Falling in Acute Mental Health Settings for Older People : Who falls, where, when and why?

Copyright: © 2014 Dickinson A et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Falls, slips and trips are a major patient safety concern in hospital settings accounting for 26 per cent of all reported patient safety incidents in England. Mental health conditions and their treatments add further to fall risk but we have little information regarding who falls, where and when within mental health settings. Methods: This paper presents an overview of the pattern of falls by older patients within an in-patient mental health setting in the South of England using routine records completed by staff when a fall occurs. 920 fall reports over three years were analysed, and 7 focus groups were undertaken with ward staff to explore how staff understood falls and their experiences of using the falls reporting system. Results: In terms of diagnosis 40% of fallers had a primary functional diagnosis, 46% an organic mental health diagnosis (14% non-specific diagnosis), average age was 81.7 years (range 59 to 99 years; SD 8.3) and 57% were female. Approximately one quarter, 27%, of falls were observed by staff. Falls were not evenly distributed across either day of week or time of day, with peak times for falls on Tuesday and Saturday and morning (7-8 and 9-10am) and subsidiary peaks between noon and 1pm and early evening (5-6pm). Almost half of falls occurred in private spaces in the ward such as bedrooms, and 42% in public spaces such as sitting rooms. However 60% of falls in public spaces were unseen. Reporting in these settings was problematic for staff and patients were sometimes described as placing themselves on the floor as a consequence of their mental health condition. The average time to first fall was 5 weeks. Conclusions: Routine mapping of falls could be undertaken at ward and organization level and contribute to better understanding of the local factors contributing to falls. Exploring incident report data in focus groups with staff helped us and them to interpret the data and to understand some of the decision making staff engage in everyday when reporting falls.Peer reviewedFinal Published versio

Teenage partner violence: young people’s views on awareness, prevention, intervention and regaining one’s sense of wellbeing

Violence and abuse between partners in teenage intimate relationships has been increasingly recognised as a prevalent but hidden issue that can impact negatively on wellbeing and future life chances. Whilst most existing research has focused on the prevalence, impact and risk factors for teenage partner violence (TPV), or on the evaluation of prevention education programmes, the current study sought to gain young people’s own views on what they thought could be helpful with regard to awareness, prevention, intervention and regaining a sense of wellbeing following the experience of an unhealthy relationship. Data were gathered through questionnaires and semi-structured interviews. Participants included 310 mainstream school pupils aged 14-18, including 161 girls and 149 boys, and 4 women from a domestic violence prevention organization. A thematic analysis of the findings resulted in four over-arching themes that encompassed several sub-themes. Participants felt there needed to be increased awareness and understanding of TPV amongst adults and YP themselves; there should be greater access to relevant, regular and interactive education and information; there should be opportunities to talk to someone; and there should be opportunities and support to build self-esteem. The findings have implications for the approach taken towards TPV in schools and it is suggested that educational psychologists may be well placed to share relevant information with teachers, YP and parents

The economic burden of inpatient paediatric care in Kenya: household and provider costs for treatment of pneumonia, malaria and meningitis

<p>Abstract</p> <p>Background</p> <p>Knowledge of treatment cost is essential in assessing cost effectiveness in healthcare. Evidence of the potential impact of implementing available interventions against childhood illnesses in developing countries challenges us to define the costs of treating these diseases. The purpose of this study is to describe the total costs associated with treatment of pneumonia, malaria and meningitis in children less than five years in seven Kenyan hospitals.</p> <p>Methods</p> <p>Patient resource use data were obtained from largely prospective evaluation of medical records and household expenditure during illness was collected from interviews with caretakers. The estimates for costs per bed day were based on published data. A sensitivity analysis was conducted using WHO-CHOICE values for costs per bed day.</p> <p>Results</p> <p>Treatment costs for 572 children (pneumonia = 205, malaria = 211, meningitis = 102 and mixed diagnoses = 54) and household expenditure for 390 households were analysed. From the provider perspective the mean cost per admission at the national hospital was US $95.58 for malaria, US$177.14 for pneumonia and US $284.64 for meningitis. In the public regional or district hospitals the mean cost per child treated ranged from US$47.19 to US $81.84 for malaria and US$54.06 to US $99.26 for pneumonia. The corresponding treatment costs in the mission hospitals were between US$43.23 to US $88.18 for malaria and US$ 43.36 to US $142.22 for pneumonia. Meningitis was treated for US$ 189.41 at the regional hospital and US $ 201.59 at one mission hospital. The total treatment cost estimates were sensitive to changes in the source of bed day costs. The median treatment related household payments within quintiles defined by total household expenditure differed by type of facility visited. Public hospitals recovered up to 40% of provider costs through user charges while mission facilities recovered 44% to 100% of costs.</p> <p>Conclusion</p> <p>Treatments cost for inpatient malaria, pneumonia and meningitis vary by facility type, with mission and tertiary referral facilities being more expensive compared to primary referral. Households of sick children contribute significantly towards provider cost through payment of user fees. These findings could be used in cost effectiveness analysis of health interventions.</p

Why do patients decline surgical trials? Findings from a qualitative interview study embedded in the Cancer Research UK BOLERO trial (Bladder cancer: Open versus Lapararoscopic or RObotic cystectomy)

Background Surgical trials have typically experienced recruitment difficulties when compared with other types of oncology trials. Qualitative studies have an important role to play in exploring reasons for low recruitment, although to date few such studies have been carried out that are embedded in surgical trials. The BOLERO trial (Bladder cancer: Open versus Lapararoscopic or RObotic cystectomy) is a study to determine the feasibility of randomisation to open versus laparoscopic access/robotic cystectomy in patients with bladder cancer. We describe the results of a qualitative study embedded within the clinical trial that explored why patients decline randomisation. Methods Ten semi-structured interviews with patients who declined randomisation to the clinical trial, and two interviews with recruiting research nurses were conducted. Data were analysed for key themes. Results The majority of patients declined the trial because they had preferences for a particular treatment arm, and in usual practice could choose which surgical method they would be given. In most cases the robotic option was preferred. Patients described an intuitive ‘sense’ that favoured the new technology and had carried out their own inquiries, including Internet research and talking with previous patients and friends and family with medical backgrounds. Medical histories and lifestyle considerations also shaped these personalised choices. Of importance too, however, were the messages patients perceived from their clinical encounters. Whilst some patients felt their surgeon favoured the robotic option, others interpreted ‘indirect’ cues such as the ‘established’ reputation of the surgeon and surgical method and comments made during clinical assessments. Many patients expressed a wish for greater direction from their surgeon when making these decisions. Conclusion For trials where the ‘new technology’ is available to patients, there will likely be difficulties with recruitment. Greater attention could be paid to how messages about treatment options and the trial are conveyed across the whole clinical setting. However, if it is too difficult to challenge such messages, then questions should be asked about whether genuine and convincing equipoise can be presented and perceived in such trials. This calls for consideration of whether alternative methods of generating evidence could be used when evaluating surgical techniques which are established and routinely available

Chlamydia infection status, genotype, and age-related macular degeneration

PURPOSE: To evaluate whether Chlamydia (C.) infections are associated with age-related macular degeneration (AMD) and to assess if this association is influenced by the complement factor H (CFH) Y402H or the high temperature requirement A serine peptidase 1 (HTRA1) rs11200638 risk genotypes.METHODS: One hundred ninety-nine AMD patients with early and late forms of the disease and 100 unaffected controls, at least 50 years old were included in the study. Patients in the AMD and control groups were selected based on known CFH Y402H variant genotype status (one third homozygous CC, one third heterozygous CT, and one third wild-type TT). Plasma from all patients and controls was tested for C. pneumoniae, C. trachomatis, and C. psittaci IgG seropositivity using a micro-immunofluorescent assay to establish previous infection status. Assays were conducted blind to risk genotypes and the results analyzed using univariate and multivariate (logistic regression) analysis.RESULTS:IgG seropositivity to C. pneumoniae was most prevalent (69.2%, n=207), followed by C. trachomatis (7.4%, n=22) and C. psittaci (3.3%, n=10). No association was found between each of the three Chlamydia species IgG seropositivity and AMD status or severity (early/late). There was also no significant association between Chlamydia species IgG seropositivity and AMD status or severity, in patients carrying at least one CFH Y402H risk allele (C) or HTRA1 rs11200638 risk allele (A), with univariate or logistic regression analysis. CONCLUSIONS:Chlamydia infection status does not appear to be associated with AMD status or severity. The presence of CFH Y402H and HTRA1 rs11200638 risk genotypes does not alter this negative association

Issues affecting therapist workforce and service delivery in the disability sector in rural and remote New South Wales, Australia: perspectives of policymakers, managers and senior therapists

Introduction: The disability sector encompasses a broad range of conditions and needs, including children and adults with intellectual and developmental disabilities, people with acquired disabilities, and irreversible physical injuries. Allied health professionals (therapists), in the disability sector, work within government and funded or charitable non-government agencies, schools, communities, and private practice. This article reports the findings of a qualitative study of therapist workforce and service delivery in the disability sector in rural and remote New South Wales (NSW), Australia. The aim was to investigate issues of importance to policy-makers, managers and therapists providing services to people with disabilities in rural and remote areas. Methods: The project gathered information via semi-structured interviews with individuals and small groups. Head office and regional office policy-makers, along with managers and senior therapists in western NSW were invited to participate. Participants included 12 policy-makers, 28 managers and 10 senior therapists from NSW government agencies and non-government organisations (NGOs) involved in providing services and support to people with disabilities in the region. Information was synthesised prior to using constant comparative analysis within and across data sets to identify issues.Results: Five broad themes resonated across participants’ roles, locations and service settings: (1) challenges to implementing policy in rural and remote NSW; (2) the impact of geographic distribution of workforce and clients; (3) workforce issues - recruitment, support, workloads, retention; (4) equity and access issues for rural clients; and (5) the important role of the NGO sector in rural service delivery and support. Conclusions: Although commitment to providing best practice services was universal, policy-related information transfer between organisations and employees was inconsistent. Participants raised some workforce and service delivery issues that are similar to those reported in the rural health literature but rarely in the context of allied health and disability services. Relatively recent innovations such as therapy assistants, information technology, and trans-disciplinary approaches, were raised as important service delivery considerations within the region. These and other innovations were expected to extend the coverage provided by therapists. Nongovernment organisations played a significant role in service delivery and support in the region. Participants recognised the need for therapists working for different organisations, in rural areas, to collaborate both in terms of peer support and service delivery to clients

‘Subjects and Objects: Material Expressions of Love and Loyalty in Seventeenth-Century England’, in special section on ‘Loyalties and Allegiances in Early Modern England’ in Journal of British Studies Vol. 48: 4 (October, 2009)

This article investigates how and where the emotive relations between subject and state were forged and how these ideas were manifested in early modern England. McShane describes an affective economy of loyalty, embodied in cheap and accessible political commodities: decorated objects made of clay, metals, and paper, on which precious household resources of time, money and emotion were spent. She argues that by engendering, inculcating and insinuating codes of political love into people’s ‘emotional, sensual, representational, and communicative’ lives, ‘loyal’ goods acted as vehicles and texts for what Victoria Kahn describes as ‘the supplementary role of the passions’ in ‘forging political obligation’ and the reformulation of ‘the duty to love’ of both subject and king in 17th-century England. McShane’s research contributes to a growing theme in scholarship, namely the active consumption of politically significant goods. This essay extends the range of objects under examination to include quotidian household items, shedding light on the dissemination and construction of early modern loyalty across a much wider social scale. The research draws on an extensive survey of collections held at the V&A, the Museum of London, Ashmolean Museum, Fitzwilliam Museum and Burrell Collection. Importantly, by putting illustrated print products back together with other political commodities in the early modern home, creating a broad archive of objects and text-objects where each informs the other, McShane’s approach challenges the typical social historical methodology, which uses material culture as merely illustrative of textual sources. This article was part of a special section on loyalty and allegiance in early modern England, co-edited by McShane with Dr Ted Vallance for one of the leading scholarly journals in the field. The material was drawn from a workshop on the topic held at the University of Liverpool funded by the British Academy, University of Liverpool and the Scouloudi Foundation (2007)

The need for new models for delivery of therapy intervention to people with a disability in rural and remote areas of Australia

Early therapy intervention by occupational therapists, physiotherapists, and speech pathologists (therapists) is recognised to yield benefits across the lifecourse (Carpenter, 2007; Law, 2002; Thomaidis, Kaderoglou, Stefou, Damianou, & Bakoula, 2000; Ziviani, Feeney, Rodger, & Watter, 2010). As a result,there have recently been increases in funding for therapy positions in disability services in New South Wales(NSW), Australia (New South Wales Government, 2006). However, research by Keane, Smith, Lincoln,and Fisher (2011), Chisholm, Russell, and Humphreys (2011), and Denham and Shaddock (2004) indicated that there is a shortage of therapists living and working in rural and remote areas of Australia

Addressing the barriers to accessing therapy services in rural and remote areas

Purpose: Throughout the world, people with a disability who live in rural and remote areas experience difficulty accessing a range of community-based services including speech-, physioand occupational therapy. This paper draws on information gathered from carers and adults with a disability living in a rural area in New South Wales (NSW), Australia to determine the extent to which people living in rural areas may receive a person-centred therapy service. Methods: As part of a larger study in rural NSW into the delivery of therapy services, focus groups and individual interviews were conducted with 78 carers and 10 adults with a disability. Data were analysed using constant comparison and thematic analysis. Results: Three related themes emerged: (i) travelling to access therapy; (ii) waiting a long time to get therapy; and (iii) limited access to therapy past early childhood. The themes overlaid the problems of recruiting and retaining sufficient therapists to work in rural areas. Conclusions: Community-based rehabilitation principles offer possibilities for increasing person-centred therapy services. We propose a person-centred and place-based approach that builds on existing service delivery models in the region and involves four inter-related strategies aimed at reducing travel and waiting times and with applicability across the life course

Integrating evidence into policy and sustainable disability services delivery in western New South Wales, Australia: the ‘wobbly hub and double spokes’ project

Background: Policy that supports rural allied health service delivery is important given the shortage of services outside of Australian metropolitan centres. The shortage of allied health professionals means that rural clinicians work long hours and have little peer or service support. Service delivery to rural and remote communities is further complicated because relatively small numbers of clients are dispersed over large geographic areas. The aim of this five-year multi-stage project is to generate evidence to confirm and develop evidence-based policies and to evaluate their implementation in procedures that allow a regional allied health workforce to more expeditiously respond to disability service need in regional New South Wales, Australia. Methods/Design: The project consists of four inter-related stages that together constitute a full policy cycle. It uses mixed quantitative and qualitative methods, guided by key policy concerns such as: access, complexity, cost, distribution of benefits, timeliness, effectiveness, equity, policy consistency, and community and political acceptability. Stage 1 adopts a policy analysis approach in which existing relevant policies and related documentation will be collected and reviewed. Policy-makers and senior managers within the region and in central offices will be interviewed about issues that influence policy development and implementation. Stage 2 uses a mixed methods approach to collecting information from allied health professionals, clients, and carers. Focus groups and interviews will explore issues related to providing and receiving allied health services. Discrete Choice Experiments will elicit staff and client/carer preferences. Stage 3 synthesises Stage 1 and 2 findings with reference to the key policy issues to develop and implement policies and procedures to establish several innovative regional workforce and service provision projects. Stage 4 uses mixed methods to monitor and evaluate the implementation and impact of new or adapted policies that arise from the preceding stages. Discussion: The project will provide policy makers with research evidence to support consideration of the complex balance between: (i) the equitable allocation of scarce resources; (ii) the intent of current eligibility and prioritisation policies; (iii) workforce constraints (and strengths); and (iv) the most effective, evidence-based clinical practice