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Original Research Articles Articles

Recognition and response to the clinically deteriorating patient

Background: Early recognition of clinical deterioration has been associated with a lower level of intervention and reduced adverse events. A widely-used approach in Australia is the Medical Emergency Team (MET) system. Research suggests having a multi-faceted approach to patient monitoring such as Modified Early Warning Score (MEWS) improves early review. Aim: To assess MET call initiation and response. Objectives: (1) In adult patients who have a MET call, was the call made immediately after meeting MET criteria? (2) In adult patients who have a MET call, was a MEWS scored > 4 reached prior to the call? Methods: 20 adult patients (> 18 years) that had a MET call made on acute medical or surgical wards at a Western Australian outer metropolitan secondary teaching hospital between 1 January and 30 April 2011 were selected. Records and observations were reviewed to determine whether MET call response was made immediately, and if MEWS were used, whether earlier review may have occurred. Results: Adjusted MET call response times (observations < 180 minutes) revealed 20% of patients did not have MET call made immediately (< one minute) and did not meet the standard. Ten percent warranted an earlier MET call and 25% achieved MEWS criteria > four within 180 minutes before MET call. Identification and responding to the patients with MEWS > 4 may have prevented 25% of MET calls. Conclusion: While all MET calls should have an immediate response, this is not always achieved. Implementation of MEWS may improve recognition and response to the deteriorating patient.

Introduction

Early recognition of clinical deterioration, followed by prompt response is associated with a lower level of intervention to stabilise patients and reduced adverse events. [1-3] Effective recognition and response to deterioration requires defined observation parameters, trained staff, appropriate equipment, policies, escalation protocol, communication and rapid response. [4] Adverse patient outcomes impact on the patient and health system, such as increased length of stay, unplanned return to theatre, increased morbidity, mortality, decreased bed availability and inefficient re-allocation of limited health resources. [5,6]

Early recognition and warning systems aim to identify and intervene before a patient deteriorates, reducing adverse outcomes. A widely-used approach in Australia is the Medical Emergency Team (MET) system, which includes staff education of the dangers of physiological instability, defining MET call criteria, improving communication and establishing policies, procedures, and systems for immediate response to patient deterioration. [7]

This study was conducted at a Western Australian outer metropolitan secondary teaching hospital (de-identified for publication and referred to herein as “health service”) to look at recognition and response to the clinically deteriorating patient. The health service uses the MET call system. According to MET Call Policy [8], calls should be made as soon as a patient meets any MET call criterion (Figure 1). An internal audit [9] looked at observation tools, adherence to protocol, documentation and response. Results revealed 62.5% of patient deterioration were recorded and 25% of deterioration were not acted upon (i.e. no MET call or escalation for review). In addition multiple forms were used to record observations, resulting in gaps on charts, reducing the ability to identify trends. These findings are similar to a randomised controlled study where the MET call system was introduced in twelve of 23 Australian hospitals. Researchers [7] found that when there were documented physical abnormalities and MET call criteria were reached, MET was called for only 30% of patients prior to unplanned intensive care unit (ICU) admissions. Furthermore, the MET system increased emergency team calling but did not substantially alter occurrence of cardiac arrest, unplanned ICU admission or unexpected death.

The Australian Commission on Safety and Quality in Healthcare has identified recognising and responding to clinical deterioration as a key issue. [4] The health service was introducing the COMPASS Modified Early Warning Score (MEWS) System (Figure 2 for calculation and Figure 3 for response). [12] Researchers reviewed outcomes of COMPASS and concluded that having a multi-faceted approach to patient monitoring improved early medical review following clinical instability. [11] The COMPASS system was being implemented to consolidate recordings and allow for a score (MEWS) to be calculated to flag early deterioration in addition to existing MET call processes.

The topic was chosen to enhance understanding of METs and early warning systems, including impact on outcomes and compliance with MET policy. The aim was to assess MET call initiation and response (process of care).

Objectives:

1. In adult patients who have a MET call, is the call made immediately after meeting MET criteria? (Compliance with policy).

2. In adult patients who have a MET call, was MEWS > 4 reached prior to the call? (MEWS > 4 requires medical review which may prevent MET call).

Methods

Setting

A Western Australian outer metropolitan secondary teaching hospital with a total of 13,070 medical and 4,558 surgical admissions in 2011 (average 1,089 medical and 380 surgical admissions per month). On general surgery areas, there is medical cover during the day and an on call consultant 24 hours. On general medical areas, there is medical cover during the day, Resident / Registrar cover after hours until 22:00 and on call consultant 24 hours. Emergencies on both wards are covered by the MET. The health service has one MET and one backup team.

Standard

The MET Call Policy is the standard for MET calls (Figure 1). [8] One hundred percent of MET call cases must have a documented response immediately after an observation that meets MET call criteria (Figure 1).

There is Level III-1 NHMRC evidence for MERIT Study Investigators who found MET calls were made for 30% of patients before unplanned intensive care admission and equivocal improvements in outcome based on MET call alone. [7] There is Level III-3 NHMRC evidence for findings on the effectiveness of COMPASS. [11]

Case Definition

A case is any adult patient (> 18 years) on the acute medical or general surgical ward at the health service that had a MET call made between 1 January and 30 April 2011.

Patient Selection

MET calls are documented in the medical record. The Resuscitation Educator maintains a log of all MET calls. Only MET calls that occurred in patients aged 18 years and over on acute medical or surgical areas were chosen. In patients with multiple MET calls in one admission only the first MET call was reviewed and patients with altered MET criteria were excluded. A sample size of 20 was selected due to time constraints in reviewing multiple forms and calculating MEWS by transcribing observations using a collection tool.

Sample Size and Analysis

A pilot study was conducted on three records from March 2011. Descriptive data were used for analysis. Confidence intervals (CI) were calculated using the modified Wald method. [15]

Data Collection

Data were obtained from medical records selected as per Patient Selection. The MET calls log was obtained for 1 January to 30 April 2011. MET calls for non-medical and non-surgical patients, patients less than 18 years and piloted records were removed. The first 20 MET calls where medical records could be located were chosen.

The Author collected data by reviewing medical records and records checked for altered MET criteria statements. Observations < 180 minutes to the MET call were checked on all forms in the admission. Within 180 minutes was chosen, as MET call criteria requires urine output over 3 hours to be checked. MEWS was calculated to the observation greater than but closest to 180 minutes before the MET call using MEWS Collection Tool. Data were entered into Microsoft Excel using data collection tool and dictionary. Demographic, exposure and outcome variables are listed in Figure 4. Missing, conflicting and ambiguous data were recorded as ‘missing’.

Other Issues

Cases were de-identified. Electronic data were password protected and collection tools stored securely. Identifying staff and patient information were not recorded, patient interaction was not required and patient consent was not necessary as per NHMRC. [16] Stakeholders included staff involved in initiating or attending METs and Executive. Clinical Quality and Safety Committee approval was obtained.

Results

Twenty of the 36 adult medical and surgical patients who had MET calls during January to March 2011 were selected (55.6% of MET calls). Age range of patients selected was 29 to 89 years, with a mean age of 74.7 years (median 79 years). In comparison, age range for the 36 patients from which patients were sampled was 29 to 92 years, with a mean age of 72.3 years and median 77.5 years. There were no patients with altered MET criteria.

Reason for MET call is summarised in Table 1. Five patients (25%) achieved two MET call categories, while no patients reached three or more categories. The most common reason for MET call was circulation problem (i.e. pulse rate < 40 or > 130 beats per minute (bpm)), with seven patients (35%) having MET call for this reason.

MET call response times varied between zero and ten minutes (Figure 5). Seventeen patients (85%) had a response within and including one minute. Three patients had a delay exceeding one minute (15%). The mean response time was one minute and median zero minutes.

Two patients (10%) were identified as reaching MET call criteria in observations before the one that resulted in MET call. The delay was 14 and 160 minutes, with an average of 87 minutes (Table 2). The patient with a 14 minute delay had a further four minute deferral after the second observation that achieved MET call criteria. The patient with 160 minute delay had the MET call made immediately after the subsequent observation that achieved MET call criteria. Consequently four patients (20%) had an adjusted MET call response time greater than one minute (mean 9.5 minutes, range 0-160 minutes, median 0 minutes, 95% CI 0.0749-0.4218).

For two patients (10%), it could not be determined whether an earlier observation fell into MET call criteria. One patient had missing progress notes and observation chart. The other had documented deviated observations in the progress notes without time recorded. It could not be ascertained whether this occurred within 180 minutes of the MET call.

Five patients (25%) achieved a calculated MEWS > 4 within the last observation greater than but closest to 180 minutes of the MET Call (Table 3). The 95% CI extends from 0.1081-0.4725. Of these, four were < 180 minutes of the MET call. Time period between MEWS > 4 and MET call ranged between five and 210 minutes (3 hours 30 minutes), with a mean of 113 minutes.

Five patients (25%) were discharged the same day as the MET call (Table 4). Of the five patients, one patient deceased (5%) and four patients (20%) were transferred to an acute hospital for further management (i.e. Royal Perth or Sir Charles Gairdner Hospitals).

Discussion

Adjusted MET call response times (inclusive of observations < 180 minutes) revealed 20% of patients did not have MET call made immediately (< one minute) and did not meet the standard. Ten percent warranted an earlier MET call and 25% achieved MEWS criteria > four within 180 minutes before MET call. Identification and responding to the patients with MEWS > 4 may have prevented 25% of MET calls. The CI of 0.1081 to 0.4725 warrants further study with increased sample size.

Twenty percent may not have met the standard due to delayed MET call response (e.g. hesitation or watchful waiting), inexperience, not recording altered MET criteria, and inaccurate documentation of times on the Resuscitation Record. The Resuscitation Record contained pulse rate > 140 bpm whereas hospital policy states pulse rate > 130 bpm warrants MET call. While this did not appear to affect data, it may create confusion for staff.

Ten percent of patients required earlier MET call, showing an improvement to a previous audit [9] where 25% of deterioration were not acted upon. While not achieving the standard, results are better than those found by MERIT Study Investigators where only 30% of patients admitted to the ICU had a MET call. [7] This study looked at various patients, not just ICU admissions which may contribute to this variance. Besides revealing current practice, the study provides a baseline for evaluation of COMPASS and effectiveness of MEWS post-implementation in achieving the standard.

Twenty-five percent of patients were discharged on the same day as the MET call. One patient who achieved a MEWS > 4 was discharged the same day and earlier identification with MEWS may have allowed for earlier planning or transfer. The deceased patient had an unpreventable condition.

Limitations:

  • Patients without MET call may have reached calling criteria. These were not included as the audit looked at MET calls made. Failure to meet the standard may be higher.
  • Observations in the preceding 180 minutes were reviewed. Patients may have had observations warranting MET call earlier than this.
  • Not all observations used in MEWS calculation were recorded in every observation set. MEWS > 4 may have been reached yet could not be determined.
  • Adult surgical and medical patients were included. Responses for other groups may differ.
  • Sample was determined from the MET call log. Missing forms or accidental omissions during logging of cases may have affected accuracy.
  • Audit period included January which may include increased agency and relief staff. This was intentional as staff should respond to and be familiar with MET call processes.
  • Patients with multiple MET calls only had the first MET call reviewed.
  • This was a single site and results may not be externally valid.
  • While data collected by the author was pre-recorded in the medical record, the author was not blinded to the study aims.

Results, feedback and recommendations were communicated with stakeholders at the health service through a summary report which was distributed by email, followed by presentation of findings and feedback session. Recommendations were as follows:

  • Record observations on a single form.
  • MET call policy requires a definition of “immediate” (e.g. less than one minute) to provide clarification and measurable outcome.
  • Reiterate to staff the importance of accurate documentation (e.g. times).
  • Conduct research to assess patient outcomes and compare with other hospitals.
  • Re-audit following MEWS Observation Chart implementation. Compare MET call response with other Australian hospitals that utilise COMPASS.
  • Obtain further stakeholder feedback on existing practice and potential for improvement (e.g. verbal discussion, email, team meetings).
  • Adjust pulse rate on the Resuscitation Record to > 130 bpm to reflect hospital policy.

Recommendations may be applicable to other health services utilising MET call system and MEWS, particularly defining what “immediate response” is with a timeframe to allow for review of compliance. Further research could review a selection of patients regardless of whether MET call was made and review observations to determine whether MET call should have been made. While this is a time consuming task, hospitals utilising MEWS charts will make this process easier.

Conclusion

While all MET calls should have an immediate response, this is not always achieved. Implementation of MEWS or secondary warning system may improve recognition and response to the clinically deteriorating patient. Responding to a patient at an early stage in their deterioration may reduce adverse outcomes and use of resources. To improve review and audit of response to clinical deterioration, further clarification of what “immediate” means is required in the standard.

Acknowledgements

Ms Deborah Goddard, Department of Health Western Australia

Conflict of interest

None declared.

Correspondence

G Parham: glenn.parham@gmail.com

References

[1] Australian Commission on Safety and Quality in Healthcare. National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration [Internet]. Sydney: ACSQHC; 2010 [cited 2011 Mar 13]. Available from: http://www.health.gov.au/internet/safety/publishing.nsf/Content/EB5349066738C24CCA2575E70026C32A/$File/
national_consensus_statement.pdf.

[2] National Institute for Health and Clinical Excellence. Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital [Internet]. London: NICE; 2007 [cited 2011 Mar 13]. Available from: http://www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf.

[3] Hillman KM, Bristow PJ, Chey T, Daffurn K, Jacques T, Norman SL, et al. Antecedents to hospital deaths. Intern Med J. 2001;31: 343-8.

[4] Australian Commission on Safety and Quality in Healthcare. Recognising and Responding to Clinical Deterioration: Background Paper [Internet]. ACSQHC; 2008 [cited March 2011]. Available from: http://www.health.gov.au/internet/safety/publishing.nsf/Content/AB9325A491E10CF1CA257483000C9AC4/$File/
BackgroundPaper-2009.pdf.

[5] Dacey MJ, Mirza ER, Wilcox V, Doherty M, Mello J, Boyer A, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007;35(9):2076-82.

[6] Devita MA, Bellomo R, Hillman K, Kellum J, Rotondi A, Teres D, et al. Findings of the first consensus conference on rapid response teams. Crit Care Med. 2006;34:2463-78.

[7] MERIT Study Investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005:365:2091-7.

[8] [name deleted] Health Service. Practice Standard for the Management of Medical Emergencies and Cardiorespiratory Arrest [Hospital Work Practice]. WA: [name deleted] 2011 Jan.

[9] [name deleted] Health Service. Audit of Observational Tools [Unpublished Audit Paper]. WA: [name deleted] 2010 Jul.

[10] [name deleted] Health Service. Practice Standard for the Management of Medical Emergencies and Cardiorespiratory Arrest [Hospital Work Practice]. WA: [name deleted] 2011 Jan. P.6.

[11] Mitchell IA, McKay H, Van Leuvan C, Berryd R, McCutcheond C, Avarda B, et al. A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation. 2010;81:658-66.

[12] COMPASS. Pointing You in the Right Direction – Adult (2nd ed.). Australian Capital Territory: ACT Publishing; 2010.

[13] COMPASS. Pointing You in the Right Direction – Adult (2nd ed.). Australian Capital Territory: ACT Publishing; 2010. P.8,9.

[14] COMPASS. Pointing You in the Right Direction – Adult (2nd ed.). Australian Capital Territory: ACT Publishing; 2010. P.11.

[15] Agresti A, Coull BA. Approximate is better than “Exact” for interval estimation of binomial proportions. Am Stat 1998:52:119-26.

[16] National Health & Medical Research Council. When does quality assurance in health care require independent review. Canberra: NHRMC; 2003.

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Original Research Articles

Emergency Department management and referral of self-harm patients

Aim: To outline the socio-demographic characteristics, the means of arrival, management and referral pathways for mental health presentations to the Emergency Department (ED) where the main reason for presentation is self-harm. Methods: A retrospective study conducted in a metropolitan hospital in Sydney. Sampled data were collected from mental health presentations to the ED for the month of May in 2005, 2006 and 2007. The data collected included patient demographics as well as management, referral and follow-up outcomes. Results: There were 606 patients in the sampled data (99.3% of all mental health presentations). The gender distribution of the patient cohort was 63:37 (male n=380 and female n=226) and the average age was 36 ± 16.7 years. Two hundred and three (33.5%) patients had self-harmed and 403 (66.5%) had other mental health problems. Self-harm patients’ mode of arrival included ambulance (38.4%), self-presentations (36.5%), police (14%), and other. Self-harmers were mainly admitted to Psychiatric Emergency Care Centre (PECC) (28%) or discharged home (51.7%). More than one third (35.5%) of self-harm patients did not receive adequate follow-up. Conclusion: Important variations between self-harm patients and other mental health patients were identified in their management and referral outcomes from the ED. Clinicians need to ensure that optimal patient care is provided through appropriate follow-up of every self-harm patient post-discharge from hospital.

 

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Original Research Articles

Exploring barriers to the provision of palliative care in Australia

Palliative care provides assistance for people living with a terminal medical condition, for which the primary goal of treatment is improving quality of life. There are numerous barriers to the provision of palliative care. There is little research into barriers to the provision of palliative care and little with an Australian context. This research explores barriers to palliative care in Australia through questionnaires and interviews with stakeholders. One hundred and one questionnaires were given to South East Palliative Care (SEPC) community nursing and allied health staff, general practitioners and aged care facility staff. Five interviews were conducted with representatives from SEPC, Palliative Care Australia and two aged care facilities. Most agreed that palliative care was essential in the community, hospital and aged care setting. Four major themes were identified from interviews: 1.) Education & stigma barriers; 2.) Communication barriers; 3.) Aged care barriers; and 4.) General practice barriers. Inadequate prescriptions of pain medication were a significant issue. These themes were supported by questionnaire data, with 25.6% identifying education and 28.2% identifying resources as major barriers. Knowledge of palliative care was poor in both aged care staff and GPs, only 8.3% and 38.5% respectively answering all palliative care questions correctly, compared to 64.2% amongst SEPC staff. The study addresses a deficit in previous research, identifying barriers to palliation in aged care. The data collected has potential for further research or interventional approaches to improve the provision of palliative care for Australians.

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Original Research Articles

Maternal attitudes towards breast and bottle feeding in a regional community

Background: Based on research demonstrating the many benefits of breastfeeding, it is recommended babies be exclusively breastfed from birth to at least six months of age. However, despite these known benefits, many women choose to bottle feed or cease breastfeeding before six months. Aim: To survey women in order to determine factors associated with their attitudes and choice to bottle feed or breastfeed their children, with the aim of identifying areas to target education to improve breastfeeding rates or duration. Methods: Anonymous surveys were distributed to a convenience sample of 106 adult female patients selected from a suburban general practice. MS-Excel and Epi Info 3.5.3 software package were used for data management. Chi square was used for analysis. Results: The response rate was 94.3% (n=100). There were trends suggesting an association between income and the respondents’ choices (p=0.26); and income and the respondents’ mothers’ choices (p=0.51). Respondents were significantly more likely to choose the feeding method their own mother used (p=0.01). Discussion: Income and respondents’ mothers’ choice regarding breastfeeding were identified as factors possibly associated with respondents’ attitudes and choice. Hence awareness of individual family dynamics may assist in targeting prenatal education to help increase rates of breastfeeding. A large proportion of respondents chose to bottle feed and also believed that the bottle was as good as breastfeeding. The needs of this group also need to be met. Conclusion: To increase breastfeeding rates, individualised prenatal education as well as supporting women through their breastfeeding problems is a likely requirement.

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Original Research Articles

Onsite and offsite use of computer aided learning in undergraduate radiology education

Aim: Computer-aided learning (CAL) is considered comparable to traditional media for undergraduate radiology teaching. Previous studies have often compared the efficacy of traditional media to onsite CAL use, yet real world usage of CAL is likely to occur in offsite settings. This study aims to compare usage and learning outcomes of a chest radiology CAL in onsite and offsite settings. Methods: Participants were fourth year medical students (n=52) at the National University of Singapore (NUS) undertaking one week radiology rotations. Students were randomly allocated to complete a web-based chest radiology CAL onsite, or offsite at a time and place of choice. Pre- and post-tests were taken to measure knowledge gain, and a questionnaire was used to explore student usage and preferences.

Results: The onsite CAL group demonstrated significant knowledge gain (+15.8%, p<0.05) whilst the offsite group did not (+5.8%, p>0.05). However, the difference between the groups was not statistically significant (p=0.069). Total time spent and completion of the program was similar between the two groups. Yet, questionnaire results showed that the offsite group multitasked more and appeared to have poorer concentration. A majority of students from both groups preferred the convenience of offsite CAL use over onsite CAL use.

Conclusion: A significant difference between the test groups was not observed, although there was a trend toward onsite CAL use being more effective. In planning CAL teaching, particularly for offsite use, educators need to provide sufficient support and integration for an optimal outcome.

Introduction

Chest radiology is important for acute and emergency management, and is therefore an essential learning component of undergraduate radiology teaching. [1] However, studies show that chest radiology competency amongst graduating medical students is poor. [2,3] Poor competency is attributed to lack of formal teaching of radiology in the curriculum. [2,3] Worldwide, radiology teaching is compromised by limited formal teaching in a hectic curriculum, and competing demands on radiologists. [4,5]

Computer aided learning (CAL) has been advocated as a potential tool to alleviate some of the limitations in radiology teaching. [6] CAL is time and cost effective for educators, [7] and especially useful in an image rich specialty such as radiology. To evaluate the effectiveness of CAL for transferring knowledge gain, previous studies have undertaken media comparisons between CAL and traditional learning, such as lectures or tutorials. Individual studies in radiology and non-radiology medical education [8,9] demonstrate that overall, knowledge gain with CAL is comparable to …

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Original Research Articles

The effect of Duchenne Muscular Dystrophy on Purkinje cell number in the mdx mouse

Figure 1. Comparison of Nissl stained and Calbindin-D28k immunostained sections. (a) Calbindin immunopositive PCs clearly visible along the PC layer. (b) PCs not visible in Nissl stained section.

Background: Duchenne muscular dystrophy (DMD) is an X-linked recessive disease which causes skeletal muscle wasting in males, resulting in premature death during their early to mid 20s. Males with DMD carry defects in the gene encoding for dystrophin, a protein important in ensuring sarcolemmal stability. Dystrophin has also been implicated in disruption to Purkinje cells in the cerebellum. This disruption to cerebellar Purkinje cells has been proposed to be involved in reducing the IQ of affected boys. Aim: To compare Purkinje cell number and distribution in mutant mdx and normal mice. Methods: Cerebellar slices from both mutant (n=4) and normal (n=4) mice were prepared and stained. The number of Purkinje cells in each slice was estimated by three different cell counting techniques. Counting methods were as follows: firstly, the actual number of Purkinje cells per lobe; secondly, a randomised estimate where five random sections of the Purkinje cells layer were selected, counted and averaged; thirdly, an estimated maximum possible count, where three segments from the Purkinje cell layer with the highest density of cells were used to estimate Purkinje cell population. Results: No statistical significance in Purkinje cell numbers between the two groups was found. However, there was a trend towards a decrease in the median number of Purkinje cells in the mutant group, particularly in lobules 3, 4/5, 6 and 10. Conclusion: The study findings suggest a decrease in Purkinje cell number in mdx mice. The small sample size of this study precludes definitive statistical analysis of Purkinje cell numbers in either group. These findings demonstrate a need for larger mouse-model studies to accurately assess differences in cell numbers between the two groups. Given that the greatest difference in cell numbers was demonstrated in lobules 3 and 4/5, the authors suggest that DMD may affect the cerebellum during the maturation of these lobules. Importantly, a reduced Purkinje cell population may be implicated in the intellectual morbidity in boys with DMD.

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Original Research Articles

The Internet as a health information source for university students

Abstract

As the prevalence of those seeking health information online rises, the potential for information overload and misinformation increases. This study aims to evaluate and explore the Internet’s role as a health information source, specifically for university students. In total, 120 university students were surveyed for their behaviours and attitudes when accessing online health information. Of the respondents, 61% had used the Internet as a personal health information source at least once in the past and 34% do so at least once a month. In comparison with other common information sources, the Internet was the third most commonly used (41%) behind General Practitioners (73%) and family and friends (60%). Despite this frequency of use, only 5% of participants regarded the Internet to be very accurate, while 27.5% had found health information on the Internet to be misleading. Online health advice had delayed appropriate medical treatment at least once for 28% of participants.  Both information inaccuracy and treatment delay pose risks to health outcomes. The findings from this research provide a useful starting point for future research into Australian Internet health information seeking behaviour.

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Original Research Articles

A survey of the ophthalmic presentations and their outcomes to a general hospital Emergency Department over twelve months

Abstract

Aim: To survey the diagnoses and discharge status of the ophthalmic presentations to a general emergency department (ED). To compare the ED diagnosis with the ophthalmologist diagnosis of referred patients. Methods: A retrospective analysis of all the ophthalmic presentations to the Gosford District Hospital from 1 January 2005 to 31 December 2005 was carried out. All referrals to and admissions by ophthalmologists were reviewed for the final diagnosis. These outcomes were compared to the initial ED diagnosis. Results: There were 509 ophthalmic presentations to the ED in 2005: 51% had corneal trauma, 14% had an unspecified red or painful eye, 9% had an unspecified eye injury and 5% had blurred vision. Most patients were discharged without referral. Twenty-two percent of patients were referred to an ophthalmologist. Four percent were admitted and transferred to Sydney Eye Hospital. In those who were referred, 13% did not have records at the specified ophthalmologist, 24% were not recorded to which specialist they were referred and 26% had significantly different specialist opinion. Conclusions: More than half of ED ophthalmic presentations were for corneal trauma and only 22% of patients were referred to an ophthalmologist, while most were treated solely in the ED or referred to general practice. Potentially vision-threatening misdiagnoses included three cases of iritis, three of keratitis and two of retinal artery occlusion. ED diagnoses of corneal problems matched exactly with ophthalmic opinion. Interestingly, recording of the visual acuity occurred in only 27% of cases.

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Original Research Articles

Investigation of lactate dehydrogenase isoenzymes as candidate biomarkers of idiopathic pulmonary arterial hypertension

Abstract

This study investigates the activity and expression of lactate dehydrogenase (LDH) in idiopathic pulmonary arterial hypertension (IPAH) patients. IPAH is a rare and highly fatal disease with a median life expectancy at diagnosis of only 2.8 years. Ideally a simple blood test for biomarkers could simplify the physician’s diagnostic work-up, resulting in earlier diagnosis and successful institution of therapy. Recent publications suggest IPAH may behave like cancer, with monoclonal proliferation and a shared pathway of mitochondrial dysfunction. LDH is often upregulated in cancers, and a similar elevation is suspected in IPAH. Discovering similar patterns of flux in the cellular bioenergetics of IPAH and cancer would support the emerging theory that IPAH has a ‘cancer phenotype’. Quantitative proteomic analysis of fourteen lung tissue homogenate samples (seven lobectomy, seven IPAH) was performed using liquid chromatography – tandem mass spectrometry (LC-MS/MS). The lung samples, as well as 30 plasma samples (ten normal, 20 IPAH) were analysed for LDH fractional isoenzyme activity and expression. A pyruvate-to-lactate spectrophotometric activity assay was performed on the 44 samples, followed by LDH isoenzyme separation on thin-layer agarose gel and densitometric analysis. A significant link exists between IPAH and increased plasma and lung levels of LDH-1 (P = 0.0114 and 0.0262 respectively on Mann-Whitney U test). Receiver Operating Characteristic analysis demonstrated plasma LDH-1 had biomarker sensitivity and specificity of 80%. Measuring plasma LDH-1 appears clinically useful in diagnosing IPAH. This work supports the re-evaluation of IPAH as a cancer-like disease and suggests a new biomarker.

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Original Research Articles

Can we predict when operating lists will finish in a regional Queensland hospital?

Winner of the Co-Op Bookshop Prize for Best Academic Article in this issue of the AMSJ

Abstract

Background: Over-running operating lists are a common cause of same-day cancellations of surgery, while under-running operating lists are a common cause of wasted health resources due to the fixed costs of operating suites. The predominant cause of operating lists running off-schedule is not known, but it is believed that if due to booking problems, it should be possible to predict when a list will over- and under-run. Aims: To understand the prevalence of cancellations, over- and under-running operating lists in a regional Queensland hospital, and to test whether over- and under-running lists can be predicted. Methods: A sample of 120 operating lists was prospectively obtained and each list timed from start to finish. A predicted duration was calculated for each list by summing the average durations for each of the operations on the list (including anaesthetic and turn-over durations), derived from past surgical records. Results: Twenty-eight percent of lists suffered a cancellation, of which 79% were predicted to over-run their scheduled duration. Of the lists that did not suffer a cancellation, 45% over-ran, of which 84% were predicted; and 37% under-ran, of which 84% were predicted. Conclusion: The large proportion of predicted over- and under-runs support the hypothesis that booking problems are the main causes of operating lists running off-schedule, as opposed to other factors affecting surgical duration that the model would not have accounted for. This suggests that operating lists running off-schedule can potentially be avoided. Further study is warranted to investigate the reasons behind over- and under-booking.