160 research outputs found

    Impact of a standardised rapid response system on clinical outcomes of female patients: an interrupted time series approach

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    Background This study aimed to assess the impact of a standardised rapid response systems (the Between the Flags (BTF)) implemented across New South Wales (NSW), Australia, among female patients. Methods We conducted an interrupted time series (2007-2013) population-based linkage study including 5 114 170 female patient (≥18 years old) admissions in all 232 public hospitals in NSW. We studied changes in levels and trends of patient outcomes after BTF implementation among four age groups of female patients. Results Before the BTF system introduction (2007-2009), for the female patients as a whole, there was a progressive decrease in rates of in-hospital cardiopulmonary arrest (IHCA), IHCA-related mortality and hospital mortality for female patients. However, there were no changes in deaths in low-mortality diagnostic-related groups (DLMDRGs), IHCA survival to discharge and 1-year post-discharge mortality after surviving an IHCA. Only the female patients aged 55 years and older showed the same results as the whole sample. After the BTF programme (2010-2013), the same trends (except for DLMDRG) continued for female patients as a whole and for those aged 55 years or older. There was a significant reduction in DLMDRG among female patients aged 35-54 years (p<0.001), those aged 75 years and over (p<0.05) and female patients as a whole (p<0.05). The decreasing secular trend of surviving an IHCA to hospital discharge before the BTF system (p<0.05) among patients aged 18-34 years old was reversed after the BTF implementation (p<0.01). Conclusions For female patients the BTF programme introduction was associated with continued reductions in the rates of IHCA, IHCA-related mortality and hospital mortality, as well as a new reduction in DLMDRG for 35-54 years old patients and those aged 75 years and older, and increased survival for those aged 18-34 years who had suffered an IHCA

    Acute clinical deterioration and consumer escalation in the hospital setting: a literature review

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    BACKGROUND: Consumer escalation systems that allow patients and/or their family/carers to escalate concerns about clinical deterioration have been proposed as a way of enhancing patient safety. However, evidence to guide implementation or to support system effectiveness remains unclear. AIM: To critically evaluate the current evidence surrounding consumer escalation within the context of clinical deterioration to identify the strengths, weaknesses and gaps in existing knowledge, essential themes, and directions for further investigation. METHOD: Database searches were conducted within Cumulative Index of Nursing and Allied Health Literature, PubMed, and the Cochrane Library for articles directly relating to consumer escalation systems published, in English, within the previous 10 year-period. Titles and abstracts were screened and relevant full-text articles included. Content was examined to identify breadth of knowledge, essential themes, and the effectiveness of current systems. RESULTS: 27 articles, containing a mixture of both quantitative and qualitative findings, were identified. Within the context of limitations in the overall depth and quality of current evidence, four key areas (relating to consumer understanding and awareness of clinical deterioration, confidence and ability to escalate concerns, education, and staff attitudes) were identified as potentially critical to the foundation, functioning, and success of consumer escalation systems. Consumer escalation processes may contribute positive effects beyond mortality rates; however, an agreed method of assessing effectiveness remains undetermined. CONCLUSIONS: The ability of consumer escalation processes to achieve their underlying goals is still to be adequately assessed. Further research is required to inform how to best implement, support and optimise consumer escalation systems.Lisa Thiele, Arthas Flabouris, Campbell Thompso

    The impact of post-operative sepsis on mortality after hospital discharge among elective surgical patients: a population-based cohort study

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    Our aim in the present study was to assess the mortality impact of hospital-acquired post-operative sepsis up to 1 year after hospital discharge among adult non-short-stay elective surgical patients.We conducted a population-based, retrospective cohort study of all elective surgical patients admitted to 82 public acute hospitals between 1 January 2007 and 31 December 2012 in New South Wales, Australia. All adult elective surgical admission patients who stayed in hospital for ≥4 days and survived to discharge after post-operative sepsis were identified using the Admitted Patient Data Collection records linked with the Registry of Births, Deaths, and Marriages. We assessed post-discharge mortality rates at 30 days, 60 days, 90 days and 1 year and compared them with those of patients without post-operative sepsis.We studied 144,503 survivors to discharge. Of these, 1857 (1.3%) had experienced post-operative sepsis. Their post-discharge mortality rates at 30 days, 60 days, 90 days and 1 year were 4.6%, 6.7%, 8.1% and 13.5% (vs 0.7%, 1.2%, 1.5% and 3.8% in the non-sepsis cohort), respectively (P < 0.0001 for all). After adjustment for patient and hospital characteristics, post-operative sepsis remained independently associated with a higher mortality risk (30-day mortality HR 2.75, 95% CI 2.14-3.53; 60-day mortality HR 2.45, 95% CI 1.94-3.10; 90-day mortality HR 2.31, 95% CI 1.85-2.87; 1-year mortality HR 1.71, 95% CI 1.46-2.00). Being older than 75 years of age (HR 3.50, 95% CI 1.56-7.87) and presence of severe/very severe co-morbidities as defined by Charlson co-morbidity index (severe vs normal HR 2.05, 95% CI 1.45-2.89; very severe vs normal HR 2.17, 95% CI 1.49-3.17) were the only other significant independent predictors of increased 1-year mortality.Among elective surgical patients, post-operative sepsis is independently associated with increased post-discharge mortality up to 1 year after hospital discharge. This risk is particularly high in the first month, in older age patients and in the presence of severe/very severe co-morbidities. This high-risk population can be targeted for interventions.Lixin Ou, Jack Chen, Ken Hillman, Arthas Flabouris, Michael Parr, Hassan Assareh and Rinaldo Bellom

    Pengaruh Kompetensi Guru Terhadap Komitmen Profesional Dan Dampaknya Pada Kinerja Serta Kepuasan Kerja Guru Matematika SMP Dan Mts

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    Penelitian ini bertujuan untuk memperoleh model hubungan kausalitas dari variabel-variabel kompetensi, komitmen profesional, kinerja dan kepuasan kerja guru matematika. Populasi dalam penelitian ini adalah seluruh guru matematika SMP dan MTs di Kabupaten Ponorogo yang berjumlah 262 orang. Sampel sejumlah 82 orang ditentukan melalui teknik two stage cluster random sampling. Instrumen penelitian ini adalah kuesioner dan lembar penilaian/observasi. Kuesioner digunakan untuk mengumpulkan data komitmen profesional dan kepuasan kerja guru matematika, sedangkan lembar penilaian/observasi digunakan untuk mengumpulkan data kompetensi dan kinerja guru matematika. Data yang diperoleh dianalisis dengan metode Structural Equation Modeling (SEM).Hasil penelitian menunjukkan bahwa: (1) terdapat pengaruh positif kompetensi terhadap komitmen profesional sebesar 15,9%; (2) terdapat pengaruh positif kompetensi terhadap kinerja sebesar 63,6%; (3) terdapat pengaruh positif komitmen profesional terhadap kinerja sebesar 15,9%; dan (4) terdapat pengaruh positif komitmen profesional terhadap kepuasan kerja sebesar 37,8%. Hasil-hasil penelitian di atas dapat mengkonfirmasi kesimpulan penelitian-penelitian sebelumnya

    Incidences and variations of hospital acquired venous thromboembolism in Australian hospitals: a population-based study.

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    Background: Data on hospital-acquired venous thromboembolism (HA-VTE) incidence, case fatality rate and variation amongst patient groups and health providers is lacking. We aim to explore HA-VTE incidences, associated mortality, trends and variations across all acute hospitals in New South Wales (NSW)-Australia. Methods: A population-based study using all admitted patients (aged 18–90 with a length of stay of at least two days and not transferred to another acute care facility) in 104 NSW acute public and private hospitals during 2002–2009. Poisson mixed models were used to derive adjusted rate ratios (IRR) in presence of patient and hospital characteristics. Results: Amongst, 3,331,677 patients, the incidence of HA-VTE was 11.45 per 1000 patients and one in ten who developed HA-VTE died in hospital. HA-VTE incidence, initially rose, but subsequently declined, whereas case fatality rate consistently declined by 22 % over the study period. Surgical patients were 128 % (IRR = 2.28, 95 % CI: 2.19–2.38) more likely to develop HA-VTE, but had similar case fatality rates compared to medical patients. Private hospitals, in comparison to public hospitals had a higher incidence of HA-VTE (IRR = 1.76; 95 % CI: 1.42–2.18) for medical patients. However, they had a similar incidence (IRR = 0.91; 95 % CI: 0.75–1.11), but a lower mortality (IRR = 0.59; 95 % CI: 0.47–0.75) amongst surgical patients. Smaller public hospitals had a lower HA-VTE incidence rate compared to larger hospitals (IRR 1.71). Hospitals with a lower reported HA-VTE incidence tended to have a higher HA-VTE case fatality rate. Conclusion: Despite the decline in HA-VTE incidence and case fatality, there were large variations in incidents between medical and surgical patients, public and private hospitals, and different hospital groups. The causes of such differences warrant further investigation and may provide potential for targeted interventions and quality improvement initiatives.Hassan Assareh, Jack Chen, Lixin Ou, Ken Hillman and Arthas Flabouri

    Gastric emptying, postprandial blood pressure, glycaemia and splanchnic flow in Parkinson's disease

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    Aim: To determine gastric emptying, blood pressure, mesenteric artery blood flow, and blood glucose responses to oral glucose in Parkinson's disease. methods: Twenty-one subjects (13 M, 8 F; age 64.2 ± 1.6 years) with mild to moderate Parkinson's disease (Hoehn and Yahr score 1.4 ± 0.1, duration of known disease 6.3 ± 0.9 years) consumed a 75 g glucose drink, labelled with 20 MBq (99m)Tc-calcium phytate. Gastric emptying was quantified with scintigraphy, blood pressure and heart rate with an automated device, superior mesenteric artery blood flow by Doppler ultrasonography and blood glucose by glucometer for 180 min. Autonomic nerve function was evaluated with cardiovascular reflex tests and upper gastrointestinal symptoms by questionnaire. Results: The mean gastric half-emptying time was 106 ± 9.1 min, gastric emptying was abnormally delayed in 3 subjects (14%). Systolic and diastolic blood pressure fell (P < 0.001) and mesenteric blood flow and blood glucose (P < 0.001 for both) increased, following the drink. Three subjects (14%) had definite autonomic neuropathy and 8 (38%) had postprandial hypotension. There were no significant relationships between changes in blood pressure, heart rate or mesenteric artery blood flow with gastric emptying. Gastric emptying was related to the score for autonomic nerve function (R = 0.55, P < 0.01). There was an inverse relationship between the blood glucose at t = 30 min (R = -0.52, P < 0.05), while the blood glucose at t = 180 min was related directly (R = 0.49, P < 0.05), with gastric emptying. Conclusion: In mild to moderate Parkinson's disease, gastric emptying is related to autonomic dysfunction and a determinant of the glycaemic response to oral glucose.Laurence G Trahair, Thomas E Kimber, Katerina Flabouris, Michael Horowitz, Karen L Jone

    Trends and variations in the rates of hospital complications, failure-to-rescue and 30-day mortality in surgical patients in New South Wales, Australia, 2002-2009

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    BACKGROUND: Despite the increased acceptance of failure-to-rescue (FTR) as an important patient safety indicator (defined as the percentage of deaths among surgical patients with treatable complications), there has not been any large epidemiological study reporting FTR in an Australian setting nor any evaluation on its suitability as a performance indicator. METHODS: We conducted a population-based study on elective surgical patients from 82 public acute hospitals in New South Wales, Australia between 2002 and 2009, exploring the trends and variations in rates of hospital complications, FTR and 30-day mortality. We used Poisson regression models to derive relative risk ratios (RRs) after adjusting for a range of patient and hospital characteristics. RESULTS: The average rates of complications, FTR and 30-day mortality were 13.8 per 1000 admissions, 14.1% and 6.1 per 1000 admission, respectively. The rates of complications and 30-day mortality were stable throughout the study period however there was a significant decrease in FTR rate after 2006, coinciding with the establishment of national and state-level peak patient safety agencies. There were marked variations in the three rates within the top 20% of hospitals (best) and bottom 20% of hospitals (worst) for each of the four peer-hospital groups. The group comprising the largest volume hospitals (principal referral/teaching hospitals) had a significantly higher rate of FTR in comparison to the other three groups of smaller-sized peer hospital groups (RR = 0.78, 0.57, and 0.61, respectively). Adjusted rates of complications, FTR and 30-day mortality varied widely for individual surgical procedures between the best and worst quintile hospitals within the principal referral hospital group. CONCLUSIONS: The decrease in FTR rate over the study period appears to be associated with a wide range of patient safety programs. The marked variations in the three rates between- and within- peer hospital groups highlight the potential for further quality improvement intervention opportunities.Lixin Ou, Jack Chen, Hassan Assareh, Stephanie J. Hollis, Ken Hillman, Arthas Flabouri

    Rate of venous thromboembolism among surgical patients in Australian hospitals: a multicentre retrospective cohort study

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    OBJECTIVES: Despite the burden of venous thromboembolism (VTE) among surgical patients on health systems in Australia, data on VTE incidence and its variation within Australia are lacking. We aim to explore VTE and subsequent mortality rates, trends and variations across Australian acute public hospitals. SETTING: A large retrospective cohort study using all elective surgical patients in 82 acute public hospitals during 2002-2009 in New South Wales, Australia. PARTICIPANTS: Patients underwent elective surgery within 2 days of admission, aged between 18 and 90 years, and who were not transferred to another acute care facility; 4 362 624 patients were included. OUTCOME MEASURES: VTE incidents were identified by secondary diagnostic codes. Poisson mixed models were used to derive adjusted incidence rates and rate ratios (IRR). RESULTS: 2/1000 patients developed postoperative VTE. VTE increased by 30% (IRR=1.30, CI 1.19 to 1.42) over the study period. Differences in the VTE rates, trends between hospital peer groups and between hospitals with the highest and those with the lowest rates were significant (between-hospital variation). Smaller hospitals, accommodated in two peer groups, had the lowest overall VTE rates (IRR=0.56:0.33 to 0.95; IRR=0.37:0.23 to 0.61) and exhibited a greater increase (64% and 237% vs 19%) overtime and greater between-hospital variations compared to larger hospitals (IRR=8.64:6.23 to 11.98; IRR=8.92:5.49 to 14.49 vs IRR=3.70:3.32 to 4.12). Mortality among patients with postoperative VTE was 8% and remained stable overtime. No differences in post-VTE death rates and trends were seen between hospital groups; however, larger hospitals exhibited less between-hospital variations (IRR=1.78:1.30 to 2.44) compared to small hospitals (IRR>23). Hospitals performed differently in prevention versus treatment of postoperative VTE. CONCLUSIONS: VTE incidence is increasing and there is large variation between-hospital and within-hospital peer groups suggesting a varied compliance with VTE preventative strategies and the potential for targeted interventions and quality improvement opportunities.Hassan Assareh, Jack Chen, Lixin Ou, Stephanie J Hollis, Kenneth Hillman, Arthas Flabouri

    Geographic variation of Failure-to-Rescue in public acute hospitals in New South Wales, Australia

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    Despite the wide acceptance of Failure-to-Rescue (FTR) as a patient safety indicator (defined as the deaths among surgical patients with treatable complications), no study has explored the geographic variation of FTR in a large health jurisdiction. Our study aimed to explore the spatiotemporal variations of FTR rates across New South Wales (NSW), Australia. We conducted a population-based study using all admitted surgical patients in public acute hospitals during 2002-2009 in NSW, Australia. We developed a spatiotemporal Poisson model using Integrated Nested Laplace Approximation (INLA) methods in a Bayesian framework to obtain area-specific adjusted relative risk. Local Government Area (LGA) was chosen as the areal unit. LGA-aggregated covariates included age, gender, socio-economic and remoteness index scores, distance between patient residential postcode and the treating hospital, and a quadratic time trend. We studied 4,285,494 elective surgical admissions in 82 acute public hospitals over eight years in NSW. Around 14% of patients who developed at least one of the six FTR-related complications (58,590) died during hospitalization. Of 153 LGAs, patients who lived in 31 LGAs, accommodating 48% of NSW patients at risk, were exposed to an excessive adjusted FTR risk (10% to 50%) compared to the state-average. They were mostly located in state's centre and western Sydney. Thirty LGAs with a lower adjusted FTR risk (10% to 30%), accommodating 8% of patients at risk, were mostly found in the southern parts of NSW and Sydney east and south. There were significant spatiotemporal variations of FTR rates across NSW over an eight-year span. Areas identified with significantly high and low FTR risks provide potential opportunities for policy-makers, clinicians and researchers to learn from the success or failure of adopting the best care for surgical patients and build a self-learning organisation and health system.Hassan Assareh, Lixin Ou, Jack Chen, Kenneth Hillman, Arthas Flabouris, Stephanie J. Holli

    The Medical Emergency Team: 12 month analysis of reasons for activation, immediate outcome and not-for-resuscitation orders

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    Abstract Objecti6e: To describe the reasons for, and immediate outcome following Medical Emergency Team (MET) activation. Methods: Retrospective analysis of MET calls in 1998. Results: There were 713 MET calls to 559 in-patients. Of the 559 patients 252 (45%) were admitted to ICU and 49 (6.9%) died during the MET response. The three commonest criteria for calling the MET were a fall in GCS \2 (n=155); a systolic blood pressure B 90 mmHg (n= 142) and a respiratory rate \ 35 (n= 109). Cardiac arrests accounted for 61 calls and had an immediate mortality of 59%. The most common MET criterion associated with admission to ICU was a respiratory rate \35. Of patients who received MET calls based only on the &apos;worried&apos; criterion 16% were admitted to ICU. The MET felt that a not-for-resuscitation order would have been appropriate in 130 cases (23%). NFR orders were documented during 27 of the MET calls. Conclusions: The MET system provides objective and subjective criteria by which medical and nursing staff can identify patients who become acutely unwell. A high proportion of these patients will require admission to Intensive Care. The MET system also provides the opportunity to identify patients for whom an NFR order should be considered. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Resumo Objecti6o: Descrever as razõ es para a activação de uma Equipa de Emergência Médica (EEM). Métodos: Análise retrospectiva das chamadas da EEM em 1998. Resultados: Houve 713 chamadas para 599 doentes internados. Dos 599 pacientes, 252 (45%) foram admitidos na UCI (Unidade de Cuidados Intensivos) e 49 (6.9%) morreram durante a resposta da EEM. Os três motivos mais comuns para activar a EEM foram diminuição na ECG (Escala de Coma de Glasgow) \ 2 (n= 155); pressão arterial sistó lica B 90 mmHg (n=142) e frequência respirató ria \ 35 (n =109). 61 das chamadas foram por paragem cardíaca e tiveram uma mortalidade imediata de 59%. O critério que mais vezes se associou a internamento na UCI foi uma frequência respirató ria \35. Quando as chamadas da EEM foram ditadas apenas nos critérios de &apos;preocupação&apos; só 16% dos doentes foram admitidos na UCI. A EEM sentiu que a Ordem de Não Reanimar (DNR) teria sido apropriada em 130 casos (22%). Existiam ordens DNR foram documentadas em 27 das chamadas da EEM. Conclusão: O sistema EEM define critérios objectivos e subjectivos através dos quais a equipa médica e de enfermagem podem identificar doentes agudizados. Uma proporção elevada destes doentes requerer admissão em Cuidados Intensivos. O sistema da EEM permite identificar doentes para quem a ordem DNR deve ser considerada
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