ORCID Profile
0000-0001-6499-2705
Current Organisations
The University of Queensland Faculty of Health and Behavioural Sciences
,
Bond University
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Publisher: Springer International Publishing
Date: 2015
Publisher: Cold Spring Harbor Laboratory
Date: 20-09-2019
DOI: 10.1101/19007138
Abstract: To understand patient/family perspective of inappropriate intensive care unit (ICU) admissions and treatment. Rapid literature review of English language articles published between 2001 and 2017 in Medline or PsycInfo. Thirteen articles covering 6,194 elderly patients or surrogate decision-makers from four countries were eligible. Perceived inappropriateness of ICU treatments was mainly expressed as dissatisfaction with clinicians’ as surrogate decision-makers, inconsistency with patient/family values, family distrust of physician’s predictions on poor prognosis, and inadequate communication on over-aggressive treatment causing suffering. Consultation on opinion before ICU admission varied from 1% to 53.6%, and treatment goals from 1.4 to 31.7%. Satisfaction with the decision-making process in ICU was higher for those who had certain level of control and involvement in the process. The patient/family perspective on inappropriateness of ICU treatments involves preferences, values and social constructs beyond medical criteria. Earlier consultation with families before ICU admission, and patient education on outcomes of life-sustaining therapies may help reconcile these provider-patient disagreements. The patient/family perspective on inappropriateness of ICU at the end of life often differs from the clinician’s opinion due to the non-medical frame of mind. To improve satisfaction with communication on treatment goals, consultation on patient values and inclusion of social constructs in addition to clinical prediction are a good start to reconcile differences between physician and health service users’ viewpoint.
Publisher: Elsevier BV
Date: 04-2016
DOI: 10.1016/J.IJNURSTU.2015.12.007
Abstract: High profile safety failures have demonstrated that recognising early warning signs of clinical and physiological deterioration can prevent or reduce harm resulting from serious adverse events. Early warning scoring systems are now routinely used in many places to detect and escalate deteriorating patients. Timely and accurate vital signs monitoring are critical for ensuring patient safety through providing data for early warning scoring systems, but little is known about current monitoring practices. To establish a profile of nurses' vital signs monitoring practices, related dialogue, and adherence to health service protocol in New South Wales, Australia. Direct observations of nurses' working practices were conducted in two wards. The observations focused on times of the day when vital signs were generally measured. Patient interactions were recorded if occurring any time during the observation periods. Participants (n=42) included nursing staff on one chronic disease medical and one acute surgical ward in a large urban teaching hospital in New South Wales. We observed 441 patient interactions. Measurement of vital signs occurred in 52% of interactions. The minimum five vital signs measures required by New South Wales Health policy were taken in only 6-21% of instances of vital signs monitoring. Vital signs were documented immediately on 93% of vitals-taking occasions and documented according to the policy in the patient's chart on 89% of these occasions. Nurse-patient interactions were initiated for the purpose of taking vital signs in 49% of interactions, with nurse-patient discourse observed during 88% of all interactions. Nurse-patient dialogue led to additional care being provided to patients in 12% of interactions. The selection of appropriate vital signs measured and responses to these appears to rely on nurses' clinical judgement or time availability rather than on policy-mandated frequency. The prevalence of incomplete sets of vital signs may limit identification of deteriorating patients. The findings from this study present an important baseline profile against which to evaluate the impact of introducing continuous monitoring approaches on current hospital practice.
Publisher: Wiley
Date: 14-12-2018
DOI: 10.1111/ACEM.13664
Publisher: Wiley
Date: 19-03-2014
DOI: 10.1002/PDS.3614
Abstract: The aim of this study was to identify antibiotic prescription patterns for community-acquired pneumonia (CAP) in Vietnam. Medical records for CAP adult patients admitted to 10 hospitals across the country were randomly selected from admission lists during the peak pneumonia season. CAP cases were identified from manual record reviews by clinical pharmacists. Data was collected using a standard data collection tool including patient clinical features on admission, comorbidities, microbiological culture results, and antibiotic regimens. Pneumonia severity was estimated using the CURB-65 score. A total of 649 medical records for adult patients (55.2% male and 52.3% urban residents, median age 68 years) met the selection criteria for CAP. Pneumonia severity was assessed as mild (64.1% of patients), moderate (23.0%), and severe (9.2%). Antibiotics were most frequently administered intravenously (93.4%) and as combination therapy (dual therapy 54.4%, monotherapy 42.5%, and triple therapy 3.1% of patients) regardless of CAP severity. Third-generation cephalosporins were used most frequently (29.3% as monotherapy and 40.4% as combination therapy). Third-generation cephalosporins were most commonly combined with penicillins and/or quinolones. This first nationwide study provides a baseline profile of antibiotic use in the treatment of CAP. Third-generation cephalosporins were widely used for initial empirical management of CAP, often in combination with quinolones, regardless of CAP severity. The study will assist in providing an evidence base to inform new national antibiotic guidelines for CAP management and will contribute locally relevant data for the national master plan addressing antibiotic resistance and the development of educational interventions to improve CAP management.
Publisher: Springer Science and Business Media LLC
Date: 07-03-2015
DOI: 10.1007/S00134-015-3712-6
Abstract: The development of ICUs as the final option for seriously ill patients, especially the elderly frail patient at the end of his/her life, has meant that intensivists have increasingly taken on the role of diagnosing the dying. Our society, and even our medical colleagues, do not necessarily understand what we can achieve in ICUs, and even more importantly, what we cannot achieve. The next crucial step for us as in iduals, and through our professional bodies, is to engage our society in discussions on our role and encourage debate and discussion, being aware of the controversies that will inevitably result. Birthing in the 1950s was medicalised without discussion with women and their families. In a similar manner, dying has been medicalised in the twenty-first century. It has not been a conspiracy and the use of futile and expensive treatment at the EoL transition is not necessarily anyone's choice. The specialty of intensive care has a particularly important role in facilitating discussions with our society in order to define different ways of managing dying.
Publisher: Cold Spring Harbor Laboratory
Date: 06-09-2022
DOI: 10.1101/2022.09.05.22278731
Abstract: This rapid review of quantitative and qualitative publications of any design indexed in PUBMED between January 2020-April 2021 investigates barriers and enablers of advancecare planning (ACP) worldwide in the early stages of the life-threatening COVID-19 pandemic. Seventy-four papers were included: 35 primary research studies (cohorts, reviews, case studies, and cross-sectional designs) and 39 commentaries. Publications from hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and goal-aligned care. Enablers of ACP included targeted public awareness, availability of telehealth, access to online tools and a person-centered approaches. Barriers included uncertainty regarding clinical outcomes, cultural or communication difficulties, legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems. The opportunities for rapid implementation of ACP offered by the social distancing restrictions and high demand for health services are valuable in informing future policy and practice. Our study adds to existing evidence by identifying emerging barriers and creative ways of overcoming them in response to a global crisis Discussions on death prospects and care of the dying were feasible and a step towards normalisation of advance care planning Despite new and overwhelming challenges, policies and practices could be rapidly implemented to satisfy clinicians and families in need of advance care planning The lessons learnt can be incorporated in future health service planning since the threat of other pandemics is real A formal evaluation of effectiveness of some of the emerging strategies would be a valuable addition to the evidence
Publisher: JMIR Publications Inc.
Date: 28-07-2021
Abstract: ental disorders are a leading cause of distress and disability worldwide. To meet patient demand, there is a need for increased access to high-quality, evidence-based mental health care. Telehealth has become well established in the treatment of illnesses, including mental health conditions. his study aims to conduct a robust evidence synthesis to assess whether there is evidence of differences between telehealth and face-to-face care for the management of less common mental and physical health conditions requiring psychotherapy. n this systematic review, we included randomized controlled trials comparing telehealth (telephone, video, or both) versus the face-to-face delivery of psychotherapy for less common mental health conditions and physical health conditions requiring psychotherapy. The psychotherapy delivered had to be comparable between the telehealth and face-to-face groups, and it had to be delivered by general practitioners, primary care nurses, or allied health staff (such as psychologists and counselors). Patient (symptom severity, overall improvement in psychological symptoms, and function), process (working alliance and client satisfaction), and financial (cost) outcomes were included. total of 12 randomized controlled trials were included, with 931 patients in aggregate therapies included cognitive behavioral and family therapies delivered in populations encompassing addiction disorders, eating disorders, childhood mental health problems, and chronic conditions. Telehealth was delivered by video in 7 trials, by telephone in 3 trials, and by both in 1 trial, and the delivery mode was unclear in 1 trial. The risk of bias for the 12 trials was low or unclear for most domains, except for the lack of the blinding of participants, owing to the nature of the comparison. There were no significant differences in symptom severity between telehealth and face-to-face therapy immediately after treatment (standardized mean difference [SMD] 0.05, 95% CI −0.17 to 0.27) or at any other follow-up time point. Similarly, there were no significant differences immediately after treatment between telehealth and face-to-face care delivery on any of the other outcomes meta-analyzed, including overall improvement (SMD 0.00, 95% CI −0.40 to 0.39), function (SMD 0.13, 95% CI −0.16 to 0.42), working alliance client (SMD 0.11, 95% CI −0.34 to 0.57), working alliance therapist (SMD −0.16, 95% CI −0.91 to 0.59), and client satisfaction (SMD 0.12, 95% CI −0.30 to 0.53), or at any other time point (3, 6, and 12 months). ith regard to effectively treating less common mental health conditions and physical conditions requiring psychological support, there is insufficient evidence of a difference between psychotherapy delivered via telehealth and the same therapy delivered face-to-face. However, there was no includable evidence in this review for some serious mental health conditions, such as schizophrenia and bipolar disorders, and further high-quality research is needed to determine whether telehealth is a viable, equivalent treatment option for these conditions.
Publisher: SAGE Publications
Date: 03-12-2021
DOI: 10.1177/1357633X211053738
Abstract: Worldwide, it is estimated that 264 million people meet the diagnostic criteria for anxiety conditions. Effective treatment regimens consist of cognitive and behavioural therapies. During the COVID-19 pandemic, treatment delivery relied heavily on telemedicine technologies which enabled remote consultation with patients via phone or video platforms. We aim to identify, appraise and synthesise randomised controlled trials comparing telehealth to face-to-face delivery of care to in iduals of any age or gender, diagnosed with anxiety disorders, and disorders with anxiety features. To conduct this systematic review and meta-analysis, we searched three electronic databases, clinical trial registries and citing-cited references of included studies. A total of five small randomised controlled trials were includable telehealth was conducted by video in three studies, and by telephone in two. The risk of bias for the 5 studies was low to moderate for most domains. Outcomes related to anxiety, depression symptom severity, obsessive-compulsive disorder, function, working alliance, and satisfaction were comparable between the two modes of delivery at each follow-up time point (immediately post-intervention, 3 months, 6 months and 12 months), with no significant differences reported ( p 0.05). None of the trials reported on the costs of telehealth compared to face-to-face care. For effectively treating anxiety and related conditions, interventions delivered by telehealth appear to be as effective as the same therapy delivered in-person. However, further high-quality trials are warranted to determine the effectiveness, acceptability, feasibility, and cost-effectiveness of telehealth interventions for the management of a wider range of anxiety disorders and treatments.
Publisher: University of Toronto Press Inc. (UTPress)
Date: 31-12-2020
Abstract: Background: Knowing the prevalence of true asymptomatic coronavirus disease 2019 (COVID-19) cases is critical for designing mitigation measures against the pandemic. We aimed to synthesize all available research on asymptomatic cases and transmission rates. Methods: We searched PubMed, Embase, Cochrane COVID-19 trials, and Europe PMC for primary studies on asymptomatic prevalence in which (1) the s le frame includes at-risk populations and (2) follow-up was sufficient to identify pre-symptomatic cases. Meta-analysis used fixed-effects and random-effects models. We assessed risk of bias by combination of questions adapted from risk of bias tools for prevalence and diagnostic accuracy studies. Results: We screened 2,454 articles and included 13 low risk-of-bias studies from seven countries that tested 21,708 at-risk people, of which 663 were positive and 111 asymptomatic. Diagnosis in all studies was confirmed using a real-time reverse transcriptase–polymerase chain reaction test. The asymptomatic proportion ranged from 4% to 41%. Meta-analysis (fixed effects) found that the proportion of asymptomatic cases was 17% (95% CI 14% to 20%) overall and higher in aged care (20% 95% CI 14% to 27%) than in non-aged care (16% 95% CI 13% to 20%). The relative risk (RR) of asymptomatic transmission was 42% lower than that for symptomatic transmission (combined RR 0.58 95% CI 0.34 to 0.99, p = 0.047). Conclusions: Our one-in-six estimate of the prevalence of asymptomatic COVID-19 cases and asymptomatic transmission rates is lower than those of many highly publicized studies but still sufficient to warrant policy attention. Further robust epidemiological evidence is urgently needed, including in subpopulations such as children, to better understand how asymptomatic cases contribute to the pandemic.
Publisher: Oxford University Press (OUP)
Date: 30-06-2017
Publisher: Springer Science and Business Media LLC
Date: 29-07-2020
DOI: 10.1186/S12877-020-01660-2
Abstract: Hospitalisation rates for the older population have been increasing with end-of-life care becoming a more medicalised and costly experience. There is evidence that some of these patients received non-beneficial treatment during their final hospitalisation with a third of the non-beneficial treatment duration spent in intensive care units. This study aims to increase appropriate care and treatment decisions and pathways for older patients at the end of life in Australia. This study will implement and evaluate a prospective feedback loop and tailored clinical response intervention at three hospitals in Queensland, Australia. A stepped-wedge cluster randomised trial will be conducted with up to 21 clinical teams in three acute hospitals over 70 weeks. The study involves clinical teams providing care to patients aged 75 years or older, who are prospectively identified to be at risk of non-beneficial treatment using two validated tools for detecting death and deterioration risks. The intervention’s feedback loop will provide the teams with a summary of these patients’ risk profiles as a stimulus for a tailored clinical response in the intervention phase. The Consolidated Framework for Implementation Research will be used to inform the intervention’s implementation and process evaluation. The study will determine the impact of the intervention on patient outcomes related to appropriate care and treatment at the end of life in hospitals, as well as the associated healthcare resource use and costs. The primary outcome is the proportion of patients who are admitted to intensive care units. A process evaluation will be carried out to assess the implementation, mechanisms of impact, and contextual barriers and enablers of the intervention. This intervention is expected to have a positive impact on the care of older patients near the end of life, specifically to improve clinical decision-making about treatment pathways and what constitutes appropriate care for these patients. These will reduce the incidence of non-beneficial treatment, and improve the efficiency of hospital resources and quality of care. The process evaluation results will be useful to inform subsequent intervention implementation at other hospitals. Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 6 May 2019),
Publisher: Informa UK Limited
Date: 2023
DOI: 10.2147/PPA.S385911
Publisher: Elsevier BV
Date: 12-1997
DOI: 10.1111/J.1467-842X.1997.TB01797.X
Abstract: Using molecular finger-printing, we provided evidence that, in a children's day-care centre, a known hepatitis B virus (HBV) hepatitis B e antigen (HBeAg) carrier transmitted HBV to another child (the index case). The chronic HBV carrier had an exudative skin lesion and a history of biting. We sought to identify other at-risk children and prevent further transmission. Blood s les were collected and tested serologically for HBV. Of the 90 other children, 78 (87 per cent) were tested and none had serological evidence of HBV infection 73 (81 per cent) were of Caucasian background 38 (49 per cent) had a history of HBV immunisation with serological confirmation. Therefore, 1 (2.4 per cent, 95 per cent confidence interval 1.0 to 12.8 per cent) of the 41 known susceptible contacts became infected. The risk of horizontal HBV transmission in a children's day-care centre is low but not negligible. Staff and children should be vaccinated when a child in a day-care centre is a known HBV carrier.
Publisher: Elsevier BV
Date: 03-2017
DOI: 10.1016/J.PEC.2016.10.007
Abstract: To describe the range of decision aids (DAs) available to enable informed choice for older patients at the end of life and assess their effectiveness or acceptability. Search strategy covered PubMed, Scopus, Ovid MEDLINE, EMBASE, EBM Reviews, CINAHL and PsycInfo between 1995 and 2015. The quality criteria framework endorsed by the International Patient Decision Aids Standards (IPDAS) was used to assess usefulness. Seventeen DA interventions for patients, their surrogates or health professionals were included. Half the DAs were designed for self-administration and few described use of facilitators for decision-making. options and associated harms and benefits, and patient preferences were most commonly included. Patient values, treatment goals, numeric disease-specific prognostic information and financial implications of decisions were generally not covered. DAs at the end of life are generally acceptable by users, and appear to increase knowledge and reduce decisional conflict but this effectiveness is mainly based on low-level evidence. Continuing evaluation of DAs in routine practice to support advance care planning is worth exploring further. In particular, this would be useful for conditions such as cancer, or situations such as major surgery where prognostic data is known, or in dementia where concordance on primary goals of care between surrogates and the treating team can be improved. Given the sensitivities of end-of-life, self-administered DAs are inappropriate in this context and genuine informed decision-making cannot happen while those gaps in the instruments remain.
Publisher: MDPI AG
Date: 22-06-2021
DOI: 10.3390/HEALTHCARE9070784
Abstract: We aimed to identify the level of prognostic disclosure, type of prognostic information and delivery format of prognostic communication that older adults diagnosed with a life-limiting illness or caregivers prefer to receive. We developed and pilot tested an open-ended survey to 15 older patients and caregivers who had experience in health services for life-limiting illness either for a relative, friend or themselves. Five hypothetical clinical scenarios of prognostic options were presented to ascertain preferences. The preferred format to receive prognostic information was verbal delivery by the clinician with a written summary. Photos and videos were less favoured, and a table with numbers ercentages was least preferred. Distress levels to the prognostic scenarios were low, with the exception of a photo. We conclude that older patients/caregivers want end-of-life prognostic information delivered the traditional way, verbally by clinicians. Options to deliver prognostic information may vary across patient groups but empower clinicians in introducing end-of-life discussions with patients/caregivers. Our study illustrates the feasibility of involving terminal patients and caregivers in research that contributes to eliciting prognostic preferences. Further research is needed to understand whether the prognostic preferences of hospitalized patients with life-limiting illness differ.
Publisher: MDPI AG
Date: 03-02-2023
DOI: 10.3390/HEALTHCARE11030444
Abstract: Shared decision making near end of life is a balancing act of communicating prognosis to patients and their surrogates/families and engaging them in considering value-concordant management choices. This cross-sectional survey aimed to determine the format in which older patients with chronic illnesses would prefer to receive prognostic information on their treatment options and disease progression, and their desired level of engagement in decision making. With a 60% participation rate, 139 inpatients in two hospitals and five surrogates were presented with six hypothetical scenarios with a randomly assigned sequence: verbal and written summary, graph, table, photo, video, and p hlet. The majority (76%) of respondents chose the traditional verbal communication of prognosis by their doctor with a written summary as a reference and to share with family the second choice was a condition-specific p hlet (63%). Many found the graph and photo to be distressing (36% and 42%, respectively). Most (71%) wanted to know everything about their condition trajectory, and 63% chose shared decision making rather than completely autonomous or full delegation to clinicians or family. There were no gender differentials between wanting to know it all, supporting shared decision making or the preferred format for breaking news (p 0.05). Older hospitalized patients with chronic conditions are willing to discuss end-of-life issues, learn about their prognosis, and be involved in shared decision making. Innovative formats such as graphs, videos, or photos were not welcome as part of the prognostic discussion.
Publisher: SAGE Publications
Date: 14-09-2012
Abstract: The Get Healthy Information and Coaching Service® (GHS), a free government-funded telephone-delivered information and coaching service was launched in February 2009 by the Australian New South Wales state government. It represents the translation of research evidence applied in the real world (T4 or Phase 4 translation), aimed at addressing the modifiable risk factors associated with the overweight and obesity. In controlled settings, it has been established that telephone-based lifestyle counseling programs are efficacious in reducing anthropometric and behavioral risk factors. This article presents the GHS case study as a population-wide intervention and describes the quasi-experimental evaluation framework used to evaluate both the process (statewide implementation) and impact (effectiveness) of the GHS in a real-world environment. It details the data collection, measures, and statistical analysis required in assessing the process of implementation—reach and recruitment, marketing and promotion, service satisfaction, intervention fidelity, and GHS setting up and operations costs—and in assessing the impact of GHS—increasing physical activity, improving dietary practices, and reducing body weight and waist circumference. The comprehensive evaluation framework designed for the GHS provides a method for building effectiveness evidence of a rare translation of efficacy trial evidence into population-wide practice.
Publisher: Springer Science and Business Media LLC
Date: 29-10-2010
Publisher: Elsevier BV
Date: 2019
DOI: 10.1016/J.ARCHGER.2018.11.002
Abstract: To determine the prevalence of frailty in Emergency Departments (EDs) examine the ability of frailty to predict poor outcomes post-discharge and identify the most appropriate instrument for routine ED use. In this prospective study we simultaneously assessed adults 65+yrs admitted and/or spent one night in the ED using Fried, the Clinical Frailty Scale (CFS), and SUHB (Stable, Unstable, Help to walk, Bedbound) scales in four Australian EDs for rapid recognition of frailty between June 2015 and March 2016. 899 adults with complete follow-up data (mean (SD) age 80.0 (8.3) years female 51.4%) were screened for frailty. Although different scales yielded vastly different frailty prevalence (SUHB 9.7%, Fried 30.4%, CFS 43.7%), predictive discrimination of poor discharge outcomes (death, poor self-reported health/quality of life, need for community services post-discharge, or reattendance to ED after the index hospitalization) for all identical final models was equivalent across all scales (AUROC 0.735 for Fried, 0.730 for CFS and 0.720 for SUHB). This study confirms that screening for frailty in older ED patients can inform prognosis and target discharge planning including community services required. The CFS was as accurate as the Fried and SUHB in predicting poor outcomes, but more practical for use in busy clinical environments with lower level of disruption. Given the limitations of objectively measuring frailty parameters, self-report and clinical judgment can reliably substitute the assessment in EDs. We propose that in a busy ED environment, frailty scores could be used as a red flag for poor follow-up outcome.
Publisher: Cardiff University Press
Date: 30-06-2020
DOI: 10.18573/BSDJ.170
Publisher: Springer Science and Business Media LLC
Date: 23-08-2012
Abstract: Research literature consistently documents that scientifically based therapeutic recommendations are not always followed in the hospital or in the primary care setting. Currently, there is evidence that some general practitioners in Australia are not prescribing appropriately for patients diagnosed with 1) hypertension (HT) and 2) chronic heart failure (CHF). The objectives of this study were to improve general practitioner’s drug treatment management of these patients through feedback on their own prescribing and small group discussions with peers and a trained group facilitator. The impact evaluation includes quantitative assessment of prescribing changes at 6, 9, 12 and 18 months after the intervention. A pragmatic multi site cluster RCT began recruiting practices in October 2009 to evaluate the effects of a multi-faceted quality improvement (QI) intervention on prescribing practice among Australian general practitioners (GP) in relation to patients with CHF and HT. General practices were recruited nationally through General Practice Networks across Australia. Participating practices were randomly allocated to one of three groups: two groups received the QI intervention (the prescribing indicator feedback reports and small group discussion) with each group undertaking the clinical topics (CHF and HT) in reverse order to the other. The third group was waitlisted to receive the intervention 6 months later and acted as a “control” for the other two groups. De-identified data on practice, doctor and patient characteristics and their treatment for CHF and HT are extracted at six-monthly intervals before and after the intervention. Post-test comparisons will be conducted between the intervention and control arms using intention to treat analysis and models that account for clustering of practices in a Network and clustering of patients within practices and GPs. This paper describes the study protocol for a project that will contribute to the development of acceptable and sustainable methods to promote QI activities within routine general practice, enhance prescribing practices and improve patient outcomes in the context of CHF and HT. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR), Trial # 320870.
Publisher: Springer Science and Business Media LLC
Date: 16-11-2022
DOI: 10.1186/S12877-022-03554-X
Abstract: Hospitalisation rates for older people are increasing, with end-of-life care becoming a more medicalised experience. Innovative approaches are warranted to support early identification of the end-of-life phase, communicate prognosis, provide care consistent with people’s preferences, and improve the use of healthcare resources. The Intervention for Appropriate Care and Treatment (InterACT) trial aimed to increase appropriate care and treatment decisions for older people at the end of life, through implementation of a prospective feedback loop. This paper reports on the care review outcomes. A stepped-wedge randomised controlled trial was conducted in three large acute hospitals in Queensland, Australia between May 2020 and June 2021. The trial identified older people nearing the end of life using two validated tools for detecting deterioration and short-term death. Admitting clinical teams were provided with details of patients identified as at-risk with the goal of increasing awareness that end of life was approaching to facilitate appropriate patient centred care and avoid non-beneficial treatment. We examined the time between when the patient was identified as ‘at-risk’ and three outcomes: clinician-led care review discussions, review of care directive measures and palliative care referrals. These were considered useful indicators of appropriate care at the end of life. In two hospitals there was a reduction in the review of care directive measures during the intervention compared with usual care at 21 days (reduced probability of − 0.08 95% CI: − 0.12 to − 0.04 and − 0.14 95% CI: − 0.21 to − 0.06). In one hospital there was a large reduction in clinician-led care review discussions at 21 days during the intervention (reduced probability of − 0.20 95% CI: − 0.28 to − 0.13). There was little change in palliative care referrals in any hospital, with average probability differences at 21 days of − 0.01, 0.02 and 0.04. The results are disappointing as an intervention designed to improve care of hospitalised older people appeared to have the opposite effect on care review outcomes. The reasons for this may be a combination of the intervention design and health system challenges due to the pandemic that highlight the complexity of providing more appropriate care at the end of life. Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019).
Publisher: Springer Science and Business Media LLC
Date: 26-02-1999
Publisher: Springer Science and Business Media LLC
Date: 31-10-2018
Publisher: European Respiratory Society (ERS)
Date: 06-2020
DOI: 10.1183/20734735.0062-2020
Abstract: The patient and family perspective on the appropriateness of intensive care unit (ICU) treatments involves preferences, values and social constructs beyond medical criteria. The clinician's perception of inappropriateness is more reliant on clinical judgment. Earlier consultation with families before ICU admission and patient education on the outcomes of life-sustaining therapies may help reconcile these provider–patient disagreements. However, global emergencies like COVID-19 change the usual paradigm of end-of-life care, as it is a new disease with only scarce predictive information about it. Pandemics can also bring about the burdensome predicament of doctors having to make unwanted choices of rationing access to the ICU when demand for otherwise life-saving resources exceeds supply. Evidence-based prognostic checklists may guide treatment triage but the principles of shared decision-making are unchanged. Yet, they need to be altered with respect to COVID-19, defining likely outcomes and likelihood of benefit for the patient, and clarifying their willingness to take on the risks inherent to being in an ICU for 2 weeks for those eligible. For patients who are admitted during the prodrome of COVID-19 disease, or those who deteriorate in the second week, clinicians have some lead time in hospital to have appropriate discussions about ceilings of treatments offered based on severity. The patient and family perspective on inappropriateness of intensive care at the end of life often differs from the clinician's opinion due to the nonmedical frame of mind. To improve satisfaction with communication on treatment goals, consultation on patient values and inclusion of social constructs in addition to clinical prediction is a good start to reconcile differences between physician and health service users’ viewpoints. During pandemics, where health systems may collapse, different admission criteria driven by the need to ration services may be warranted. To explore the extent to which older patients and their families are involved in decisions about appropriateness of intensive care admission or treatments To understand how patients or their families define inappropriate intensive care admission or treatments To reflect on the implications of decision to admit or not to admit to the intensive care unit in the face of acute resource shortages during a pandemic
Publisher: Informa UK Limited
Date: 03-2007
Publisher: Elsevier BV
Date: 11-2017
DOI: 10.1016/J.EJIM.2017.09.026
Abstract: Frailty is a state of vulnerability resulting from cumulative decline in many physiological systems during a lifetime. It is progressive and considered largely irreversible, but its progression may be controlled and can be slowed down and its precursor -pre-frailty- can be treated with multidisciplinary intervention. The aim of this narrative review is to provide an overview of the different ways of measuring frailty in community settings, hospital, emergency, general practice and residential aged care suggest occupational groups who can assess frailty in various services discuss the feasibility of comprehensive geriatric assessments and summarise current evidence of its management guidelines. We also suggest practical recommendations to recognise frail patients near the end of life, so discussions on goals of care, advance care directives, and shared decision-making including early referrals to palliative and supportive care can take place before an emergency arises. We acknowledge the barriers to systematically assess frailty and the absence of consensus on best instruments for different settings. Nevertheless, given its potential consequences including prolonged suffering, disability and death, we recommend identification of frailty levels should be universally attempted in older people at any health service, to facilitate care coordination, and honest discussions on preferences for advance care with patients and their caregivers.
Publisher: Wiley
Date: 13-03-2019
DOI: 10.1111/AJAG.12630
Abstract: To investigate views, determinants and barriers to end-of-life discussions for doctors, nurses and members of the public (MoP) and their acceptability of risk prediction tools. Concurrent surveys of 360 doctors and nurses and 497 MoP. Sixty per cent of clinicians reported high confidence in initiating end-of-life discussions, and 55.8% regularly engaged in them. Barriers to end-of-life communication reported by clinicians were uncertainty on the likely time to death (44.7%) and family requests to withhold information from patients (44.2%). By contrast, most (92.8%) MoP wanted information about life expectancy 89.9% wanted involvement in treatment decisions if the likelihood of death was high and 23.8% already had an advance care directive. A dissonance exists between doctor/nurses perception of older peoples' preference for receiving prognostic information and the public desire for involvement in decision-making at the end of life. As public attitudes change, strategies for greater involvement of patients in shared end-of-life planning are warranted.
Publisher: SAGE Publications
Date: 13-10-2023
Publisher: Elsevier BV
Date: 10-2017
DOI: 10.1016/J.DIABRES.2017.07.032
Abstract: There is strong and consistent evidence from large scale randomised controlled trials that type 2 diabetes can be prevented or delayed through lifestyle modification which improves diet quality, increases physical activity and achieves weight loss in people at risk. Worldwide, the prevalence of type 2 diabetes is increasing in in iduals of Chinese descent. Culturally tailored programs are required to address the risk in the Chinese population. This paper analyses effectiveness of a culturally tailored community-based lifestyle modification program (Sydney Diabetes Prevention Program (SDPP)) targeting Mandarin speakers. The SDPP was a 12 month translational study aiming to promote increased physical activity and dietary changes. Effectiveness was assessed through the improvement of anthropometric, metabolic, physical activity and dietary outcomes and number of goals met. Seventy-eight Mandarin-speaking participants at a high risk (Australian Diabetes Risk, AUSDRISK≥15) of developing diabetes were recruited for this study. In this cohort, waist circumference, total cholesterol and fat intake significantly improved at the 12-month review. In comparison to the English-speaking stream, the Mandarin-speaking stream achieved fewer improvements in outcomes and goals. The SDPP was not effective in reducing the risk factors associated with developing type 2 diabetes in this cohort of high risk Mandarin-speaking in iduals living in Sydney.
Publisher: Informa UK Limited
Date: 21-12-2020
Publisher: Hindawi Limited
Date: 16-07-2018
DOI: 10.1111/IJCP.13222
Abstract: Predicting risk of death based on personalised and objective clinical indicators is an improvement over intuition and clinical judgement. Risk assessment can benefit clinicians by improving prognostic certainty, and truth disclosure helps patients and families by preventing futile management. Some argue that consent should be obtained before a patient is given an estimate of their prognosis as disclosure of bad news can overburden patients. In this article, we argue that it is unethical not to use existing person-specific information to guide diagnosis and shared decision making on management in partnership with well-informed patients. Disclosure of a poor prognosis should be normalised in personalised medicine, performed incrementally and with sensitivity so that it is acceptable to patients, and only occur if patients want to know it. However, a requirement of consent for truth disclosure should not be mandatory. Despite some level of imprecision, personalised risk estimations can be used to tailor management to the patient's informed wishes and ensure that healthcare providers and families are acting ethically in the patient's best interest.
Publisher: Elsevier BV
Date: 05-2018
DOI: 10.1016/J.ARCHGER.2018.02.014
Abstract: Prognostic uncertainty inhibits clinicians from initiating timely end-of-life discussions and advance care planning. This study evaluates the efficacy of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist in emergency departments. Prospective cohort study of patients aged ≥65 years with any diagnosis admitted via emergency departments in ten hospitals in Australia, Denmark and Ireland. Electronic and paper clinical records will be used to extract risk factors such as nursing home residency, physiological deterioration warranting a rapid response call, personal history of active chronic disease, history of hospitalisations or intensive care unit admission in the past year, evidence of proteinuria or ECG abnormalities, and evidence of frailty to be concurrently measured with Fried Score and Clinical Frailty Scale. Patients or their informal caregivers will be contacted by telephone around three months after initial assessment to ascertain survival, self-reported health, post-discharge frailty and health service utilisation since discharge. Logistic regression and bootstrapping techniques and AUROC curves will be used to test the predictive accuracy of CriSTAL for death within 90 days of admission and in-hospital death. The CriSTAL checklist is an objective and practical tool for use in emergency departments among older patients to determine in idual probability of death in the short-term. Its validation in this cohort is expected to reduce clinicians' prognostic uncertainty on the time to patients' death and encourage timely end-of-life conversations to support clinical decisions with older frail patients and their families about their imminent or future care choices.
Publisher: No publisher found
Date: 2018
Publisher: Wiley
Date: 08-1999
DOI: 10.1046/J.1440-1754.1999.00385.X
Abstract: To determine whether a 7-year-old child with extrapulmonary and pulmonary tuberculosis (TB) and direct smear positive sputum for acid-fast bacilli was infectious to home and school contacts, and to ascertain potential adult sources of infection for these contacts. Contact tracing by Mantoux testing was conducted on 220 children at a primary school and after-school care facility, and 59 selected adults considered potential sources of infection. The participation rate for the children was 98% and 92% for the adults. Mantoux positivity (induration >/= 10 mm, or >/= 15 mm with previous BCG) among children was 13% at the school (anticipated rate 2-3%), 26% among school staff, and 7% among children at the after-school care centre where the index case attended. One exposed adult hospital staff member converted from Mantoux negative to positive. No other cases of TB disease were detected among children or adults tested. Although spread of TB from children to others is rare, the findings of this investigation indicate that transmission of TB from a young child to other children and an adult may have occurred, and that sputum testing and contact tracing for sputum smear positive children should be considered.
Publisher: SAGE Publications
Date: 10-07-2016
Abstract: Administration of non-beneficial life-sustaining treatments in terminal elderly patients still occurs due to lack of knowledge of patient’s wishes or delayed physician–family communications on preference. To determine whether advance care documentation encourages healthcare professional’s timely engagement in end-of-life discussions. Systematic review of the English language articles published from January 2000 to April 2015. EMBASE, MEDLINE, EBM REVIEWS, PsycINFO, CINAHL and Cochrane Library and manual searches of reference lists. A total of 24 eligible articles from 10 countries including 23,914 subjects met the inclusion criteria, mostly using qualitative or mixed methods, with the exception of two cohort studies. The influence of advance care documentation on initiation of end-of-life discussions was predominantly based on perceptions, attitudes, beliefs and personal experience rather than on standard replicable measures of effectiveness in triggering the discussion. While health professionals reported positive perceptions of the use of advance care documentations (18/24 studies), actual evidence of their engagement in end-of-life discussions or confidence gained from accessing previously formulated wishes in advance care documentations was not generally available. Perceived effectiveness of advance care documentation in encouraging end-of-life discussions appears to be high but is mostly derived from low-level evidence studies. This may indicate a willingness and openness of patients, surrogates and staff to perceive advance directives as an instrument to improve communication, rather than actual evidence of timeliness or effectiveness from suitably designed studies. The assumption that advance care documentations will lead to higher physicians’ confidence or engagement in communicating with patients/families could not be objectively demonstrated in this review.
Publisher: Elsevier BV
Date: 03-2023
Publisher: Springer Science and Business Media LLC
Date: 12-2021
DOI: 10.1186/S12877-021-02680-2
Abstract: Overtreatment in advanced age i.e. aggressive interventions that do not improve survival and are potentially harmful, can impair quality of care near the end of life (EOL). As healthcare provider perspectives on care quality may differ from that of service users, the aim of this study was to explore the views of older patients near EOL or their caregivers about the quality of health care at the EOL based on their lived experience, and to identify healthcare service improvements. Medline and backward citation searches were conducted for qualitative or quantitative studies reported on the views of patients and/or informal caregivers about EOL care quality. Thematic analysis was used to summarise qualitative data (primary analysis) narrative and tabulations were used to summarise quantitative data (secondary analysis). Thirty articles met the inclusion criteria. Five main qualitative themes regarding quality care emerged: (1) Effective communication between clinicians and patients/caregivers (2) Healthcare that values patient preferences and shared decision making (3) Models of care that support quality of life and death with dignity (4) Healthcare services that meet patient expectations and (5) Support for informal caregivers in dealing with EOL challenges. The quantitative articles supported various aspects of the thematic framework. The findings of this study show that many of the issues highlighted by patients or bereaved relatives have persisted over the past two decades. There is an urgent need for comprehensive evaluation of care across the healthcare system and targeted redesign of existing EOL care pathways to ensure that care aligns with what patients and informal caregivers consider high-quality patient-centred care at the EOL.
Publisher: BMJ
Date: 05-01-2015
Publisher: Research Square Platform LLC
Date: 12-09-2022
DOI: 10.21203/RS.3.RS-2017943/V1
Abstract: International students, particularly those from non-English speaking countries seeking admission to higher degree by research in Anglophone universities face multiple challenges in understanding the educational system rules, and socially adapting to the host country. Through a targeted literature search we identified barriers and facilitators to the multicultural students’ integration into a foreign education system which could hinder either their admission to postgraduate research courses or their performance during Master’s or doctoral enrolment. The four emerging themes were incorporated into checklists: English proficiency, Academic literacy, Communication and interpersonal skills, and Socio-demographic and cultural influences. These formed the basis for the development of the Supervisor’s Tool for Assessment of Readiness (STAR), an amalgamation of the checklists to provide an objective and comprehensive view of all aspects potential supervisors -and higher degree by research candidates- need to consider in the postgraduate admission process. We encourage readers to test and validate STAR in their academic environments and modify to suit their local needs.
Publisher: BMJ
Date: 08-2008
Abstract: Little is known about the burden or causes of injury in rural villages in India. To examine injury-related mortality and morbidity in villages in the state of Andhra Pradesh, India. A verbal-autopsy-based mortality surveillance study was used to collect mortality data on all ages from residents in 45 villages in 2003-2004. In early 2005, a morbidity survey in adults was carried out using stratified random s ling in 20 villages. Participants were asked about injuries sustained in the preceding 12 months. Both fatal and non-fatal injuries were coded using classification methods derived from ICD-10. Response rates for the mortality surveillance and morbidity survey were 98% and 81%, respectively. Injury was the second leading cause of death for all ages, responsible for 13% (95% CI 11% to 15%) of all deaths. The leading causes of fatal injury were self-harm (36%), falls (20%), and road traffic crashes (13%). Non-fatal injury was reported by 6.7% of survey participants, with the leading causes of injury being falls (38%), road traffic crashes (25%), and mechanical forces (16.1%). Falls were more common in women, with most (72.3%) attributable to slipping and tripping. Road traffic injuries were sustained mainly by men and were primarily the result of motorcycle crashes (48.8%). Injury is an important contributor to disease burden in rural India. The leading causes of injury-falls, road traffic crashes, and suicides-are all preventable. It is important that effective interventions are developed and implemented to minimize the impact of injury in this region.
Publisher: Informa UK Limited
Date: 15-03-2022
DOI: 10.1080/21548331.2022.2054633
Abstract: Understanding the longitudinal patient experience outcomes following major trauma can promote successful recovery. A novel, hospital-led telephone follow-up program was implemented by a multi-disciplinary clinical trauma service team at a Level I trauma center. This process evaluation examined what factors promoted or impeded the program's implementation. A prospective convergent mixed-methods process evaluation design was used. Quantitative data included patient and injury demographics and program feasibility data such number of telephone calls attempted/completed and call duration. Qualitative data consisted of semi-structured interviews with program participants (staff, patients, and caregivers) who had participated in the program. Descriptive statistics and thematic analysis were applied to quantitative and qualitative data, respectively. Data were collected concurrently and merged in the results to understand and describe the implementation and sustainability of the program.274 major trauma patients (ISS ≥ 12) were eligible for follow-up. A response rate of over 75% was achieved, with nurses responsible for most of the calls. Limited time and competing clinical demands were identified as barriers to the timely completion of the calls. Participants valued the preexisting trauma service atient relationship, and this facilitated program implementation. Clinicians were motivated to evaluate their patient's recovery, whilst patients felt 'cared for' and 'not forgotten' post-hospital discharge. Teamwork and leadership were highly valued by the clinical staff throughout the implementation period as ongoing source of motivation and support.Staff spontaneously developed the program to incorporate clinical follow-up processes by providing guidance, advice, and referrals to patients who indicated ongoing issues such as pain or emotional problems. Telephone follow-up within a clinical trauma service team is feasible, accepted by staff and valued by patients and families. Despite time constraints, the successful implementation of this program is reliant on existing clinical atient relationships, staff teamwork and leadership support.
Publisher: Springer Science and Business Media LLC
Date: 10-06-2010
Publisher: Elsevier BV
Date: 10-2010
Publisher: Ubiquity Press, Ltd.
Date: 12-08-2022
DOI: 10.5334/GH.1142
Publisher: Oxford University Press (OUP)
Date: 09-2022
DOI: 10.1111/JAM.15655
Abstract: The aim of this study was to assess a phage-displayed MilA protein of Myc. bovis in an indirect ELISA for the detection of Myc. bovis antibodies in milk s les. The desired sequence of milA gene was synthesized and cloned into pCANTAB-F12 phagemid vector. The expression of the MilA on the phage surface was confirmed by Western blotting. The recombinant phage was used in the development of an indirect ELISA to detect Myc. bovis antibodies in milk s les. There was a significant agreement between the results of phage-based ELISA and recombinant GST-MilA ELISA for the detection of Myc. bovis antibodies in milk s les. The inexpensive and convenient phage-based ELISA can be used instead of recombinant protein eptide ELISA as an initial screening of Myc. bovis-associated mastitis. Mastitis associated with Myc. bovis is a continuous and serious problem in the dairy industry. Sero-monitoring of Myc. bovis infection cases are one of the key factors for surveillance of the infections in dairy farms. Despite the existence of some commercially serological assays for Myc. bovis antibodies, they have some limitations regarding their sensitivity and availability. The development of accurate diagnosis tools could contribute to control programmes of Myc. bovis-associated mastitis in the dairy herds.
Publisher: Oxford University Press (OUP)
Date: 17-06-2016
Abstract: Early detection of patient deterioration and prevention of adverse events are key challenges to patient safety. This study investigated clinical staff perceptions of current monitoring practices and the planned introduction of continuous monitoring devices on general wards. Multi-method study comprising structured surveys, in-depth interviews and device trial with log book feedback. Two general wards in a large urban teaching hospital in Sydney, Australia. Respiratory and neurosurgery nursing staff and two doctors. Nurses were confident about their abilities to identify patients at risk of deterioration, using a combination of vital signs and visual assessment. There were concerns about the accuracy of current vital signs monitoring equipment and frequency of intermittent observation. Both the nurses and the doctors were enthusiastic about the prospect of continuous monitoring and perceived it would allow earlier identification of patient deterioration provide reassurance to patients and support interdisciplinary communication. There were also reservations about continuous monitoring, including potential decrease in bedside nurse-patient interactions increase in inappropriate escalations of patient care and discomfort to patients. While continuous monitoring devices were seen as a potentially positive tool to support the identification of patient deterioration, drawbacks, such as the potential for reduced patient contact, revealed key areas that will require close surveillance following the implementation of devices. Training and improved interdisciplinary communication were identified as key requisites for successful implementation.
Publisher: Informa UK Limited
Date: 08-2022
DOI: 10.2147/COPD.S366412
Publisher: Oxford University Press (OUP)
Date: 22-09-2006
DOI: 10.1093/IJE/DYL168
Abstract: India is undergoing rapid epidemiological transition as a consequence of economic and social change. The pattern of mortality is a key indicator of the consequent health effects but up-to-date, precise, and reliable statistics are few, particularly in rural areas. Deaths occurring in 45 villages (population 180 162) were documented during a 12-month period in 2003-04 by multipurpose primary healthcare workers trained in the use of a verbal autopsy tool. Algorithms were used to define causes of death according to a limited list derived from the international classification of disease version 10. Causes were assigned by two independent physicians with disagreements resolved by a third. A total of 1354 deaths were recorded with verbal autopsies completed for 98%. A specific underlying cause of death was assigned for 82% of all verbal autopsies done. The crude death rate was 7.5/1000 (95% confidence interval, 7.1-7.9). Diseases of the circulatory system were the leading causes of mortality (32%), with similar proportions of deaths attributable to ischaemic heart disease and stroke. Second was injury and external causes of mortality (13%) with one-third of these deaths attributable to deliberate self harm. Third were infectious and parasitic diseases (12%). Tuberculosis and intestinal conditions each caused one-third of deaths within this category. HIV was assigned as the cause for 2% of all deaths. The fourth and fifth leading causes of death were neoplasms (7%) and diseases of the respiratory system (5%). Non-communicable and chronic diseases are the leading causes of death in this part of rural India. The observed pattern of death is unlikely to be unique to these villages and provides new insight into the rapid progression of epidemiological transition in rural India.
Publisher: Oxford University Press (OUP)
Date: 09-2016
Abstract: To investigate the extent of objective 'non-beneficial treatments (NBTs)' (too much) anytime in the last 6 months of life in routine hospital care. English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-April 2015). All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL). A 13-item quality score estimated independently by two authors. Evidence from 38 studies indicates that on average 33-38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11-90%). Mean death in intensive care unit (ICU) was 42% (range 11-90%) and mean death rate in a hospital ward was 44.5% (range 29-60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7-77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11-75% (mean 38%). Non-beneficial tests were performed on 33-50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0-33%) for chemotherapy in the last six weeks of life was 33% (95% CI 24-41%). This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.
Publisher: Springer Science and Business Media LLC
Date: 26-05-2020
Publisher: Springer Science and Business Media LLC
Date: 13-03-2021
Publisher: Cold Spring Harbor Laboratory
Date: 23-09-2020
DOI: 10.1101/2020.09.20.20198184
Abstract: As the world struggles with the COVID-19 pandemic, health service demands have increased to a point where healthcare resources may prove inadequate to meet demand. Guidelines and tools on how to best allocate intensive care beds and ventilators developed during previous epidemics can assist clinicians and policy-makers to make consistent, objective and ethically sounds decisions about resource allocation when healthcare rationing is inevitable. This scoping review of 62 published guidelines, triage protocols, consensus statements and prognostic tools from crisis and non-crisis situations sought to identify a multiplicity of objective factors to inform healthcare rationing of critical care and ventilator care. It also took ethical considerations into account. Prognostic indicators and other decision tools presented here can be combined to create locally-relevant triage algorithms for clinical services and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. Community awareness of the triage protocol is recommended to build trust and alleviate anxiety among the public. This review provides a unique resource and is intended as a discussion starter for clinical services and policy makers to consider formalising an objective triage consensus document that fits the local context. An evidence-based catalogue of objective variables from 62 published resources tested in crisis and non-crisis situations can help clinicians make locally relevant triage decisions on ICU and ventilator allocation in inevitable COVID-19 health rationing.
Publisher: Elsevier BV
Date: 07-2017
DOI: 10.1016/J.EJIM.2017.04.014
Abstract: Older people with advance chronic illness use hospital services repeatedly near the end of life. Some of these hospitalizations are considered inappropriate. To investigate extent and causes of inappropriate hospital admission among older patients near the end of life. English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-December 2016) covering community and nursing home residents aged ≥60years admitted to hospital. measurements of inappropriateness. A 17-item quality score was estimated independently by two authors. The definition of 'Inappropriate admissions' near the end of life incorporated system factors, social and family factors. The prevalence of inappropriate admissions ranged widely depending largely on non-clinical reasons: poor availability of alternative sites of care or failure of preventive actions by other healthcare providers (1.7-67.0%) family requests (up to 10.5%) or too late an admission to be of benefit (1.7-35.0%). The widespread use of subjective parameters not routinely collected in practice, and the inclusion of non-clinical factors precluded the true estimation of clinical inappropriateness. Clinical inappropriateness and system factors that preclude alternative community care must be measured separately. They are two very different justifications for hospital admissions, requiring different solutions. Society has a duty to ensure availability of community alternatives for the management of ambulatory-sensitive conditions and facilitate skilling of staff to manage the terminally ill in non-acute settings. Only then would the evaluation of local variations in clinically inappropriate admissions and inappropriate length of stay be possible to undertake.
Publisher: Informa UK Limited
Date: 04-01-2022
Publisher: Elsevier BV
Date: 02-1995
Abstract: To assess the utility of a new, rapid, economical procedure that may prove valuable in cervical screening, Fourier transform infrared (ir) spectroscopy was performed on 25 cervicovaginal lavage specimens from women referred for colposcopy on the basis of a cytological abnormality detected on their Pap smear and whose lavage specimen was positive for human papillomavirus. Of the 18 classed as CIN I or less by histopathology, 11 showed band frequencies that deviated only slightly from spectra that characterize normal cervical cells and 3 of 5 "atypia" specimens had spectra identical to normal. Two of 3 classed as CIN II had spectra only slightly more abnormal to these 11. In the case of 2 graded as CIN I, several bands were similarly altered in the direction of the pattern seen for 4 CIN III specimens. A further CIN I s le gave a spectrum that was even further shifted toward the latter and the remaining CIN I s le had a pattern that matched the 4 CIN IIIs. The most obvious change in each of the CIN IIIs was an additional peak at 972 cm-1 and this has been suggested as a key indicator for malignancy. One of the 3 CIN IIs had this peak. Other characteristic spectral changes were seen as well in the CIN III s les. High-risk HPV18 was present in 3 of the CIN III s les, as well as in one specimen classed as atypia, but having an abnormal ir spectrum. Low-risk HPV 6 or 11 was seen along in s les with a normal or slightly abnormal ir spectrum, but never in those that showed an ir pattern that was abnormal. The current study has therefore shown complete concordance between ir spectral findings and histopathology result in the case of CIN III specimens, but less precise matching for other grades of CIN. The spectral differences revealed by ir spectroscopy are likely to characterize molecular abnormalities in cervical cells during progression to cancer and may therefore have potential in assisting with clinical decision making. More studies will, however, be required to establish the place of this technique in cervical screening.
Publisher: Hindawi Limited
Date: 31-08-2016
DOI: 10.1111/IJCP.12846
Abstract: Vital signs monitoring is an old hospital practice for patient safety but evaluation of its effectiveness is not widespread. We aimed to identify strategies to improve intermittent or continuous vital signs monitoring in general wards and their effectiveness in preventing adverse events on general hospital wards. Publications searched between 1980 and June 2014 in five databases. Main outcome measures were in-hospital death, cardiac arrest, intensive care unit (ICU) transfers, length of stay, identification of physiological deterioration and activation of rapid response systems. Twenty-two studies assessing the effect of continuous (9) or intermittent monitoring (13) and reporting outcomes on 203,407 patients in-hospital wards across 13 countries were included in this review. Both monitoring practices led to early identification of patient deterioration, increased rapid response activations and improvements in timeliness or completeness of vital signs documentation. Innovative intermittent monitoring approaches are associated with modest reduction in in-hospital mortality over intermittent vital signs monitoring in 'usual care'. However, there was no evidence of significant reduction in ICU transfers or other adverse events with either intermittent or continuous monitoring. This review of heterogeneous monitoring approaches found no conclusive confirmation of improvements in prevention of cardiac arrest, reduction in length of hospital stay, or prevention of other neurological or cardiovascular adverse events. The evidence found to date is insufficient to recommend continuous vital signs monitoring in general wards as routine practice. Future evaluations of effectiveness need to be undertaken with more rigorous methods and homogeneous outcome measurements.
Publisher: Informa UK Limited
Date: 26-11-2018
DOI: 10.1080/10410236.2018.1548335
Abstract: Initiating end-of-life (EoL) discussions with patients is often delayed or avoided altogether by healthcare practitioners even in light of imminent death. This continues despite the availability of guidelines and conceptual frameworks on how to communicate prognoses at EoL. We surveyed healthcare practitioners to elicit their exposure to and confidence in EoL discussions and to better understand factors that enable or challenge the initiation of discussions in Australian healthcare settings. Thematic analysis identified that EoL discussions could be emotionally burdensome for healthcare practitioners but were regarded as valuable. Effective communications were challenged by conflict with families and between healthcare practitioners as to appropriate care goal transition, and by prognostic uncertainty. Communication skills appeared to be developed more from experience, and beneficial strategies such as role play and mentoring particularly for younger nurses and doctors were identified. Specific training in EoL communications should target undergraduates and new healthcare practitioners.
Publisher: Mary Ann Liebert Inc
Date: 09-2022
Publisher: S. Karger AG
Date: 2020
DOI: 10.1159/000509103
Abstract: The large scale and rapid spread of the current COVID-19 pandemic has changed the way hospitals and other health services operate. Opportunities for patient-centered decision-making at the end of life are being jeopardized by a scarcity of health system resources. In response, the traditional doctor-initiated advanced care planning (ACP) for critical illness may also need to be readjusted. We propose nurse-led and allied health-led ACP discussions to ensure patient and family inclusion and understanding of the disease prognosis, prevention of overtreatment, and potential outcomes in crisis times. We highlight known barriers and list enablers, long-term and short-term opportunities to assist in the culture change.
Publisher: WHO Press
Date: 2023
Publisher: BMJ
Date: 11-2022
DOI: 10.1136/BMJOPEN-2022-062755
Abstract: Low-value care can lead to patient harm, misdirected clinician time and wastage of finite healthcare resources. Despite worldwide endeavours, deimplementing low-value care has proved challenging. Multifaceted, context and barrier-specific interventions are essential for successful deimplementation. The aim of this literature review is to summarise the evidence about barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice. A mixed methods scoping review using the Arksey and O’Malley framework will be conducted. MEDLINE, CINAHL, EMBASE, EMCare, Scopus and grey literature will be searched from inception. Primary studies will be included. Barriers, enablers and interventions will be mapped to the domains of the Theoretical Domains Framework. Study selection, data collection and quality assessment will be performed by two independent reviewers. NVivo software will be used for qualitative data analysis. Mixed Methods Appraisal Tool will be used for quality assessment. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework will be used to present results. Ethics approval is not required for this scoping review. This review will generate an evidence summary regarding barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice. This review will facilitate discussions about deimplementation with relevant stakeholders including healthcare providers, consumers and managers. These discussions are expected to inform the design and conduct of planned future projects to identify context-specific barriers and enablers then codesign, implement and evaluate barrier-specific interventions.
Publisher: American Diabetes Association
Date: 07-2006
DOI: 10.2337/DC06-0621
Publisher: Informa UK Limited
Date: 11-2022
DOI: 10.2147/CIA.S384691
Publisher: Elsevier BV
Date: 12-2016
DOI: 10.1016/J.RESUSCITATION.2016.09.031
Abstract: To investigate associations between clinical parameters - beyond the evident physiological deterioration and limitations of medical treatment - with in-hospital death for patients receiving Rapid Response System (RRS) attendances. Retrospective case-control analysis of clinical parameters for 328 patients aged 60 years and above at their last RRS call during admission to a single teaching hospital in the 2012-2013 calendar years. Generalised estimating equation modelling was used to compare the deceased with a randomly selected s le of those who had RRS calls and survived admission (controls), matched by age group, sex, and hospital ward. In addition to a pre-existing order for limitation of treatment or cardiac arrest (OR 6.92 95%CI 4.61-10.27), nursing home residence, proteinuria, advanced malignancy, acute myocardial infarction, chronic kidney disease, cognitive impairment and frailty were associated with high risk of death. After adjusting for all the clinical indicators investigated, the strongest risk factors for in-hospital death for patients with a RRS call were advanced malignancy (OR 3.95 95%CI 2.16-7.21) and new myocardial infarction (OR 2.79 95%CI 1.86-4.20). Patients with cognitive impairment, frailty indicator or chronic kidney disease were twice as likely to die as patients without those risk factors. In a s le of older deteriorated patients requiring a RRS attendance, multiple indicators of chronic illness, cognitive impairment and frailty were significantly associated with high risk of death. These clinical features beyond the evident orders for limitation of medical treatment should signal the need for clinicians to initiate end-of-life discussions that may prevent futile interventions.
Publisher: Springer Science and Business Media LLC
Date: 20-05-2019
DOI: 10.1038/S41564-019-0443-4
Abstract: The upper respiratory tract is continuously exposed to a vast array of potentially pathogenic viruses and bacteria. Influenza A virus (IAV) has particular synergism with the commensal bacterium Streptococcus pneumoniae in this niche, and co-infection exacerbates pathogenicity and causes significant mortality. However, it is not known whether this synergism is associated with a direct interaction between the two pathogens. We have previously reported that co-administration of a whole-inactivated IAV vaccine (γ-Flu) with a whole-inactivated pneumococcal vaccine (γ-PN) enhances pneumococcal-specific responses. In this study, we show that mucosal co-administration of γ-Flu and γ-PN similarly augments IAV-specific immunity, particularly tissue-resident memory cell responses in the lung. In addition, our in vitro analysis revealed that S. pneumoniae directly interacts with both γ-Flu and with live IAV, facilitating increased uptake by macrophages as well as increased infection of epithelial cells by IAV. These observations provide an additional explanation for the synergistic pathogenicity of IAV and S. pneumoniae, as well as heralding the prospect of exploiting the phenomenon to develop better vaccine strategies for both pathogens.
Publisher: Springer International Publishing
Date: 2017
Publisher: Springer Science and Business Media LLC
Date: 27-10-2020
Publisher: Wiley
Date: 06-01-2019
DOI: 10.1111/HEX.12860
Publisher: Oxford University Press (OUP)
Date: 16-04-2020
Abstract: General practitioners’ (GPs) play a central role in facilitating end-of-life discussions with older patients nearing the end-of-life. However, prognostic uncertainty of time to death is one important barrier to initiation of these discussions. To explore GPs’ perceptions of the feasibility and acceptability of a risk prediction checklist to identify older patients in their last 12 months of life and describe perceived barriers and facilitators for implementing end-of-life planning. Qualitative, semi-structured interviews were conducted with 15 GPs practising in metropolitan locations in New South Wales and Queensland between May and June 2019. Data were analysed thematically. Eight themes emerged: accessibility and implementation of the checklist, uncertainty around checklist’s accuracy and usefulness, time of the checklist, checklist as a potential prompt for end-of-life conversations, end-of-life conversations not an easy topic, end-of-life conversation requires time and effort, uncertainty in identifying end-of-life patients and limited community literacy on end-of-life. Most participants welcomed a risk prediction checklist in routine practice if assured of its accuracy in identifying which patients were nearing end-of-life. Most participating GPs saw the value in risk assessment and end-of-life planning. Many emphasized the need for appropriate support, tools and funding for prognostic screening and end-of-life planning for this to become routine in general practice. Well validated risk prediction tools are needed to increase clinician confidence in identifying risk of death to support end-of-life care planning.
Publisher: Springer Science and Business Media LLC
Date: 12-08-2021
Publisher: Mark Allen Group
Date: 02-02-2023
DOI: 10.12968/IJPN.2023.29.2.83
Abstract: Background: Without objective screening for risk of death, the palliative care needs of older patients near the end of life may be unrecognised and unmet. Aim: This study aimed to estimate the usefulness of the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) tool in determining older patients’ risk of death within 3-months after initial hospital admission. Methods: A prospective cohort study of 235 patients aged 70+ years, who presented to two rural emergency departments in two adjacent Australian states, was utilised. The ‘risk of death’ of each patient was screened with the CriSTAL prognostic tool. Their 3-month follow-up outcomes were assessed through telephone interviews and a clinical record review. Findings: A CriSTAL cut-off score of more than 7 yielded a sensitivity of 80.7% and specificity of 70.81% for a 3-month risk of death. Palliative care services were only used by 31% of the deceased in their last trimester of life. Conclusion: Prognostic tools provide a viable means of identifying in iduals with a poor prognosis. Identification can trigger an earlier referral to palliative care, which will benefit the patient's wellbeing and quality of life.
Publisher: Informa UK Limited
Date: 06-05-2021
Publisher: Elsevier BV
Date: 02-2016
DOI: 10.1016/J.DIABRES.2015.11.010
Abstract: The Sydney Diabetes Prevention Program (SDPP) was a community-based type 2 diabetes prevention translational research study with screening and recruitment in the primary health care setting. We aimed to investigate the program's effectiveness in reducing risk factors for diabetes as well as the program's reach, adoption and implementation. 1238 participants aged 50-65 years at high-risk of developing type 2 diabetes were recruited by primary care physicians in the greater Sydney region. The intervention, delivered by trained allied health professionals, included an initial consultation, three group sessions/in idual sessions, three follow-up phone calls, and a final review at 12 months. Biomarkers and behavioural goals were compared between baseline and 12 months. At baseline, the mean age of those who entered the program was 58.8 ± 4.4 years, 63% female, and the mean body mass index was 31.6 ± 5.2 kg/m(2). There was a significant weight reduction of 2 ± 4.3 kg (p<0.02) in the 850 participants who completed the 12-month follow-up accompanied by improvements in diet (total fat, saturated fat, and fibre intake) and physical activity. There were also significant reductions in waist circumference 2.6 ± 4.7 cm (p<0.001) and total cholesterol -0.2 ± 0.8 mmol/L (p<0.001) but not blood glucose. The diabetes risk reduction was estimated to be 30%, consistent with similar trials. This study demonstrates that a community-based lifestyle modification program is effective in reducing important risk factors for diabetes in in iduals at high-risk of developing type 2 diabetes.
Publisher: Elsevier BV
Date: 03-2007
DOI: 10.1016/J.IJCARD.2006.03.043
Abstract: Heart attack and stroke are problems already faced by some urban populations of India, but less is known about cardiovascular disease and risk factors in rural areas. The aim of the study was to investigate the levels and management of major cardiovascular risk factors and the prevalence of cardiovascular disease in two villages in rural Andhra Pradesh, India. A cross-sectional survey was done by selecting a random s le stratified by age and gender from each village using census lists compiled in 2002. For each in idual, trained study staff administered a Telugu-translation of a structured questionnaire, performed a brief physical examination and collected a fasting venous blood s le. Weighted estimates of mean (or percentages with) risk factor levels in the population were calculated and are reported with confidence intervals unless otherwise specified. Data was collected from 345 adults aged 20 to 90. The average household size was 4.2 and the mean combined household income was about Indian Rupees 25,454 (580 US dollars) per year. The mean systolic blood pressure was 116 (114-117) mm Hg, diastolic blood pressure 73 (114-120) mm Hg, total cholesterol 4.6 (4.5-4.7) mmol/L, HDL-cholesterol 0.8 (0.8-0.9) mmol/L, LDL-cholesterol 3.2 (3.1-3.3) mmol/L and triglyceride 1.3 (1.2-1.4) mmol/L. The prevalence of current smoking was 19.9% (15.4-24.4%), hypertension 20.3% (16.2-24.4%), diabetes 3.7% (1.8-5.5%), overweight 16.9% (12.3-21.5%) and obesity 4.4% (1.9-6.8%). A medical diagnosis of cardiovascular disease (previous heart attack, stroke or angina) was reported by 2.5% (1.1-3.9%) and a further 1.1% (0.1-2.1%) had angina by the 'Rose' classification. The possibility of increasing cardiovascular risk factors and prevalence of vascular disease in areas of rural India represent a public health concern. Larger and repeated epidemiological studies focusing on chronic diseases are required to inform treatment and prevention strategies suitable for use in these areas and other resource poor settings.
Publisher: JMIR Publications Inc.
Date: 11-03-2022
DOI: 10.2196/31780
Abstract: Mental disorders are a leading cause of distress and disability worldwide. To meet patient demand, there is a need for increased access to high-quality, evidence-based mental health care. Telehealth has become well established in the treatment of illnesses, including mental health conditions. This study aims to conduct a robust evidence synthesis to assess whether there is evidence of differences between telehealth and face-to-face care for the management of less common mental and physical health conditions requiring psychotherapy. In this systematic review, we included randomized controlled trials comparing telehealth (telephone, video, or both) versus the face-to-face delivery of psychotherapy for less common mental health conditions and physical health conditions requiring psychotherapy. The psychotherapy delivered had to be comparable between the telehealth and face-to-face groups, and it had to be delivered by general practitioners, primary care nurses, or allied health staff (such as psychologists and counselors). Patient (symptom severity, overall improvement in psychological symptoms, and function), process (working alliance and client satisfaction), and financial (cost) outcomes were included. A total of 12 randomized controlled trials were included, with 931 patients in aggregate therapies included cognitive behavioral and family therapies delivered in populations encompassing addiction disorders, eating disorders, childhood mental health problems, and chronic conditions. Telehealth was delivered by video in 7 trials, by telephone in 3 trials, and by both in 1 trial, and the delivery mode was unclear in 1 trial. The risk of bias for the 12 trials was low or unclear for most domains, except for the lack of the blinding of participants, owing to the nature of the comparison. There were no significant differences in symptom severity between telehealth and face-to-face therapy immediately after treatment (standardized mean difference [SMD] 0.05, 95% CI −0.17 to 0.27) or at any other follow-up time point. Similarly, there were no significant differences immediately after treatment between telehealth and face-to-face care delivery on any of the other outcomes meta-analyzed, including overall improvement (SMD 0.00, 95% CI −0.40 to 0.39), function (SMD 0.13, 95% CI −0.16 to 0.42), working alliance client (SMD 0.11, 95% CI −0.34 to 0.57), working alliance therapist (SMD −0.16, 95% CI −0.91 to 0.59), and client satisfaction (SMD 0.12, 95% CI −0.30 to 0.53), or at any other time point (3, 6, and 12 months). With regard to effectively treating less common mental health conditions and physical conditions requiring psychological support, there is insufficient evidence of a difference between psychotherapy delivered via telehealth and the same therapy delivered face-to-face. However, there was no includable evidence in this review for some serious mental health conditions, such as schizophrenia and bipolar disorders, and further high-quality research is needed to determine whether telehealth is a viable, equivalent treatment option for these conditions.
Publisher: MDPI AG
Date: 21-08-2020
DOI: 10.3390/HEALTHCARE8030284
Abstract: Residents of Aged Care Facilities (RACF) experience burdensome hospital transfers in the last year of life, which may lead to aggressive and potentially inappropriate hospital treatments. Anticipating these transfers by identifying risk factors could encourage end-of-life discussions that may change decisions to transfer. The aim was to examine the feasibility of identifying an end-of-life risk profile among RACF residents using a predictive tool to better anticipate predictors of hospital transfers, death or poor composite outcome of hospitalisation and/or death after initial assessment. A retrospective cohort study of 373 permanent residents aged 65+ years was conducted using objective clinical factors from records in nine RACFs in metropolitan Sydney, Australia. In total, 26.8% died and 34.3% experienced a composite outcome. Cox proportional hazard regression models confirmed the feasibility of estimating the level of risk for death or a poor composite outcome. Knowing this should provide opportunities to initiate advance care planning in RACFs, facilitating decision making near the end of life. We conclude that the current structure of electronic RACF databases could be enhanced to enable comprehensive assessment of the risk of hospital re-attendance without admission. Automation tools to facilitate the risk score calculation may encourage the adoption of prediction checklists and evaluation of their association with hospital transfers.
Publisher: BMJ
Date: 12-2022
DOI: 10.1136/BMJOPEN-2022-064447
Abstract: The treatment workload associated with end-stage kidney disease (ESKD) is high. The treatment burdens experienced by patients with ESKD are not well understood. In this study, we aimed to elucidate the most important areas of treatment burden for discussion in a clinical encounter from the perspectives of patients with ESKD and nephrologists. We sought to explore possible solutions to these high priority treatment burden challenges. Nominal group technique (NGT) sessions. Three in-person NGT sessions were conducted with 19 patients with dialysis-dependent ESKD from one tertiary treatment centre (mean age 64 years range 47–82). All patients were either retired or on a disability pension 74% perceived moderate or severe treatment burden and 90% spent more than 11 hours on treatment-related activities per week (range 11–30). One online NGT session was conducted with six nephrologists from two Australian states. The primary outcome was a ranked list of treatment burden priorities. The secondary outcome was potential solutions to these treatment burden challenges. Every patient group ranked health system issues as the most important treatment burden priority. This encompassed lack of continuity and coordination of care, dissatisfaction with frequent healthcare encounters and challenges around healthcare access. Psychosocial burdens on patients and families were perceived to be the most important area of treatment burden by physicians, and were ranked the second highest priority by patients. Discussing treatment burden in a clinical encounter may lead to a better understanding of patients’ capacity to cope with their treatment workload. This could facilitate tailored care, improve health outcomes, treatment sustainability and patients’ overall quality of life.
Publisher: Cold Spring Harbor Laboratory
Date: 15-05-2020
DOI: 10.1101/2020.05.10.20097543
Abstract: The prevalence of true asymptomatic COVID-19 cases is critical to policy makers considering the effectiveness of mitigation measures against the SARS-CoV-2 pandemic. We aimed to synthesize all available research on the asymptomatic rates and transmission rates where possible. We searched PubMed, Embase, Cochrane COVID-19 trials, and Europe PMC (which covers pre-print platforms such as MedRxiv). We included primary studies reporting on asymptomatic prevalence where: (a) the s le frame includes at-risk population, and (b) there was sufficiently long follow up to identify pre-symptomatic cases. Meta-analysis used fixed effect and random effects models. We assessed risk of bias by combination of questions adapted from risk of bias tools for prevalence and diagnostic accuracy studies. We screened 2,454 articles and included 13 low risk-of-bias studies from seven countries that tested 21,708 at-risk people, of which 663 were positive and 111 were asymptomatic. Diagnosis in all studies was confirmed using a RT-PCR test. The proportion of asymptomatic cases ranged from 4% to 41%. Meta-analysis (fixed effect) found that the proportion of asymptomatic cases was 17% (95% CI: 14% - 20%) overall higher in aged care 20% (14% - 27%), and lower in non-aged care 16% (13% - 20%). Five studies provided direct evidence of forward transmission of the infection by asymptomatic cases. Overall, there was a 42% lower relative risk of asymptomatic transmission compared to symptomatic transmission (combined Relative Risk: 0.58 95% CI 0.335-0.994, p=0.047). Our estimates of the prevalence of asymptomatic COVID-19 cases and asymptomatic transmission rates are lower than many highly publicized studies, but still sufficient to warrant policy attention. Further robust epidemiological evidence is urgently needed, including in sub-populations such as children, to better understand the importance of asymptomatic cases for driving spread of the pandemic. OB is supported by NHMRC Grant APP1106452. PG is supported by NHMRC Australian Fellowship grant 1080042. KB is supported by NHMRC Investigator grant 1174523. All authors had full access to all data and agreed to final manuscript to be submitted for publication. There was no funding source for this study.
Publisher: Informa UK Limited
Date: 04-03-2023
Publisher: Elsevier BV
Date: 09-2018
DOI: 10.1016/J.JCJQ.2018.04.001
Abstract: Many patients near the end of life are subject to rapid response system (RRS) calls. A study was conducted in a large Sydney teaching hospital to identify a cutoff point that defines nonbeneficial treatment for older hospital patients receiving an RRS call, describe interventions administered, and measure the cost of hospitalization. This was a retrospective cohort of 733 adult inpatients with data for the period three months before and after their last placed RRS call. Subgroup analysis of patients aged ≥ 80 years was conducted. Log-rank, chi-square, and t-tests were used to compare survival, and logistic regression was used to examine predictors of death. Overall, 65 (8.9%) patients had a preexisting not-for-resuscitation (NFR) or not-for-RRS order none of those patients survived to three months. By contrast, patients without an NFR or not-for-RRS order had three-month survival probability of 71% (log-rank χ Identifiable risk factors clearly associated with poor clinical outcomes and death can be used as a guide to administer less aggressive treatments, including reconsideration of ICU transfers, adherence to NFR orders, and transition to end-of-life management instead of calls to the RRS team.
Publisher: Elsevier BV
Date: 2016
Publisher: Elsevier BV
Date: 10-2017
DOI: 10.1016/J.IJNURSTU.2017.07.017
Abstract: Research indicates up to one-third of rapid response team calls relate to end-of-life symptoms. The CriSTAL criteria were developed as a screening tool to identify high risk of death within three months. The primary purpose of this pilot study was to investigate the timing of palliative care referrals in patients receiving rapid response team services, and patients' CriSTAL criteria score on admission. The potential feasibility of using the CriSTAL tool to stimulate earlier Palliative Care Team (PCT) referral served as an underlying goal, and investigation of a relationship between specific CriSTAL criteria and the prediction of in-hospital death was a secondary objective. A retrospective chart review of rapid response calls made in 2015 was used to identify patient risk of death on admission based on the CriSTAL criteria. The presence and timing of PCT referral as well as patient survival status to hospital discharge were documented for comparison. A s le of 183 charts from 584 inpatients involved in over 600 RRT events recorded in 2015. The study was undertaken in a 676-bed teaching hospital in the Midwestern U.S. Ninety-one patients died during the hospital stay while 92 patients from the 493 in iduals who survived were randomly selected for full analysis. Applying CriSTAL criteria to the 141 in iduals aged 50 years or older indicated that frailty (OR=1.43, 95%CI 1.08-1.89, p=0.012), being a male (OR=3.14 95%CI 1.40-7.05, p=0.006), and the presence of two or more comorbidities (OR=3.71, 95%CI 1.67-8.24, p=0.001) were the most significant predictors of in-hospital death after adjusting for age. A CriSTAL score of 6 was the optimal cut-off for high-risk of in-hospital death. Palliative care consultations within the high-risk population occurred for 45.2% of the deceased and 40.4% of the survivors. Consultation often occurred within two days of the RRT event and many patients (46.8%) died within one day of the consultation. A positive relationship was found between the CriSTAL score, palliative care referral, and in-hospital mortality in patients who received RRT services. The study indicates a need for earlier PCT referral, showcases the potential to identify high risk of in-hospital death upon admission and supports the feasibility of using the CriSTAL criteria tool to encourage earlier PCT referrals.
Location: Netherlands
Location: Australia
Start Date: 2018
End Date: 2020
Funder: National Health and Medical Research Council
View Funded ActivityStart Date: 2019
End Date: 2019
Funder: University of New South Wales
View Funded Activity