Palliative care professional education via video conference builds confidence to deliver palliative care in rural and remote locations

BACKGROUND: People living in rural and remote locations are disadvantaged in accessing palliative care. This can be attributed to several factors including the role diversity and the low numbers of patients with specific conditions, as well as the difficulties rural health practitioners have in accessing opportunities for professional education. A program of multidisciplinary palliative care video conferences was presented to health practitioners across part of northern Australia in an effort to address this problem. METHOD: The educational content of the video conferences was developed from participant responses to an educational needs assessment. Following cycles of four consecutive video conferences, 101 participants completed evaluative on-line surveys. The quantitative data were analysed using frequencies and analysis of variance tests with post-hoc analyses where appropriate, and an accessibility and remoteness index was used to classify their practice location. RESULTS: All participants found the content useful regardless of their remoteness from the tertiary centre, their years of experience caring for palliative care patients or the number of patients cared for each year. However, change in confidence to provide palliative care as a result of attending the video conferences was significant across all disciplines, regardless of location. Doctors, medical students and allied health professionals indicated the greatest change in confidence. CONCLUSIONS: The provision of professional education about palliative care issues via multidisciplinary video conferencing increased confidence among rural health practitioners, by meeting their identified need for topic and context specific education. This technology also enhanced the networking opportunities between practitioners, providing an avenue of ongoing professional support necessary for maintaining the health workforce in rural and remote areas. However, more attention should be directed to the diverse educational needs of allied health professionals

Compliance and surgical team perceptions of WHO Surgical Safety Checklist: systematic review

This systematic review aimed to assess surgical safety checklist compliance and evaluate surgical team perceptions and attitudes, post-checklist implementation in the operating room. The World Health Organization (WHO) surgical safety checklist (SSC) has decreased complications and mortality. However, it is unclear whether this reduction is influenced by the vicarious enhancement in teamwork, communication, and staff awareness established by SSC implementation. The preferred reporting items for systematic reviews and meta-analyses model of review guided a search across MEDLINE, PubMed, and Embase databases. English-language studies using any adapted form of the WHO-SSC in operating rooms were reviewed by abstract and full text. Twenty-six studies, 13 assessing SSC compliance and 13 investigating surgical team perceptions of SSC, were evaluated. Compliance studies showed a checklist initiation rate of >90%, but actual observed completion rate varied widely across studies. Sign out was the most poorly performed phase of the checklist (90%) of compliance across studies, but "verification of team-members'' was significantly less compliant. Studies assessing surgical team perceptions found that SSC improved participants' perception of teamwork, communication, patient safety, and staff awareness of adverse events. However, when stakeholders placed differing degrees of importance on SSC completion, results indicated the SSC might actually antagonize team relationships. SSC compliance varies significantly across studies, being highly dependent on staff perceptions, training, and effective leadership. Surgical teams have positive perceptions of SSC; thus with effective implementation strategies, compliance rates across all phases can be substantially improved

What do beginning students, in a rurally focused medical course, think about rural practice?

Background: Medical schools may select students for their attitudes towards rural medical practice, yet the rural–urban disparity in availability of medical practitioners and services has not diminished in recent times despite government initiatives and increasing numbers being trained for a career in medicine. One medical school, with a focus on rural and remote medicine, aims to select students with positive perceptions for rural medical practice. A research project collected data on the perceptions of these medical students in the first week of their medical studies. Methods: Students completed a low stakes essay on the life and work of a rural doctor. Initially, this formed part of a literacy assessment to determine any students requiring remediation. All students were asked if they would consent to their essay being reviewed for a research project. Data was obtained from those students who consented and handed their essays in for review. The 103 student essays underwent thematic analysis and sentences were coded into three main themes of rural lifestyle, doctor role and rural practice. Second level themes were further elicited and results were quantified according to whether they were positive or negative. Positive themes included rural lifestyle, doctor role, views of doctor, impact on community, broader work and skills knowledge, and better relationships with community and patients. Negative themes included doctor's health, pressure on doctor, family problems, greater workload, privacy and confidentiality issues, cultural issues, isolation, limited resources and financial impacts. Quantitisation of this data was used to transform essay sentences into a numerical form which allowed statistical analysis and comparison of perceptions using Z tests. Results: No significant differences on the number of positive and negative responses for rural lifestyle and rural practice were found. The rural doctor role had a significantly more positive than negative views. Significant differences were found for positive views of the rural doctor role and negative views of rural practice. Participants from a capital city background reported a significantly higher percentage of responses related to negative views of rural practice than their regional and rural counterparts. Students from capital city areas had significantly more negative views about the rural doctor role, especially related to workload, limited resources and isolation than students from rural and regional areas. Conclusion: Students entering medical school already have both positive and negative views about the life and work of a rural doctor. Those students from capital city areas have significantly more negative views despite being selected to enter a medical course with a rural focus based on their expressed rural perceptions. Further work is required to refine selection criteria and the year level experiences and learning opportunities which may positively influence student perceptions about rural medical practice to overcome early negative perceptions at the beginning of medical school

The Refugee Co-Location Model may be useful in addressing refugee barriers to care. What do refugees think?

Co-location of services for refugees may be beneficial in addressing barriers to care. This model of care involves support for a specialist refugee nurse service with general practice, as well as developing partnerships with settlement support agencies and Primary Health Networks. We consider published literature on refugee perceptions of co-location, different models of care, upcoming research and priorities in the area

Perspectives of time: a qualitative study of the experiences of parents of critically ill newborns in the neonatal nursery in North Queensland interviewed several years after the admission

Design: A qualitative study informed by grounded theory principles to explore the experiences of parents who had extremely preterm or babies with antenatally diagnosed life-Threatening diagnoses who were cared for in a regional tertiary neonatal unit. The study was conducted when the child was old enough to be diagnosed with long-Term neurodevelopmental or medical sequelae. Setting: North Queensland is a large area in Eastern Australia of 500 000 km 2, which is served by one tertiary neonatal unit. Participants: Seventeen families representing 21 extremely preterm babies and one baby with congenital malformations who was not expected to survive prior to delivery (but did) were interviewed using grounded theory principles. Interviews were coded and themes derived. Results: Parents who recollect their neonatal experiences from 3 to 7 years after the baby was cared for in the neonatal intensive care described negative themes of grief and loss, guilt and disempowerment. Positive enhancers of care included parental strengths, religion and culture, family supports and neonatal unit practices. Novel findings included that prior pregnancy loss and infertility formed part of the narrative for parents, and hope was engendered by religion for parents who did not usually have a religious faith. Conclusions: An understanding of both the negative aspects of neonatal care and the positive enhancers is necessary to improve the neonatal experience for parents. Parents are able to contextualise their previous neonatal experiences within both the long-Term outcome for the child and their own life history

Use of telehealth in the management of non/critical emergencies in rural or remote emergency departments: a systematic review

Background: Telehealth has been used extensively in Emergency Departments to improve healthcare provision. However, its impact on the management of non-critical emergency presentations within rural and remote ED settings has not been adequately explored. The objective of this systematic review is to identify how telehealth has been used to assist in the management of non-critical presentations in rural and remote emergency departments and the outcomes. Methods: Articles were identified through database searches of CINAHL, Cochrane, MEDLINE(OVID), Informit and SCOPUS, as well as screening of relevant article reference and citation lists. To determine how telehealth can assist in the management of non-critical emergencies. Information was extracted relating to telehealth program model, the scope of service and participating health professionals. The outcomes of telehealth programs were determined by analysing the uptake and usage of telehealth, the impact on altering diagnosis or management plan as well as patient disposition including patient transfer, discharge, local hospital admission and rates of discharge against medical advice. Results: Of the 2532 identified records, fifteen were found to match the eligibility criteria and were included in the review. Uptake and usage increased for telehealth programs predominantly utilised by nursing staff with limited local medical support. Tele-consultation conservatively altered patient diagnosis or management in 18-66% of consultations. Although teleconsultation was associated with increased patient transfer rates, unnecessary transfers were reduced. Simultaneously, an increase in local hospital admission was noted and less patients were discharged home. Discharge against medical advice rates were low at 0.92-1.1%. Conclusion: The most widely implemented hub-and-spoke telehealth model could be incorporated into existing referral frameworks. Telehealth programs may assist in reducing unnecessary patient transfer and secondary overtriage, while increasing the capacity of ED staff to diagnose and manage patients locally, which may translate into increased local hospital admission and reduced discharge rates following teleconsultation

The efficacy of oral azithromycin in clearing ocular chlamydia: mathematical modeling from a community-randomized trachoma trial.

Mass oral azithromycin distributions have dramatically reduced the prevalence of the ocular strains of chlamydia that cause trachoma. Assessing efficacy of the antibiotic in an individual is important in planning trachoma elimination. However, the efficacy is difficult to estimate, because post-treatment laboratory testing may be complicated by nonviable organisms or reinfection. Here, we monitored ocular chlamydial infection twice a year in pre-school children in 32 communities as part of a cluster-randomized clinical trial in Tanzania (prevalence in children was lowered from 22.0% to 4.7% after 3-year of annual treatment). We used a mathematical transmission model to estimate the prevalence of infection immediately after treatment, and found the effective field efficacy of antibiotic in an individual to be 67.6% (95% CI: 56.5-75.1%) in this setting. Sensitivity analyses suggested that these results were not dependent on specific assumptions about the duration of infection. We found no evidence of decreased efficacy during the course of the trial. We estimated an 89% chance of elimination after 10 years of annual treatment with 95% coverage

A comprehensive systematic review of stakeholder attitudes to alternatives to prospective informed consent in paediatric acute care research

Background: A challenge of performing research in the paediatric emergency and acute care setting is obtaining valid prospective informed consent from parents. The ethical issues are complex, and it is important to consider the perspective of participants, health care workers and researchers on research without prospective informed consent while planning this type of research. Methods: We performed a systematic review according to PRISMA guidelines, of empirical evidence relating to the process, experiences and acceptability of alternatives to prospective informed consent, in the paediatric emergency or acute care setting. Major medical databases and grey sources were searched and results were screened and assessed against eligibility criteria by 2 authors, and full text articles of relevant studies obtained. Data were extracted onto data collection forms and imported into data management software for analysis. Results: Thirteen studies were included in the review consisting of nine full text articles and four abstracts. Given the heterogeneity of the methods, results could not be quantitatively combined for meta-analysis, and qualitative results are presented in narrative form, according to themes identified from the data. Major themes include capacity of parents to provide informed consent, feasibility of informed consent, support for alternatives to informed consent, process issues, modified consent process, child death, and community consultation. Conclusion: Our review demonstrated that children, their families, and health care staff recognise the requirement for research without prior consent, and are generally supportive of enrolling children in such research with the provisions of limiting risk, and informing parents as soon as possible. Australian data and perspectives of children are lacking and represent important knowledge gaps

Adaptive Wolf Management: The Regulated Public Harvest Component

Montana’s wolf (Canis lupus) conservation and management plan is based on adaptive management principles and includes regulated public harvest as a population management tool. The need and opportunity to implement public harvest in 2008, 2009, and 2010 required Montana Fish, Wildlife and Parks (FWP) to develop a stepped down adaptive management framework specific to harvest. For 2008 and 2009, FWP set modest objectives: implement a harvest, maintain a recovered population, and begin the learning process to inform development of future hunting regulations and quotas. In 2010, FWP used a formal Structured Decision Making Process to more clearly define priorities and challenges of setting a wolf season, outline objectives of a successful season, and evaluate consequences and trade-offs between alternative management actions. For all years, FWP used a modeling process to simulate a wide range of harvest rates across three harvest units and to predict harvest effects on the minimum number of wolves, packs and breeding pairs. Model inputs were derived from minimum wolf numbers observed in the field. Modeling allowed consideration of a range of harvest quotas, predicted outcomes, and risk that harvest could drive the population below federally-required minimums. It also facilitated explicit consideration of how well a particular quota achieved objectives and how to adapt future regulations and quotas. Legal challenges to federal delisting restricted implementation of the first fair chase hunting season to 2009. Montana’s wolf population is securely recovered, despite the dynamic political and legal environments. Regardless, FWP remains committed to a scientific, data-driven approach to adaptive management