Regional Queensland Hospital Research Articles

An Experience of “Antegrade Only” Chronic Total Occlusion Program Without Onsite Surgical Backup at Mackay Base Hospital, A Regional Hospital in Queensland and the Result of the First 20 Cases

Background: Chronic total occlusion (CTO) intervention requires specialised skill. While the risks of the retrograde approach require the procedure to be performed with onsite surgical backup, the antegrade approach is considered lower risk. In 2015 an “antegrade only” CTO program was established at Mackay Base Hospital (MBH). Methods: Specific guidelines have been implemented and are sub-divided into “Case Selection”, “Technical Considerations” and “Emergency Management”. Suitable case selection stipulates that only CTOs with a J-CTO score ≤ 3 are considered for intervention. A policy of “antegrade approach only” has been established. A time constraint of sixty minutes for wiring is allowed. Bilateral access is compulsory. The catheterisation laboratory must maintain stock of correct equipment including embolization devices and a pericardiocentesis kit. Results: Procedural success occurred in 15 of the 20 cases (75%). Mean age was 66.95 years (range 50 – 96 years). Mean J-CTO score was 1.73(range 0-3) for the successful cases and J-CTO score 3 for the rest. Mean procedure time was 133.85 ± 30.00 minutes. All cases required wire escalation. The complications were a branch dissection and a wire perforation, neither with consequences. There were no adverse events at one to six month follow-up. Of the five unsuccessful cases one required coronary bypass graft surgery, one underwent CTO intervention via a retrograde approach, one waiting for reattempt-CTO under general anaesthesia and two are for medical therapy. Conclusion: The CTO program established at MBH is feasible and safe without onsite surgical backup amid a success rate meeting the international standard.

Review of antibiotic use in respiratory disorders at a regional hospital in Queensland

Adherence to antibiotic guidelines has been shown to improve outcomes in several clinical situations. Respiratory conditions are a major cause of mortality and morbidity in Queensland. A recent study showed low levels of compliance with antibiotic guidelines in a Queensland metropolitan hospital. We undertook an audit of antibiotic use in a regional Queensland hospital against Therapeutic Guideline recommendations. Therapeutic Guideline recommendations were followed in 16% of cases with ceftriaxone the most commonly prescribed. Re-admission rate within 28days was for 53%, 26%, 11% and 5% respectively for ceftriaxone, benzylpenicillin, amoxicillin/clavulanate and ceftriaxone combined doxycycline. Less than half of patients treated for pneumonia had concordant radiographic changes. Admission via the emergency department may be a factor in the preference for intravenous injection of ceftriaxone and presence of non-infective co-morbidities may also contribute to re-admissions. Considerable challenges exist in improving compliance with antibiotic guidelines which can improve patient outcomes and antibiotic stewardship.

Su1671 Prevalence of Serrated Adenomas at Colonoscopy in a Regional Hospital in Queensland, Australia

Su1671 Prevalence of Serrated Adenomas at Colonoscopy in a Regional Hospital in Queensland, Australia

6. A case of human immunodeficiency virus presenting with alk-negative anaplastic large cell lymphoma, with positive epstein-barr virus expression

Background Anaplastic large cell lymphoma (ALCL) is a mature T-cell lymphoma which is sub-classified into ALK-positive and ALK-negative primary systemic variants, and thirdly primary cutaneous anaplastic lymphoma. In the current WHO classification, ALK-negative ALCL is included as a provisional separate entity, occurring most commonly in elderly men and carrying a poor prognosis. Both ALK-positive and negative ALCL in the general population have been reported to be consistently negative for Epstein-Barr virus (EBV) expression. Case A 40 year-old woman presented to a regional Queensland hospital with a recent history of weight loss, sweats, cough and right neck swelling. An axillary lymph node biopsy was performed as a part of a broad work-up. Histology revealed a lymphoproliferative tumour consisting of sheets of non-cohesive large atypical cells, with multi-lobate nuclei, and frequent mitoses. Immunohistochemical staining was positive for CD45, CD30, CD4, CD43 and EBER-ish; and negative for S100, pan-cytokeratin (AE1/AE3), CD20, CD79a, CD138, CD2, CD3, CD5, CD8, CD15, PAX5 and ALK1. Concurrent pathology investigations subsequently revealed that the patient was in fact HIV positive, and thus these findings were in keeping with a HIV-associated ALK-negative anaplastic large cell lymphoma. Discussion Despite a paucity of reported cases, there is growing recognition of a unique HIV-associated ALCL which arises in the setting of immunosuppression. A small case series published in 2010 analysed 37 cases and found: an average age of 38 years; a male to female predominance of 4:1; a majority of cases were ALK-negative; one third showed positive EBV expression; and there was a variable loss of T-cell markers. This case represents another extremely rare example of HIV-associated ALCL, with positive EBV expression.

Clinical supervisors and cultural competence

To investigate how clinical supervisors of junior doctors provide feedback and assessment on cultural competence, one of several professionalism skills outlined in the Australian Curriculum Framework for Junior Doctors. Twenty clinical supervisors were recruited to a qualitative study in a regional hospital in Queensland, Australia. Data from semi-structured interviews (June-August 2011) were thematically analysed. Interviews revealed that cultural competence was interpreted by the supervising clinicians as a vague concept, and that junior doctors were not assessed in this area. Additional themes related to the cultural competence of junior doctors, as reported by their supervisors, included: limited direct supervision of, and feedback to, junior doctors; variations in approaches to assessment; clinicians' communication focuses on clinical aspects of disease process; perceived lack of cultural diversity among staff and patients; acceptance of laypersons as English interpreters; language barriers with international medical graduates; and patients' low levels of health literacy. Supervisors were unable to define cultural competence in ways that enable them to apply the concept to clinical training for junior doctors. Specific training in cultural competence, and guidelines for its assessment, is therefore recommended for clinical supervisors and junior doctors to improve their approaches to patient care and health outcomes.

PT385 Compliance with ACCF/ASE Appropriateness Criteria for Transoesophageal Echocardiography at a regional hospital in Queensland, Australia

PT385 Compliance with ACCF/ASE Appropriateness Criteria for Transoesophageal Echocardiography at a regional hospital in Queensland, Australia

Physical and psychosocial wellbeing of nurses in a regional Queensland hospital

Occupational stress is common among nurses. Two factors that may influence stress levels are diet and physical activity. The purpose of this study was to investigate the diets and physical activity levels of nurses and to quantify the relationships between these behaviours and anxiety, depressed mood, stress, and burnout. Nurses (N = 52) from one regional hospital completed a survey assessing physical activity, nutrition, and psychological functioning. Almost two-thirds (65%) of participants had met recommended levels of both moderate and vigorous physical activity in the week prior. Participants met recommended levels for fruit, but not vegetable, consumption. Burnout and stress levels were close to norms for physicians and nurses. Scores for depressed mood, anxiety, and stress symptoms were within one standard deviation of norms for the Australian adult population. Several moderately sized correlations were found between the psychological constructs measured and both physical activity and nutrition. Although most of the participants were physically active and seemed to be consuming nutritious diets, some nurses may need encouragement to adopt similarly healthy behaviours.

A pilot trial of a speech pathology telehealth service for head and neck cancer patients

We explored the feasibility of providing access to specialist speech pathology services via telehealth for patients with head and neck cancer. A weekly telehealth clinic was conducted between the speech pathology departments of a tertiary hospital and a regional hospital in Queensland. Over a 5-month period, 50 telehealth sessions were conducted for 18 patients. There were 38 patient consultations, nine case discussions between clinicians and three clinical training sessions relating to the skills needed for specific client management (e.g. voice prosthesis selection). Eight sessions had multidisciplinary involvement. All cases were successfully managed via telehealth. All patients agreed that they were comfortable using telehealth and would be happy to use it again in future. Both clinicians agreed that they could competently assess patients using the telehealth system. There appeared to be financial benefits for the patient, because by receiving specialist intervention at a local facility their travel expenses were lower. There was also the opportunity for workforce training and development through online case discussion and clinical consultation.

The impact of medical emergency teams on ICU admission rates, cardiopulmonary arrests and mortality in a regional hospital

Context In-hospital cardiac arrests are commonly associated with poor outcomes and preceded by observable signs of clinical deterioration. Medical emergency teams (METs) have emerged to provide early specialist care intervention to critically ill patients. Objective To determine the effect of MET implementation on hospital-wide mortality rates, cardiopulmonary arrests and admissions to the intensive care unit (ICU) in a regional Queensland hospital. Method A prospective cohort before and after interventional trial was conducted on adult and paediatric inpatients admitted in 2004–2008 at a 150 bed regional teaching hospital in Australia. MET was introduced in 2006 and attended clinically unstable patients. Response was activated by the bedside nurse or doctor according to predefined criteria. Results There were a total of 296 MET activations. After MET implementation, mean hospital-wide mortality rates decreased from 9.9 to 7.5 per 1000 admissions (relative risk reduction, RRR: 24.2%; p = 0.003). Similarly, ICU admissions decreased from 22.4 to 17.6 per 1000 admissions (RRR: 21.4%; p < 0.0001). There was also a significant decline in hospital-wide cardiopulmonary arrests post intervention (77 versus 42, RRR: 45.5%; p = 0.0025) however this may be explained by the increase in the number of patients deemed not for resuscitation by the MET. Secondary analysis revealed evidence of MET underuse that may have affected the mortality findings. Conclusion Implementation of the MET in a regional hospital was associated with statistically significant reductions in hospital-wide mortality rates, ICU admissions and cardiopulmonary arrests.

Speaking Out! Qualitative Insights on the Experience of Mothers Who Wanted a Vaginal Birth after a Birth by Cesarean Section

: Despite the documented rise in the rates of births by cesarean section (CS) in Australia, there is scant work on the psycho-social aspects of such birth choices. To address the lack of research on this topic, this article presents a subset of findings from a research project that explored, from the mothers' perspectives, the birthing experience and process of decision making about the mode of delivery for a subsequent birth after a previous CS. : The focus of this article is on the subset of findings that recorded the frustration of women who valued a vaginal delivery but who delivered by CS. : The study utilized descriptive phenomenology, with in-depth, open-ended interviews conducted with the research participants. The setting was a small regional hospital in Queensland, Australia, with about 20% of patients managed on the midwifery model of care. This article is based on the subset of findings that record the frustration of women (eight mothers of a total participant group of 20) who valued a vaginal delivery but who delivered by CS. The women all had a previous CS and had a subsequent birth at the Redland Hospital 6 weeks prior to the interviews, which were held in June 2008. : The findings establish that this group of mothers felt frustrated by their body's inability to give birth naturally, disappointed that they had no option but a CS, and carried emotional pain about the unfairness of the judgment that they should have achieved a vaginal birth after a birth by CS. : These women expressed a strong desire to have their story told. It is the hope and expectation that this article will enable their voice to be heard and, in so doing, make a contribution towards deepening our understanding of the multiplicity of perspectives that women bring to their birthing experiences. The findings are a strong argument against any generalization that women who opt for an elective CS are doing so simply for reasons of ease and convenience.

Keeping the lid on infection: infection control practices of a regional Queensland hospital 1930-50.

Nurses have played an important role in infection control practices throughout the past century. However, the desire for minimisation of cross infection has not always been the basis for many of the activities undertaken by nurses within the general ward. This paper is a historical analysis of those practices that formed the basis of infection control within the medical and surgical wards of the Rockhampton Hospital between 1930 and 1950. In particular, those activities dealing with the disposal of body fluids, ward cleaning, aseptic techniques and associated sterilisation of instruments and articles, the nurses' personal cleanliness and isolation nursing have been addressed. This study has identified economic factors, professional image and local traditions as being influential in the origins and persistence of many activities which may be loosely grouped as infection control measures.

What does radiotherapy add to survival over endoscopic intubation alone in inoperable squamous cell oesophageal cancer?

The place of radiotherapy in the management of squamous cell oesophageal cancer remains uncertain. Survival of oesophageal cancer patients from the Nottingham area in the years 1982-5 was reviewed. Surgical resection was attempted in 44 of 131 patients with squamous cell oesophageal cancer. Among the remainder 32 had endoscopic intubation alone, 27 had radical radiotherapy alone (six) or combined with endoscopic intubation (21), and 28 had other treatment combinations including surgical intubation and palliative radiotherapy. Patients treated by intubation alone had a mean age of 75 years. They were significantly older and metastases were more common (31%) in this group than in patients treated with radiotherapy (mean age 69 years), of whom 11% had metastases. Some 34% (11 of 32) of patients treated by intubation alone died within 30 days of diagnosis and were therefore not eligible for radiotherapy. Beyond 30 days, survival in the radiotherapy group (median survival 188 days; 95% confidence limits 133-253) was not significantly greater than that for the group treated by intubation alone (median survival 98 days (73-154)). The radiotherapy patients had a median hospital stay of 46 days compared with 23 days for the patients treated by intubation alone. In patients with squamous cell oesophageal cancer unsuitable for surgery, the survival advantage associated with radiotherapy and intubation is small and does not compensate for the extra morbidity and prolonged hospital stay. A controlled trial of radiotherapy in these patients is now needed.