A tool to evaluate patients' experience of nursing care in Australian general practice: Development of the Patient Enablement and Satisfaction Survey (PESS)

Australian health policy initiatives have increasingly supported the employment of nurses in general practice. An understanding of the impact of nursing care on patients in this setting is integral to assuring quality, safety and a patient-centred focus

Development and implementation of a nurse-led walk-in centre: evidence lost in translation?

Objectives: The design of the first Australian public nurse-led primary care walk-in centre was modelled on those established in the English National Health Service (NHS). An independent evaluation of the first 12 months of operation of the Australian Ca

One lithium level >1.0 mmol/L causes an acute decline in eGFR: findings from a retrospective analysis of a monitoring database

Objectives Lithium is a mainstay of bipolar disorder treatment, however, there are still differences in opinion on the effects of lithium use on renal function. The aim of this analysis was to determine if there is an association between short-term exposure to various elevated lithium levels and estimated-glomerular filtration rate (eGFR) at ≤3 months, 6 months (±3 months) and 1 year (±3 months) follow-up. Setting Norfolk-wide (UK) lithium register and database. Participants 699 patients from the Norfolk database. Primary outcome measures eGFR change from baseline at ≤3 months, 6 months (±3 months) and 1 year (±3 months) after exposure to a lithium level within these ranges: 0.81–1.0 mmol/L (group 2), 1.01–1.2 mmol/L (group 3) and 1.21–2.0 mmol/L (group 4). The reference group was patients whose lithium levels never exceeded 0.8 mmol/L. Results Compared to the reference group, groups 3 and 4 showed a significant decrease in eGFR in the first 3 months after exposure (p=0.047 and p=0.040). At 6 months (±3 months) postexposure group 4 still showed a decline in eGFR, however, this result was not significant (p=0.298). Conclusions These results show for the first time that a single incident of a lithium level >1.0 mmol/L is associated with a significant decrease in eGFR in the following 3 months when compared to patients whose lithium levels never exceeded 0.8 mmol/L. It is still not known whether the kidneys can recover this lost function and the impact that more than a single exposure to a level within these ranges can have on renal function. These results suggest that lithium level monitoring should be undertaken at least every 3 months, in line with current UK guidelines and not be reduced further until the impact of more than one exposure to these lithium levels has been fully established

Stakeholder perceptions of a nurse led walk-in centre

BACKGROUND As many countries face primary care medical workforce shortages and find it difficult to provide timely and affordable care they seek to find new ways of delivering first point of contact health care through developing new service models. In common with other areas of rural and regional Australia, the Australian Capital Territory (ACT) is currently experiencing a general practitioner (GP) workforce shortage which impacts significantly on the ability of patients to access GP led primary care services. The introduction of a nurse led primary care Walk-in Centre in the ACT aimed to fulfill an unmet health care need in the community and meet projected demand for health care services as well as relieve pressure on the hospital system. Stakeholders have the potential to influence health service planning and policy, to advise on the potential of services to meet population health needs and to assess how acceptable health service innovation is to key stakeholder groups. This study aimed to ascertain the views of key stakeholders about the Walk-in Centre. METHODS Stakeholders were purposively selected through the identification of individuals and organisations which had organisational or professional contact with the Walk-in Centre. Semi structured interviews around key themes were conducted with seventeen stakeholders. RESULTS Stakeholders were generally supportive of the Walk-in Centre but identified key areas which they considered needed to be addressed. These included the service's systems, full utilisation of the nurse practitioner role and adequate education and training. It was also suggested that a doctor could be available to the Centre as a source of referral for patients who fall outside the nurses' scope of practice. The location of the Centre was seen to impact on patient flows to the Emergency Department. CONCLUSION Nurse led Walk-in Centres are one response to addressing primary health care medical workforce shortages. Whilst some stakeholders have reservations about the model others are supportive and see the potential the model has to provide accessible primary health care. Any further developments of nurse-led Walk-in Centres need to take into account the views of key stakeholders so as to ensure that the model is acceptable and sustainable.This study was funded by Australian Capital Territory (ACT) Health

The Australian Capital Territory Patient Enablement and Satisfaction Study (ACTPESS): A mixed methods study examining the impact of nursing care on the quality of care in Australian general practice

BACKGROUND: In response to demographic changes, increasing rates of chronic disease and demand for primary health care services, since the early 2000’s Australia has increased the number and roles of general practice nurses (GPNs). There is a scarcity of evidence establishing whether the increased availability and use of nursing care in general practice has resulted in improved patient outcomes. Two key quality outcomes – patient satisfaction and enablement – have been examined extensively as outcomes of general practitioner care; however an evidence gap exists regarding these outcomes in relation to GPN care. The aim of this study was to examine the relationship between general practice and GPN consultation characteristics, and patient satisfaction and enablement. METHODS: A concurrent mixed methods study was conducted. The quantitative component consisted of a cross-sectional study of 678 patients (response rate = 41%) receiving GPN care in 21 general practices in the Australian Capital Territory. Patient Enablement and Satisfaction Surveys were distributed to these patients between September 2013 and March 2014. Multilevel mixed effect models were used to analyse these data. The qualitative component took a grounded theory approach to in-depth interviews with GPNs (n=16), patients (n=23) and practice managers (n=9) from these same general practices. Data generation and analysis were conducted concurrently using constant comparative analysis and theoretical sampling. After the separate quantitative and qualitative analyses, findings were integrated. This involved quantification of selected qualitative variables for inclusion in multilevel analyses and a secondary integration of findings. FINDINGS: The results of this study provided evidence of: ● a significant association between patient satisfaction and Nursing scope of practice and autonomy, Continuity of GPN care, Patients making appointments to see a particular GPN, Consultation type and Duration of consultation; ● a significant association between patient enablement and Nursing scope of practice and autonomy, Consultation type and Duration of consultation;● behaviours that characterise ‘the just right nurse’; ● an interconnection between patient satisfaction and enablement. This evidence is presented in the form of a theoretical model called, developing a positive patient experience with nurses in general practice: an integrated model of patient satisfaction and enablement. This process-based model includes general practice and GPN consultation characteristics underpinning actions and interactions that support the triggering of health care partnerships between patients and GPNs, and tailoring care to meet each patient’s unique needs. The effectiveness of this model is contingent on the general practice context in which it operates. Examination of characteristics that support broad scopes of nursing practice coupled with high levels of autonomy facilitated an understanding of ‘enabling’ and ‘less-enabling’ general practices. CONCLUSION: This integrated model of patient satisfaction and enablement is a practical tool to inform education and training for GPNs and other clinicians, particularly in relation to the management of patients with chronic and long-term conditions. This evidence provides impetus to deepen our insight into general practice models of care that facilitate enhanced nursing scope of practice and autonomy, continuity of care and adequate time for nursing consultations. Integral to patient-centred care, these interprofessional models are the key to optimising GPN roles and the associated quality patient outcomes

Social value of maintaining baby-friendly hospital initiative accreditation in Australia: case study

Background: Breastfeeding has positive impacts on the health, environment, and economic wealth of families and countries. The World Health Organization (WHO) launched the Baby Friendly Hospital Initiative (BFHI) in 1991 as a global program to incentivize maternity services to implement the Ten Steps to Successful Breastfeeding (Ten Steps). These were developed to ensure that maternity services remove barriers for mothers and families to successfully initiate breastfeeding and to continue breastfeeding through referral to community support after hospital discharge. While more than three in four births in Australia take place in public hospitals, in 2020 only 26% of Australian hospitals were BFHI-accredited. So what is the social return to investing in BFHI accreditation in Australia, and does it incentivize BFHI accreditation? This study aimed to examine the social value of maintaining the BFHI accreditation in one public maternity unit in Australia using the Social Return on Investment (SROI) framework. This novel method was developed in 2000 and measures social, environmental and economic outcomes of change using monetary values. Method: The study was non-experimental and was conducted in the maternity unit of Calvary Public Hospital, Canberra, an Australian BFHI-accredited public hospital with around 1000 births annually. This facility provided an opportunity to illustrate costs for maintaining BFHI accreditation in a relatively affluent urban population. Stakeholders considered within scope of the study were the mother-baby dyad and the maternity facility. We interviewed the hospital’s Director of Maternity Services and the Clinical Midwifery Educator, guided by a structured questionnaire, which examined the cost (financial, time and other resources) and benefits of each of the Ten Steps. Analysis was informed by the Social Return on Investment (SROI) framework, which consists of mapping the stakeholders, identifying and valuing outcomes, establishing impact, calculating the ratio and conducting sensitivity analysis. This information was supplemented with micro costing studies from the literature that measure the benefits of the BFHI. Results: The social return from the BFHI in this facility was calculated to be AU$1,375,050. The total investment required was AU$ 24,433 per year. Therefore, the SROI ratio was approximately AU$55:1 (sensitivity analysis: AU$ 16–112), which meant that every AU$1 invested in maintaining BFHI accreditation by this maternal and newborn care facility generated approximately AU$55 of benefit. Conclusions: Scaled up nationally, the BFHI could provide important benefits to the Australian health system and national economy. In this public hospital, the BFHI produced social value greater than the cost of investment, providing new evidence of its effectiveness and economic gains as a public health intervention. Our findings using a novel tool to calculate the social rate of return, indicate that the BHFI accreditation is an investment in the health and wellbeing of families, communities and the Australian economy, as well as in health equityThis study is funded by Indonesian Endowment Fund for Education (LPDP) and Department of Health Services Research and Policy, Research School of Population Health, Australian National University

Integrating Multiple Inputs Into an Artificial Pancreas System: Narrative Literature Review

Background: Type 1 diabetes (T1D) is a chronic autoimmune disease in which a deficiency in insulin production impairs the glucose homeostasis of the body. Continuous subcutaneous infusion of insulin is a commonly used treatment method. Artificial pancreas systems (APS) use continuous glucose level monitoring and continuous subcutaneous infusion of insulin in a closed-loop mode incorporating a controller (or control algorithm). However, the operation of APS is challenging because of complexities arising during meals, exercise, stress, sleep, illnesses, glucose sensing and insulin action delays, and the cognitive burden. To overcome these challenges, options to augment APS through integration of additional inputs, creating multi-input APS (MAPS), are being investigated. Objective: The aim of this survey is to identify and analyze input data, control architectures, and validation methods of MAPS to better understand the complexities and current state of such systems. This is expected to be valuable in developing improved systems to enhance the quality of life of people with T1D. Methods: A literature survey was conducted using the Scopus, PubMed, and IEEE Xplore databases for the period January 1, 2005, to February 10, 2020. On the basis of the search criteria, 1092 articles were initially shortlisted, of which 11 (1.01%) were selected for an in-depth narrative analysis. In addition, 6 clinical studies associated with the selected studies were also analyzed. Results: Signals such as heart rate, accelerometer readings, energy expenditure, and galvanic skin response captured by wearable devices were the most frequently used additional inputs. The use of invasive (blood or other body fluid analytes) inputs such as lactate and adrenaline were also simulated. These inputs were incorporated to switch the mode of the controller through activity detection, directly incorporated for decision-making and for the development of intermediate modules for the controller. The validation of the MAPS was carried out through the use of simulators based on different physiological models and clinical trials. Conclusions: The integration of additional physiological signals with continuous glucose level monitoring has the potential to optimize glucose control in people with T1D through addressing the identified limitations of APS. Most of the identified additional inputs are related to wearable devices. The rapid growth in wearable technologies can be seen as a key motivator regarding MAPS.</p

Mineralogical and Chemical Characteristics of Some Natural Jarosites

This paper presents a detailed study of the mineralogical, microscopic, thermal, and spectral characteristics of jarosite and natrojarosite minerals. Systematic mineralogic and chemical examination of a suite of 32 natural stoichiometric jarosite and natrojarosite samples from diverse supergene and hydrothermal environments indicates that there is only limited solid solution between Na and K at low temperatures, which suggests the presence of a solvus in the jarosite-natrojarosite system at temperatures below about 140 °C. The samples examined in this study consist of either end members or coexisting end-member pairs of jarosite and natrojarosite. Quantitative electron-probe microanalysis data for several natural hydrothermal samples show only end-member compositions for individual grains or zones, and no detectable alkali-site deficiencies, which indicates that there is no hydronium substitution within the analytical uncertainty of the method. In addition, there is no evidence of Fe deficiencies in the natural hydrothermal samples. Hydronium-bearing jarosite was detected in only one relatively young supergene sample suggesting that terrestrial hydronium-bearing jarosites generally are unstable over geologic timescales. Unit-cell parameters of the 20 natural stoichiometric jarosites and 12 natural stoichiometric natrojarosites examined in this study have distinct and narrow ranges in the a- and c-cell dimensions. There is no overlap of these parameters at the 1r level for the two end-member compositions. Several hydrothermal samples consist of fine-scale (2–10 lm) intimate intergrowths of jarosite and natrojarosite, which could have resulted from solid-state diffusion segregation or growth zoning due to variations in the Na/K activity ratio of hydrothermal solutions