Systematic review of trends in emergency department attendances : an Australian perspective

Emergency departments (EDs) in many developed countries are experiencing increasing pressure due to rising numbers of patient presentations and emergency admissions. Reported increases range up to 7% annually. Together with limited inpatient bed capacity, this contributes to prolonged lengths of stay in the ED; disrupting timely access to urgent care, posing a threat to patient safety. The aim of this review is to summarise the findings of studies that have investigated the extent of and the reasons for increasing emergency presentations. To do this, a systematic review and synthesis of published and unpublished reports describing trends and underlying drivers associated with the increase in ED presentations in developed countries was conducted. Most published studies provided evidence of increasing ED attendances within developed countries. A series of inter-related factors have been proposed to explain the increase in emergency demand. These include changes in demography and in the organisation and delivery of healthcare services, as well as improved health awareness and community expectations arising from health promotion campaigns. The factors associated with increasing ED presentations are complex and inter-related and include rising community expectations regarding access to emergency care in acute hospitals. A systematic investigation of the demographic, socioeconomic and health-related factors highlighted by this review is recommended. This would facilitate untangling the dynamics of the increase in emergency demand

Integrating Incident Reporting into an Electronic Patient Record System

Developments in information technology offer new opportunities to design electronic patient record systems (EPR) which integrate a broad range of functions such as clinical decision support, order entry, or electronic alerts. It has been recently suggested that EPR could support new applications for disease surveillance and patient safety. We describe the integration of a voluntary incident reporting system into an EPR used in operating theatres, to allow the reporting of accidents and preventable complications. We assessed system's reliability and users' acceptance. During the 4-years observation period (2002-2006), 48,983 interventional procedures were performed. Clinicians documented 85.1% of procedures on the incident reporting form. Agreement between chart review and electronically reported incidents was 80.6%. The integration of an incident reporting system into an EPR is reliable and well supported by health care professional

Implementation fidelity of a nurse-led falls prevention program in acute hospitals during the 6-PACK trial

Background: When tested in a randomized controlled trial (RCT) of 31,411 patients, the nurse-led 6-PACK falls prevention program did not reduce falls. Poor implementation fidelity (i.e., program not implemented as intended) may explain this result. Despite repeated calls for the examination of implementation fidelity as an essential component of evaluating interventions designed to improve the delivery of care, it has been neglected in prior falls prevention studies. This study examined implementation fidelity of the 6-PACK program during a large multi-site RCT. Methods: Based on the 6-PACK implementation framework and intervention description, implementation fidelity was examined by quantifying adherence to program components and organizational support. Adherence indicators were: 1) falls-risk tool completion; and for patients classified as high-risk, provision of 2) a ‘Falls alert’ sign; and 3) at least one additional 6-PACK intervention. Organizational support indicators were: 1) provision of resources (executive sponsorship, site clinical leaders and equipment); 2) implementation activities (modification of patient care plans; training; implementation tailoring; audits, reminders and feedback; and provision of data); and 3) program acceptability. Data were collected from daily bedside observation, medical records, resource utilization diaries and nurse surveys. Results: All seven intervention components were delivered on the 12 intervention wards. Program adherence data were collected from 103,398 observations and medical record audits. The falls-risk tool was completed each day for 75% of patients. Of the 38% of patients classified as high-risk, 79% had a ‘Falls alert’ sign and 63% were provided with at least one additional 6-PACK intervention, as recommended. All hospitals provided the recommended resources and undertook the nine outlined program implementation activities. Most of the nurses surveyed considered program components important for falls prevention. Conclusions: While implementation fidelity was variable across wards, overall it was found to be acceptable during the RCT. Implementation failure is unlikely to be a key factor for the observed lack of program effectiveness in the 6-PACK trial. Trial registration: The 6-PACK cluster RCT is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000332921 (29 March 2011)

THE ROLE OF PROFESSIONAL CONTROL IN THE MANAGEMENT OF COMPLEX ORGANIZATIONS*

The limitations of formal administrative controls in organizations performing complex production tasks have created the need for less obtrusive forms of management control. When formal administrative controls cannot cater to the unpredictability of complex work demands, one strategy is to employ “professionals” who have been trained to cope with these demands and whose behaviour is primarily controlled through social and self-control mechanisms. There is some question, however, as to the effectiveness of this strategy. There is evidence that integrating pmfessionals into bureaucratic organizations creates the potential for a “clash of cultures”. Conflict emerges when salaried professionals engage in behaviour directed towards increasing their own autonomy (or in some cases maintaining it) and management implement control systems designed to control that bebaviour. This paper argues that the degree of conflict experienced will depend on the individual role orientation of the professional and the extent to which management confront professionals with bureaucratic administrative systems which restricf their self-regulatory activities. The study was undertaken in a large public teaching hospital in Australia and the results support the theoretical position taken in the paper

Introduction of C17 side chains in steroids. The use of phosphoryl substituted methyl isocyanides as connective reagents

steroids are an important group of natural products, which play a prominent role in life. In many steroids the basic ring system is equipped with a side chain at C17. subclasses of steroids carry characteristic side chains, which may differ considerably in length and functional groups. ... Zie: Summary

Sustaining Medicare through consumer choice of health funds: lessons from the Netherlands

The current escalation in costs of Australia’s health care system does not appear to be sustainable. Sustainable financing requires direct engagement of consumers — instead of the current political process driven by special interest groups, targeted at gaining a larger share of the federal and state governments’ budgets. Reforms in the Netherlands, directed at achieving universal insurance with consumer choice of health fund, provide valuable lessons for Australia on how to design sustainable financing

Is ‘Crew Resource Management' an Alternative to Procedure-Based Strategies to Improve Patient Safety in Hospitals?

In hospitals, procedure-based strategies can be defined as the systematic use of procedures or series of steps followed in a regular order to complete a task. This definition covers a mix of several different mechanisms aimed at controlling, organizing and standardizing clinical work processes. This chapter analyses mechanisms to show how procedures are implemented to control and standardize healthcare professional's clinical activities and improve patient safety. Crew Resource Management (CRM) is designed to improve the way healthcare professional's think and act during crisis or routine management of patients by improving communication and teamwork. The key concept of CRM is: 'Training crews to reduce "pilot errors" by making better use of the human resources on the flight deck'. This case report shows that CRM-based training programmes developed within the aviation community can be implemented in hospitals and are an effective way to improve teamwork and ultimately quality and safety of care

Sustaining Medicare through consumer choice of health funds: lessons from the Netherlands

• The current escalation in costs of Australia's health care system does not appear to be sustainable. • Sustainable financing requires direct engagement of consumers - instead of the current political process driven by special interest groups, targe