.744 and 0.801) also had higher proportion of false alerts. None of the alternative EWSs seem to provide marked benefits over Q-ADDS. At present, there is insufficient evidence to replace Q-ADDS with an alternative EWS. Because the EWSs were only able to identify half of the deteriorating patients, EWSs should be used in conjunction with good clinical judgment.