Changes in acute hospital costs after employing clinical facilitators to improve stroke care in Victoria, Australia

BackgroundHospital costs for stroke are increasing and variability in care quality creates inefficiencies. In 2007, the Victorian Government (Australia) employed clinical facilitators for three years in eight public hospitals to improve stroke care. Literature on the cost implications of such roles is rare. We report changes in the costs of acute stroke care following implementation of this program.MethodsObservational controlled before-and-after cohort design. Standardised hospital costing data were compared pre-program (financial year 2006-07) and post-program (2010-11) for all admitted episodes of stroke or transient ischaemic attack (TIA) using ICD-10 discharge codes. Costs in Australian dollars (AUD) were adjusted to a common year 2010. Generalised linear regression models were used for adjusted comparisons.ResultsA 20% increase in stroke and TIA episodes was observed: 2624 pre-program (age>75years: 53%) and 3142 post-program (age>75years: 51%); largely explained by more TIA admissions (up from 785 to 1072). Average length of stay reduced by 22% (pre-program 7.3days to post-program 5.7days, pPeer reviewe

Molecular mechanisms of cell death: recommendations of the Nomenclature Committee on Cell Death 2018.

Over the past decade, the Nomenclature Committee on Cell Death (NCCD) has formulated guidelines for the definition and interpretation of cell death from morphological, biochemical, and functional perspectives. Since the field continues to expand and novel mechanisms that orchestrate multiple cell death pathways are unveiled, we propose an updated classification of cell death subroutines focusing on mechanistic and essential (as opposed to correlative and dispensable) aspects of the process. As we provide molecularly oriented definitions of terms including intrinsic apoptosis, extrinsic apoptosis, mitochondrial permeability transition (MPT)-driven necrosis, necroptosis, ferroptosis, pyroptosis, parthanatos, entotic cell death, NETotic cell death, lysosome-dependent cell death, autophagy-dependent cell death, immunogenic cell death, cellular senescence, and mitotic catastrophe, we discuss the utility of neologisms that refer to highly specialized instances of these processes. The mission of the NCCD is to provide a widely accepted nomenclature on cell death in support of the continued development of the field

National survey of management of transient ischaemic attack in Australia: Take Immediate Action

Objective: To understand the current organisation of services for people with transient ischaemic attack (TIA) and the processes of assessment and management across Australian hospitals

Nurse-initiated acute stroke care in emergency departments

Background and Purpose: We aimed to evaluate the effectiveness of an intervention to improve triage, treatment, and transfer for patients with acute stroke admitted to the emergency department (ED). Methods: A pragmatic, blinded, multicenter, parallel group, cluster randomized controlled trial was conducted between July 2013 and September 2016 in 26 Australian EDs with stroke units and tPA (tissue-type plasminogen activator) protocols. Hospitals, stratified by state and tPA volume, were randomized 1:1 to intervention or usual care by an independent statistician. Eligible ED patients had acute stroke \u3c48 hours from symptom onset and were admitted to the stroke unit via ED. Our nurse-initiated T3 intervention targeted (1) Triage to Australasian Triage Scale category 1 or 2; (2) Treatment: tPA eligibility screening and appropriate administration; clinical protocols for managing fever, hyperglycemia, and swallowing; (3) prompt (\u3c4 hours) stroke unit Transfer. It was implemented using (1) workshops to identify barriers and solutions; (2) face-to-face, online, and written education; (3) national and local clinical opinion leaders; and (4) email, telephone, and site visit follow-up. Outcomes were assessed at the patient level. Primary outcome: 90-day death or dependency (modified Rankin Scale score of ≥2); secondary outcomes: functional dependency (Barthel Index ≥95), health status (Short Form [36] Health Survey), and ED quality of care (Australasian Triage Scale; monitoring and management of tPA, fever, hyperglycemia, swallowing; prompt transfer). Intention-to-treat analysis adjusted for preintervention outcomes and ED clustering. Patients, outcome assessors, and statisticians were masked to group allocation. Results: Twenty-six EDs (13 intervention and 13 control) recruited 2242 patients (645 preintervention and 1597 postintervention). There were no statistically significant differences at follow-up for 90-day modified Rankin Scale (intervention: n=400 [53.5%]; control n=266 [48.7%]; P=0.24) or secondary outcomes. Conclusions: This evidence-based, theory-informed implementation trial, previously effective in stroke units, did not change patient outcomes or clinician behavior in the complex ED environment. Implementation trials are warranted to evaluate alternative approaches for improving ED stroke care. Clinical Trial Registration: URL: http://www.anzctr.org.au. Unique identifier: ACTRN1261400093969

Improving acute stroke care in regional hospitals:clinical evaluation of the Victorian Stroke Telemedicine program

OBJECTIVES: To evaluate the impact of the Victorian Stroke Telemedicine (VST) program during its first 12 months on the quality of care provided to patients presenting with suspected stroke to hospitals in regional Victoria. DESIGN: Historical controlled cohort study comparing outcomes during a 12-month control period with those for the initial 12 months of full implementation of the VST program at each hospital. SETTING: 16 hospitals in regional Victoria that participated in the VST program between 1 January 2010 and 30 January 2016. PARTICIPANTS: Adult patients with suspected stroke presenting to the emergency departments of the participating hospitals. MAIN OUTCOME MEASURES: Indicators for key processes of care, including symptom onset-to-arrival, door-to-first medical review, and door-to-CT times; provision and timeliness of provision of thrombolysis to patients with ischaemic stroke. RESULTS: 2887 patients with suspected stroke presented to participating emergency departments during the control period, 3178 during the intervention period; the patient characteristics were similar for both periods. A slightly larger proportion of patients with ischaemic stroke who arrived within 4.5 hours of symptom onset received thrombolysis during the intervention than during the control period (37% v 30%). Door-to-CT scan time (median, 25 min [IQR, 13-49 min] v 34 min [IQR, 18-76 min]) and door-to-needle time for stroke thrombolysis (73 min [IQR, 56-96 min] v 102 min [IQR, 77-128 min]) were shorter during the intervention. The proportions of patients who received thrombolysis and had a symptomatic intracerebral haemorrhage (4% v 16%) or died in hospital (6% v 20%) were smaller during the intervention period. CONCLUSIONS: Telemedicine has provided Victorian regional hospitals access to expert care for emergency department patients with suspected acute stroke. Eligible patients with ischaemic stroke are now receiving stroke thrombolysis more quickly and safely

Nurse-initiated acute stroke care in emergency departments: The triage, treatment, and transfer implementation cluster randomized controlled trial

Background and Purpose-: We aimed to evaluate the effectiveness of an intervention to improve triage, treatment, and transfer for patients with acute stroke admitted to the emergency department (ED). Methods-: A pragmatic, blinded, multicenter, parallel group, cluster randomized controlled trial was conducted between July 2013 and September 2016 in 26 Australian EDs with stroke units and tPA (tissue-type plasminogen activator) protocols. Hospitals, stratified by state and tPA volume, were randomized 1:1 to intervention or usual care by an independent statistician. Eligible ED patients had acute stroke =2); secondary outcomes: functional dependency (Barthel Index >=95), health status (Short Form [36] Health Survey), and ED quality of care (Australasian Triage Scale; monitoring and management of tPA, fever, hyperglycemia, swallowing; prompt transfer). Intention-to-treat analysis adjusted for preintervention outcomes and ED clustering. Patients, outcome assessors, and statisticians were masked to group allocation. Results-: Twenty-six EDs (13 intervention and 13 control) recruited 2242 patients (645 preintervention and 1597 postintervention). There were no statistically significant differences at follow-up for 90-day modified Rankin Scale (intervention: n=400 [53.5%]; control n=266 [48.7%]; P=0.24) or secondary outcomes. Conclusions-: This evidence-based, theory-informed implementation trial, previously effective in stroke units, did not change patient outcomes or clinician behavior in the complex ED environment. Implementation trials are warranted to evaluate alternative approaches for improving ED stroke care

Kohti kulttuuripolkua Tuusulan kunnassa – kulttuuripolun mahdollisuudet menetelmänä lastenkulttuuripalvelujen kohdentamisessa

Opinnäytetyön tavoitteena oli ryhtyä suunnittelemaan Tuusulan kuntaan kulttuuripolkumallia ja tutkia kulttuuripolkua palvelujen kohdentamisen välineenä. Kulttuuripolku ja kulttuuriopetussuunnitelma ovat koulujen ja kulttuurilaitosten sekä koulujen ja kunnallisten kulttuuritoimien välistä yhteistyötä ohjaavia suunnitelmallisesti luokka-asteelta toiselle eteneviä malleja. Työn tilaaja oli Tuusulan kunnan kulttuuripalvelut, jossa kirjoittaja on työskennellyt lastenkulttuurista vastaavana tuottajana vuodesta 2006 lähtien. Yhteistyökumppanina sekä kulttuuripolkujen asiantuntijana kehittämistyössä toimi valtakunnallinen lastenkulttuurikeskusten verkosto Taikalamppu. Työssä kartoitettiin Suomessa jo olemassa olevia kulttuuripolkuja ja kulttuuriopetussuunnitelmia. Menetelminä kartoituksessa käytettiin benchmarkkausta (vertaisarviointi) ja dokumenttianalyysiä. Tietoa kerättiin lisäksi kyselyllä. Näin kerättyä tutkimustietoa käytettiin kehittämisen välineenä Tuusulan kulttuuripalvelujen lastenkulttuuritiimin työpajoissa. Työpajojen, kartoituksen ja kyselyn pohjalta hahmoteltiin askeleet kunnalliselle kulttuuritoimelle kohti kulttuuripolkua. Kartoituksesta ilmeni, että kulttuuripolkujen ja kulttuuriopetussuunnitelmien laatimisessa on kaksi pääsuuntausta. Kyselyssä selvisi, että olennaista kulttuuripolkutyössä on moniammatillinen, kulttuuritoimen ja opetustoimen hallinnonrajat ylittävä yhteistyö. Kyselyssä selvisi myös, että kulttuuripolkutoiminta on useassa kunnassa sidoksissa Taikalamppuresursseihin. Sekä kyselyssä että työpajoissa päädyttiin samaan lopputulokseen: kulttuuripolku menetelmänä palvelujen tuotannossa helpottaa aika- ja raharesurssien ennakointia. Työpajoissa selvisi, että Tuusulan kulttuuripalvelujen eri yksiköissä (kulttuuri, museo ja kirjasto) on jo olemassa useita ”kulttuuripolku-elementtejä” ja lastenkulttuuritiimi on tarpeellinen tiedonkulun reitti Tuusulan lastenkulttuuripalveluiden kehittämisessä. Taikalamppu-verkoston haasteena on saada toimintamallit leviämään myös verkoston ulkopuolisiin kuntiin ja mallintaa kulttuuripolkutoimintaa uudessa hankkeessa, johon tämä tutkimus tuotti pohjatietoa. Sovellusarvo tästä opinnäytetyöstä muille kunnallisille kulttuuritoimille on laaja kartoitus olemassa olevista kulttuuripoluista sekä hahmotelma askeleiksi, kuinka käynnistää kulttuuripolkutyö omassa kunnassa.The aim of the thesis was start to plan the Culture Path program to municipality of Tuusula and to study the method Culture Path as a tool to direct the cultural services equally. Culture path and Cultural Curriculum are models to guide systematically the cooperation between schools and cultural institutions from 1st grade to 9th grade throughout the Finnish comprehensive school. The subscriber of this thesis was the cultural services unit of the municipality of Tuusula, where the Author of this thesis has been working since 2006 as a cultural manager in charge of the children´s culture. The co-operation partner and specialist in the subject was Taikalamppu - Aladdin´s Lamp network. It´s a Finnish network of regional Art Centers for Children and young people. The principal methods used in this thesis were benchmarking, document analysis, survey and workshops. The information found by benchmarking and survey was used in the workshops for the children´s culture team of cultural services unit of Tuusula. The team includes members from the art museum, library and cultural management unit. The results from the workshops, benchmarking and survey helped to describe the steps how to build up the Culture Path in municipal cultural services. The benchmarking showed that there are two main trends to make the Culture Path or cultural curriculum. The survey expressed that it´s essential to make good co-operation between municipal educational administration and municipal cultural administration when designing and implementing the Path. The survey showed also that the Culture Path work in many cities and municipalities is dependent on the Taikalamppu network´s resources. Both the workshops and the survey showed that the Culture Path method helps to foreshadow the needed resources in advance. The workshops showed that there are already many Culture Path elements in museum´s, library´s and cultural management unit´s services in Tuusula and the children´s culture team is necessary. It would be possible to plan a Culture Path with existing budget by targeting the services differently. The general result for the Taikalamppu network was the challenge to spread the good practices to those municipalities which are not part of the network

Nurse-initiated acute stroke care in emergency departments : the triage, treatment, and transfer implementation cluster randomized controlled trial

Background and Purpose-We aimed to evaluate the effectiveness of an intervention to improve triage, treatment, and transfer for patients with acute stroke admitted to the emergency department (ED). Methods-A pragmatic, blinded, multicenter, parallel group, cluster randomized controlled trial was conducted between July 2013 and September 2016 in 26 Australian EDs with stroke units and tPA (tissue-type plasminogen activator) protocols. Hospitals, stratified by state and tPA volume, were randomized 1:1 to intervention or usual care by an independent statistician. Eligible ED patients had acute stroke <48 hours from symptom onset and were admitted to the stroke unit via ED. Our nurse-initiated T3 intervention targeted (1) Triage to Australasian Triage Scale category 1 or 2; (2) Treatment: tPA eligibility screening and appropriate administration; clinical protocols for managing fever, hyperglycemia, and swallowing; (3) prompt (<4 hours) stroke unit Transfer. It was implemented using (1) workshops to identify barriers and solutions; (2) face-to-face, online, and written education; (3) national and local clinical opinion leaders; and (4) email, telephone, and site visit follow-up. Outcomes were assessed at the patient level. Primary outcome: 90-day death or dependency (modified Rankin Scale score of ≥2); secondary outcomes: functional dependency (Barthel Index ≥95), health status (Short Form [36] Health Survey), and ED quality of care (Australasian Triage Scale; monitoring and management of tPA, fever, hyperglycemia, swallowing; prompt transfer). Intention-to-treat analysis adjusted for preintervention outcomes and ED clustering. Patients, outcome assessors, and statisticians were masked to group allocation. Results-Twenty-six EDs (13 intervention and 13 control) recruited 2242 patients (645 preintervention and 1597 postintervention). There were no statistically significant differences at follow-up for 90-day modified Rankin Scale (intervention: n=400 [53.5%]; control n=266 [48.7%]; P=0.24) or secondary outcomes. Conclusions-This evidence-based, theory-informed implementation trial, previously effective in stroke units, did not change patient outcomes or clinician behavior in the complex ED environment. Implementation trials are warranted to evaluate alternative approaches for improving ED stroke care. Clinical Trial Registration-URL: http://www.anzctr.org.au. Unique identifier: ACTRN12614000939695