Teaching Hospital In Melbourne Research Articles

Depression, anxiety and stress in women following acute coronary syndrome: Implications for secondary prevention

To document incidence of depression, anxiety, and stress in women more than 6 months following an acute coronary syndrome. Participants were identified from a coronary care unit database. The Depression Anxiety Stress Scales 21 (DASS 21) was sent to potential participants via postal survey. A metropolitan teaching hospital in Melbourne, Australia. The cohort of women was aged between 55 and 70 years. They had been admitted to hospital with a diagnosis of acute coronary syndrome (ACS) between 6 and 14 months prior to participating in this study. Scores on Depression, Anxiety, and Stress Scale (DASS 21). Of the 117 posted questionnaires, 39 women with a mean age of 63 (S.D. 4.97) responded to the survey, representing a response rate of 33.3%. Most participants scored within normal levels of depression (66.7%), anxiety (60.5%), and stress (70.3%), however, mild to extremely severe levels of each construct (33.4%, 39.6%, and 29.7%, respectively) were found. The reporting of elevated levels of depression, anxiety and stress in a subset of women more than 6 months following an ACS event underscores the importance of ongoing screening for risk factors impacting on psychological well-being and the inclusion of this information in education and counseling strategies in both the inpatient and outpatient settings. Based on these pilot data, consideration of a screening system in the immediate post discharge period for women at risk and an education or support service are recommended.

Falls in the acute hospital setting — impact on resource utilisation

To determine the resource utilisation of patients who fall within an acute metropolitan hospital. Retrospective observational study, part of a larger falls prevention project in a 323-bed acute care, tertiary teaching hospital in Melbourne, Australia. A review of falls incidents was undertaken for all patient admissions for 18 months from January 2002, excluding the Day Procedure Unit, Intensive Care Unit, Coronary Care Unit and the Emergency Department. The most common diagnosis related groups (DRGs) associated with fallers were identified, and within each DRG, fallers were matched to non-fallers by age and gender. Difference in hospital length of stay (LOS) and disparity in resource consumption by these two groups were calculated. The DRG with the highest proportion of fallers was "Dementia and other chronic disturbances of cerebral function" (24%). Three of the top six DRGs had significantly longer LOS for fallers compared with non-fallers ("Delirium", "Stroke" and "Respiratory conditions") (P<0.05). Hospital-related costs were significantly higher for fallers compared with non-fallers for the DRG "Stroke with severe/complicating diagnosis/procedure" only (P<0.05). Inpatient LOS and total associated costs for patients who fell and were classified among the DRGs with the highest proportion of fallers were substantially higher than those of matched non-fallers. Effective falls prevention activities targeting these high-risk groups should be a priority, in the context of broader falls prevention activities within a hospital setting.

Patients’ Decision-Making Strategies for Managing Postoperative Pain

Despite technological advances, many postoperative patients continue to suffer unrelieved pain. The aim of this study was to identify the strategies used by postoperative patients to bring about pain management decisions. A single-group noncomparative study design was chosen using observations as the means of examining pain activities in 2 surgical units of a metropolitan teaching hospital in Melbourne, Australia. A total of 52 nurses and 312 patients participated in the study, and 316 pain activities were observed. The most common strategy used was patients acting as a passive recipient for pain relief (60%), whereas problem solving (23%) and active negotiation (17%) were less commonly used. Patients in this study were admitted for surgical treatment of a particular condition, and their subsequent pain was specifically related to this acute event. Therefore, the lack of familiarity of the situation and the severity of pain experienced may have encouraged passivity. Patients may have also felt uncertain about how to approach the pain decision, preferring to defer to nurses. Because increased pain levels can be associated with fear, patients could have been unwilling to speak with nurses to discuss their need for pain relief. Perspective This paper shows that patient decision making for postoperative pain relief largely involves the use of passive requests, compared with problem solving and active negotiation. Effective communication must be supported between health professionals and patients if shared understandings about treatment options are to become a reality.

The incidence and outcome of septic shock patients in the absence of early-goal directed therapy

IntroductionThe purpose of the present study was to measure the incidence and outcome of septic patients presenting at the emergency department (ED) with criteria for early goal-directed therapy (EGDT).MethodThis hospital-based, retrospective, observational study using prospectively collected electronic databases was based in a teaching hospital in Melbourne, Australia. We conducted outcome-blinded electronic screening of patients with infection admitted via the ED from 1 January 2000 to 30 June 2003. We obtained data on demographics, laboratory and clinical features on admission. We used paper records to confirm electronic identification of candidates for EGDT and to study their treatment. We followed up all patients until hospital discharge or death.ResultsOf 4,784 ED patients with an infectious disease diagnosis, only 50 fulfilled published clinical inclusion criteria for EGDT (EGDT candidates). Of these patients, 37 (74%) survived their hospital admission, two (4%) died in the ED, eight (16%) died in the intensive care unit and three (6%) died in the ward. After review of all ward cardiac arrests and non-NFR ('not for resuscitation') ward deaths, we identified a further two potential candidates for EGDT for an overall mortality of 28.8% (15 out of 52 patients). Analysis of treatment showed that twice as many (70%) of the EGDT candidates received vasopressor therapy in the ED, and their initial mean central venous pressure (10.8 mmHg) was almost twice that in patients from the EGDT study conducted by Rivers and coworkers.ConclusionIn an Australian teaching hospital candidates for EGDT were uncommon and, in the absence of an EGDT protocol, their mortality was lower than that reported with EGDT.

Spontaneous Pneumomediastinum: A Benign Curiosity or a Significant Problem?

To identify the significance of spontaneous pneumomediastinum (SPM) and to optimize its management. A retrospective analysis was undertaken of all patients presenting with SPM over a 5-year period. Eighteen patients were identified, and information on their presentations, initial diagnoses, comorbidities, investigations, clinical courses, length of hospital stays, and outcomes were collated. The emergency department referrals of two major Melbourne teaching hospitals. SPM is an uncommon condition presenting in approximately 1 in 30,000 emergency department referrals. The typical patient identified from this study is a young man who is likely to have a history of asthma, and who is also likely to smoke or to use illicit drugs. The most common presentation is nonspecific pleuritic chest pain with dyspnea. Complications are rare, and the clinical course benign, but the possibility of a ruptured viscus or an initial misdiagnosis often leads to a great number of investigations. A proposed algorithm of management is given. Other serious and potentially life-threatening conditions, such as Boerhaave syndrome need to be excluded.

Nurses’ Strategies for Managing Pain in the Postoperative Setting

Abstract Acute pain is a significant problem in the postoperative setting. Patients report a lack of information about pain-control measures and ineffective pain control. Nurses continue to rely on pharmacologic measures and tend to under-administer analgesics. The purpose of this study was to determine the strategies nurses used to manage patients’ pain in the postoperative setting. It also sought to examine the effect of context, including organization of care, nurses’ prioritization of work activities, and pressures during a working shift, on their pain-management strategies. An observational design was used in two surgical units of a metropolitan teaching hospital in Melbourne, Australia. Six fixed observation times were identified as key periods for pain activities, each comprising a 2-hour duration. An observation period was examined at least 12 times, resulting in the completion of 74 observations and the identification of 316 pain cases. Fifty-two nurses were observed during their normal day’s work with postoperative patients. Six themes were identified: managing pain effectively; prioritizing pain experiences for pain management; missing pain cues for pain management; regulators and enforcers of pain management; preventing pain; and reactive management of pain. The findings highlighted the critical nature of communication between clinicians and patients and among clinicians. It also demonstrated the influence of time on management strategies and the relative importance that nurses place on nonpharmacologic measures in actual practice. This research, which portrays what happens in actual clinical practice, has facilitated the identification of new data that were not evident from other research studies.

Assessment of patient pain in the postoperative context.

Because of its subjective nature, the assessment of pain requires the use of comprehensive practices that accurately reflect a patient's experiences of pain. The purpose of this study was to determine how nurses make decisions in their assessment of patients' pain in the postoperative clinical setting. An observational design was chosen as the means of examining pain activities in two surgical units of a metropolitan teaching hospital in Melbourne, Australia. Six fixed observation times were selected. Each 2-hour observation period was examined 12 times thus resulting in 74 observations. In total, 316 pain activities were determined. Five themes relating to assessment were identified from the data analysis: simple questioning, use of a pain scale, complex assessment, the lack of pain assessment, and physical examination for pain. The study identified how nurses' prioritization of work demands created barriers in conducting timely and comprehensive pain assessment decisions.

Bridging the divide: a survey of nurses' opinions regarding barriers to, and facilitators of, research utilization in the practice setting.

Many researchers have explored the barriers to research uptake in order to overcome them and identify strategies to facilitate research utilization. However, the research-practice gap remains a persistent issue for the nursing profession. The aim of this study was to gain an understanding of perceived influences on nurses' utilization of research, and explore what differences or commonalities exist between the findings of this research and those of studies that have been conducted in various countries during the past 10 years. Nurses were surveyed to elicit their opinions regarding barriers to, and facilitators of, research utilization. The instrument comprised a 29-item validated questionnaire, titled Barriers to Research Utilisation Scale (BARRIERS Scale), an eight-item scale of facilitators, provision for respondents to record additional barriers and/or facilitators and a series of demographic questions. The questionnaire was administered in 2001 to all nurses (n=761) working at a major teaching hospital in Melbourne, Australia. A 45% response rate was achieved. Greatest barriers to research utilization reported included time constraints, lack of awareness of available research literature, insufficient authority to change practice, inadequate skills in critical appraisal and lack of support for implementation of research findings. Greatest facilitators to research utilization reported included availability of more time to review and implement research findings, availability of more relevant research and colleague support. One of the most striking features of the findings of the present study is that perceptions of Australian nurses are remarkably consistent with reported perceptions of nurses in the US, UK and Northern Ireland during the past decade. If the use of research evidence in practice results in better outcomes for our patients, this behoves us, as a profession, to address issues surrounding support for implementation of research findings, authority to change practice, time constraints and ability to critically appraise research with conviction and a sense of urgency.

Pain and anxiety management in the postoperative gastro-surgical setting.

Despite increasing knowledge and technological advances, patients continue to experience pain and anxiety in the postoperative setting. The aim of this study was to examine how nurses managed patients' pain and anxiety within the gastro-surgical hospital setting. An observational design was selected to examine nurses' management of postoperative patients' pain and anxiety. Six nurses who were involved in direct patient care in one of two gastro-surgical wards in a public teaching hospital in Melbourne, Australia, were randomly selected to participate. The observation period comprised a fixed 2-hour segment, and each nurse was observed on three different occasions. Patient assessment was a major concern for participants, which was influenced by the modes of assessment used, patients' medical condition and operation procedure, and their self-reports of pain or anxiety. Communication with health care professionals and policy and protocol concerns also affected nurses' pain and anxiety management decisions. Formal communication through the multidisciplinary ward round tended to be somewhat fragmented, as the medical consultant did not seek out the bedside nurse. Nurses had good knowledge of unit policies and protocols and, while attempting to enforce them, spent considerable time encouraging medical colleagues to abide by these guidelines. Finally, nurses made complex clinical judgements which extended beyond the administration of analgesics or antianxiety drugs. It is possible that nurses demonstrated a raised awareness of how they managed patients' pain and anxiety during observation periods. The study confirmed the importance of examining the complexities of the clinical context in determining how nurses manage pain and anxiety in the postoperative setting.

Thyrotoxic, hypokalaemic periodic paralysis in Australasian men.

Abstract The present study describes the clinical and laboratory features of 11 patients with thyrotoxic, hypokalaemic periodic paralysis, presenting to five Melbourne teaching hospitals between 1991 and 2000. All 11 patients were Asian or Polynesian men aged 18-41 years, and most had experienced previous episodes of acute, unexplained paralysis. All cases resolved without significant morbidity. Thyrotoxic, hypokalaemic periodic paralysis is a potentially life-threatening and terrifying condition, which is often under-recognized and will present with increasing frequency in the community. The diagnosis should be considered in any Asian-Australian male presenting with sudden onset paralysis.

Prescribing of Warfarin, and Brand Selection

Journal of Pharmacy Practice and ResearchVolume 32, Issue 4 p. 259-261 Letter to the EditorFree Access Prescribing of Warfarin, and Brand Selection Michael Dooley BPharm, Grad Dip Hosp Pharm, Corresponding Author Michael Dooley BPharm, Grad Dip Hosp Pharm Chairman MTHDUG@vduac.org.au Melbourne Teaching Hospitals' Drug Usage Group POBox423 Carlton South Vic. 3053Search for more papers by this author Michael Dooley BPharm, Grad Dip Hosp Pharm, Corresponding Author Michael Dooley BPharm, Grad Dip Hosp Pharm Chairman MTHDUG@vduac.org.au Melbourne Teaching Hospitals' Drug Usage Group POBox423 Carlton South Vic. 3053Search for more papers by this author First published: 01 December 2002 https://doi.org/10.1002/jppr2002324259aAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume32, Issue4December 2002Pages 259-261 ReferencesRelatedInformation

Observation of pain assessment and management--the complexities of clinical practice.

Pain assessment and management are complex issues that embrace physiological, emotional, cognitive, and social dimensions. This observational study sought to investigate nurse-patient interactions associated with pain assessment and management in hospitalized postsurgical patients in clinical practice settings. Twelve field observations were carried out on Registered Nurses' activities relating to pain with their assigned patients. All nurses were involved in direct patient care in one surgical unit of a metropolitan teaching hospital in Melbourne, Australia. Six observation times were identified as key periods for activities relating to pain, which included change of shift and high activity periods. Each observation period lasted 2 hours and was examined on two occasions. Four major themes were identified as barriers to effective pain management: nurses' responses to interruptions of activities relating to pain, nurses' attentiveness to patient cues of pain, nurses' varying interpretations of pain, and nurses' attempts to address competing demands of nurses, doctors and patients. These findings provide some understanding of the complexities impacting on nurses' assessment and management of postoperative pain. Further research using this observational methodology is indicated to examine these influences in more depth. This knowledge may form the basis for developing and evaluating strategic intervention programmes that analyse nurses' management of postoperative pain and, in particular, their administration of opioid analgesics.

Work, Women and Their Beliefs

AbstractMany women now juggle the multiple roles of wife, mother, home maker, and paid worker. Although their behaviours may have changed, many of these women still adhere to traditional beliefs about their roles, which may predispose them to conflict and stress. Questionnaires were sent to all women working at a large urban teaching hospital in metropolitan Melbourne in a study to explore, among other factors, the relationship between occupational status, education level, and women's beliefs. Of the 2562 questionnaires sent out 974 (44%) were completed and returned, 422 of the questionnaires were completed by women who were living with a male partner and children. Multivariant analyses of variance were performed on the data. Results indicated a relationship between occupational status and adherence to traditional beliefs. Blue collar women had the most traditional beliefs followed by clerical women, then nurses. Managerial women and professional women had the least traditional beliefs. A similar relationship was found between level of education and beliefs; women with lower levels of education adhered to more traditional beliefs than women with higher education levels. It is possible that, as a result of adherence to traditional beliefs, women who are blue-collar workers and those with lower levels of education may be more predisposed to stress than other women when juggling their multiple roles.

Postoperative serious adverse events in a teaching hospital: a prospective study.

To assess the incidence and nature of postoperative serious adverse events (SAEs) among inpatients having surgery in a tertiary hospital, and to determine which subgroups of patients might be at greatest risk. Prospective observational study from 1 December 1998 - 31 March 1999. Tertiary teaching hospital in Melbourne, Victoria. 1,125 subjects having inpatient surgery during the study period. Inhospital mortality, length of hospital stay, and SAEs (myocardial infarction, pulmonary embolism, acute pulmonary oedema, unscheduled tracheostomy, respiratory failure, cardiac arrest, stroke, severe sepsis, acute renal failure, and emergency admission to intensive care unit [ICU]). There were 414 SAEs in 190 of the 1,125 patients (16.9%); 80 patients died (7.1%). The most common adverse events were emergency admission to ICU (95), respiratory failure (52) and readmission to ICU (37). In patients without SAEs, mean duration of hospital stay was 18.4 days (95% Cl, 15.4-21.4), while in those with SAEs it was 38.5 days (95% CI, 35.3-41.7) (P < 0.0001). SAEs, including deaths, were more common after unscheduled surgery and in patients over 75 years of age. The combination of these two factors carried a 20% mortality. There were no differences in the incidence of SAEs among the major surgical specialties. SAEs are common and result in high mortality, especially in older surgical inpatients and those having unscheduled surgery. These findings raise important issues of optimal perioperative management in tertiary hospitals.

Will Australian men use male hormonal contraception? A survey of a postpartum population.

To survey the attitudes of a population of Australian men to potential use of male hormonal contraception (MHC). Survey of male partners of women who had recently given birth. Men were approached while visiting their female partners on the ward. 118 out of 148 Australian-born English-speaking men who were approached. Postnatal ward of Monash Medical Centre (a public teaching hospital in Melbourne), between October 2000 and April 2001. Attitudes towards potential use of MHC, rated on a five-point scale. 89/118 men surveyed (75.4%; 95% Cl, 67.7%-83.2%) indicated that they would consider trying MHC if it were available. The three most popular choices for method of administration of MHC were (in descending order) an oral pill, a three-monthly injection, or a two-yearly injection. A statistically significant association was found between acceptability of vasectomy and acceptability of MHC (70.5% of men who indicated they would try MHC [MHC "triers"] found vasectomy acceptable versus 44.5% of MHC "non-triers"; P = 0.011). Triers reported a higher rate of approval of MHC by their female partners than non-triers (79.8% v 13.8%, respectively; P < 0.0001). MHC appears to be acceptable to a majority of Australian men when surveyed in a postpartum context. Attitudes of men towards existing male contraception, as well as the attitudes of their partners, appear to exert a strong influence on acceptability of MHC.

A survey of Australian general practice management of hepatitis C-infected patients from non-English-speaking backgrounds.

Australia receives many migrants from countries with a high prevalence of hepatitis C infection. General practitioners, who are often the first health professionals consulted, need to be aware of risk factors and complications associated with hepatitis C in this group. Four hundred and forty-seven general practitioners, obtained from registries at two Melbourne teaching hospitals serving large non-English-speaking migrant populations, were sent a questionnaire. Two hundred and forty-one returned a completed questionnaire. The survey attempted to assess knowledge of risk factors, complications, currently recommended antiviral therapy, referral practice to specialists and difficulties encountered by practitioners and patients in accessing information about HCV. Sexual and vertical transmission were listed as more common risk factors than iatrogenic causes or injecting drug use. Most respondents interpreted basic diagnostic tests correctly but there was a range of estimates regarding progression to cirrhosis and hepatocellular carcinoma with many seriously overestimating these aspects of natural history. Interferon and ribavirin were commonly listed as optimal therapy, but both interferon monotherapy and lamivudine, a treatment for hepatitis B, were stated as optimal therapy by 25% of respondents. Considerable frustration was expressed regarding access to reliable information about treatment outcomes and to linguistically and culturally appropriate patient information. The wide response range regarding modes of acquisition of HCV in patients from non-English-speaking backgrounds, rates of progression to cirrhosis and hepatocellular carcinoma and optimal antiviral therapy suggests a need to improve provision of appropriate educational resources that will facilitate general practice management of a common and important public health problem.

Evaluating the effectiveness of stroke rehabilitation: Choosing a discriminative measure

Brock KA, Goldie PA, Greenwood KM. Evaluating the effectiveness of stroke rehabilitation: choosing a discriminative measure. Arch Phys Med Rehabil 2002;83:92-9. Objective: To evaluate the discriminative ability of several measures of physical disability used to determine quality of outcome for poststroke rehabilitation. Design: A comparative study, using Rasch analysis, of the discriminative ability of functional status and mobility measures in rehabilitation patients with stroke. Setting: A 26-bed rehabilitation unit, on site of a tertiary teaching hospital in Melbourne, Australia. Participants: A consecutive sample of 106 patients with acute stroke admitted for rehabilitation. Interventions: Not applicable. Main Outcome Measures: Rasch analysis of the motor subscale of the FIM™ instrument, Motor Assessment Scale, Functional Ambulation Classification, gait velocity, and gait endurance. Results: The more difficult items of the FIM motor scale adequately discriminated among higher functioning patients. The gait velocity measure further distinguished 9% of the sample, who functioned at a higher level than could be indicated by FIM motor subscale. The other measures did not add levels of discrimination to that provided by the FIM motor. Ability estimates provided by Rasch analysis of the FIM motor scale were a more accurate indication of ability than raw scores. Raw scores underestimated change in ability observed at higher levels of ability. Conclusion: Rasch estimates of the FIM motor subscale provide a discriminative measure for evaluating outcomes and change in ability achieved in stroke rehabilitation. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Risk factors for colonization with vancomycin-resistant enterococci in a Melbourne hospital.

To determine risk factors for colonization with vancomycin-resistant enterococci (VRE) in a hospital outbreak. Outbreak investigation and case-control study. A referral teaching hospital in Melbourne, Australia. Cases were inpatients colonized (with or without clinical disease) with VRE between July 26 and November 28, 1998; controls were hospitalized patients without VRE. Five cases of VRE were identified between July 26 and November 8, 1998, by growth of VRE from various sites. Active case finding by cultures of rectal swabs from patients surveyed in wards was commenced on July 26, after the first isolate of VRE. There were 19 cases and 66 controls. All the VRE identified were vanB, and all were Enterococcus faecium. One molecular type predominated (18/19 cases). In a logistic-regression model, being on the same ward as a VRE case was the highest risk factor (odds ratio [OR], 82; 95% confidence interval [CI95], 5.7-1,176; P=.001). Having more than five antibiotics (OR, 11.9; CI95 1.1-129.6; P<.05), use of metronidazole (OR, 10.9; CI95, 1.7-69.8; P=.01), and being a medical patient (OR, 8.1; CI95, 1.4-47.6; P<.05) also were significant. Intensive care unit admission was associated with decreased risk (OR, 0.1; CI95, 0.01-0.8; P<.05). Our findings are consistent with an acute hospital outbreak. Monitoring and control of antibiotic use, particularly metronidazole, may reduce VRE in our hospital. Ongoing surveillance and staff education also are necessary.

A midwife led debriefing session after operative childbirth did not reduce postpartum depression

(2000) BMJ 321, 1043. Small R, Lumley J, Donohue L, et al. . Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth. . Oct 28;...

Measurement of cardiac troponin I levels in the emergency department: predictive value for cardiac and all-cause mortality.

To assess the predictive value of cardiac troponin I levels in cardiac and all-cause mortality in patients presenting to an emergency department. A prospective cohort study. The emergency department of a major tertiary teaching hospital in metropolitan Melbourne over a six-week period in 1998. All patients with requests for cardiac enzyme level measurement. Cardiac and all-cause mortality within 30 days of presentation. 424 patients (232 men, 192 women; age range, 16-93 years) were reviewed. The 30-day mortality rate was 7.3% (31/424); in patients with raised levels of both creatine kinase (CK)-MB isoenzyme and troponin I this rate was 27% (7/26; 95% CI, 13%-44%); and in those with troponin I levels above 2 microg/L, but normal CK-MB values, it was 24% (5/21; 95% CI, 5%-43%). The mortality rate in the group with normal results of cardiac markers was 4.3% (14/328; 95% CI, 2.1%-6.5%). Patients with minor increases in troponin I levels (minimal myocardial damage) showed an intermediate 30-day mortality rate (13%, 5/39; 95% CI, 2%-24%). Other predictors of 30-day mortality included age, presentation with shortness of breath, and electrocardiography (ECG) changes diagnostic of acute myocardial infarction or consistent with ischaemia. Cardiovascular causes were responsible for most of the deaths in patients with raised troponin I levels. Multivariate logistic regression analysis showed that raised levels of troponin (> 2.0 microg/L), but not of CK-MB, predict 30-day mortality rate. Compared with CK-MB, cardiac troponin I more accurately predicts 30-day mortality rates in patients presenting to the emergency department. Moreover, troponin I levels identify additional groups of patients at increased risk of death not so identified by measuring CK-MB values.