Data-Driven Implementation Strategy to Optimise Clinician Behaviour Change at Scale in Complex Clinical Environments: A Multicentre Emergency Care Study.

AIM: To develop an evidence-driven, behaviour change focused strategy to maximise implementation and uptake of HIRAID (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) in 30 Australian rural, regional and metropolitan emergency departments. DESIGN: An embedded, mixed-methods study. METHODS: This study is the first phase of a step-wedge cluster randomised control trial of HIRAID involving over 1300 emergency nurses. Concurrent quantitative and qualitative data were collected via an electronic survey sent to all nurses to identify preliminary barriers and enablers to HIRAID implementation. The survey was informed by the Theoretical Domains Framework, which is a synthesis of behavioural change theories that applies the science of intervention implementation in health care to effect change. Quantitative data were analysed using descriptive statistics and qualitative data with inductive content analysis. Data were then integrated to generate barriers and enablers to HIRAID implementation which were mapped to the Theoretical Domains Framework. Corresponding intervention functions and Behaviour Change techniques were selected and an overarching implementation strategy was developed through stakeholder consultation and application of the APEASE criteria (Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects/safety and Equity). RESULTS: Six barriers to HIRAID implementation were identified by 670 respondents (response rate ~58%) representing all 30 sites: (i) lack of knowledge about HIRAID; (ii) high workload, (iii) lack of belief anything would change; (iv) not suitable for workplace; (v), uncertainty about what to do and (vi) lack of support or time for education. The three enablers were as follows: (i) willingness to learn and adopt something new; (ii) recognition of the need for something new and (iii) wanting to do what is best for patient care. The 10 corresponding domains were mapped to seven intervention functions, 21 behaviour change techniques and 45 mechanisms. The major components of the implementation strategy were a scaffolded education programme, clinical support and environmental modifications. CONCLUSIONS: A systematic process guided by the behaviour change wheel resulted in the generation of a multifaceted implementation strategy to implement HIRAID across rural, regional and metropolitan emergency departments. Implementation fidelity, reach and impact now require evaluation. IMPACT: HIRAID emergency nursing assessment framework reduced clinical deterioration relating to emergency care and improved self-confidence and documentation in emergency departments in pilot studies. Successful implementation of any intervention in the emergency department is notoriously difficult due to workload unpredictability, the undifferentiated nature of patients and high staff turnover. Key barriers and enablers were identified, and a successful implementation strategy was developed. This study uses theoretical frameworks to identify barriers and enablers to develop a data-driven, behavioural-focused implementation strategy to optimise the uptake of HIRAID in geographically diverse emergency departments which can be used to inform future implementation efforts involving emergency nurses. REPORTING METHOD: The CROSS reporting method (Supporting Information S3) was used to adhere to EQUATOR guidelines. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution. TRIAL REGISTRATION: Australian New Zealand; Clinical Trials Registry (ANZCTR) number: ACTRN12621001456842, registered 25/10/2021.

Interdisciplinary eHealth for the care of people living with traumatic brain injury: A systematic review.

OBJECTIVE: To identify literature which discusses the barriers and enablers of eHealth technology and which evaluates its role in facilitating interdisciplinary team work for the care of people with a traumatic brain injury (TBI). DESIGN: Systematic review. DATA SOURCES: Studies were identified by searching CINAHL, Embase, Medline, PsycINFO, Scopus, and Web of Science. STUDY SELECTION: Studies included in the review were required to feature an eHealth intervention which assisted interdisciplinary care for people with TBI. DATA EXTRACTION: Descriptive data for each study described the eHealth intervention, interdisciplinary team, outcomes, and barriers and facilitators in implementing eHealth interventions. RESULTS: The search resulted in 1389 publications, of which 35 were retrieved and scanned in full. Six studies met all the inclusion criteria for the review. Four different eHealth interventions were identified: (i) an electronic goals systems, (ii) telerehabilitation, (iii) videoconferencing, and (iv) a point-of-care team-based information system. Various barriers and facilitators were identified in the use of eHealth. CONCLUSION: eHealth interventions have been reported to support interdisciplinary teams for the care of TBI. However, there is a substantial gap in existing literature regarding the barriers and enablers which characterize a successful interdisciplinary eHealth model for people with TBI.

eHealth Intervention for Problematic Internet Use (PIU).

Excessive use of the Internet is considered a problematic behaviour by clinicians and researchers. Cognitive behaviour therapy (CBT) has been advocated for a long time as a treatment approach and has been extended to include family therapy in the recent years. As eTherapy (eHealth) has become an important component in the treatment of many mental health problems, it is prudent to explore the current status of the eHealth approach as an intervention option for this problem. This systematic review aims to examine the current development of online intervention programmes for this particular condition. The PRISMA guidelines for systematic reviews and meta-analysis were employed to conduct the search for literature following a systematic and structured approach. Of the 182 articles screened, three satisfied the selection criteria. Information was extracted and analysed systematically for each study and tabulated. All these studies were pilot studies with small sample sizes. Two of these articles aimed to explore the therapeutic efficacy of newly developed online intervention programmes for Internet addiction (IA) and online gaming addiction. The third article described the design and development of an App for smartphone addiction. The results obtained from this review have provided insight into the on-going development of eHealth interventions as well as the health informatics approaches in offering a possible and practical solution to tackle this growing problem.

The Prevalence of Caregiving among Young People.

With the increasing number of people with chronic diseases and disabilities, the number of family members as caregivers have also been growing. Despite the attention paid to caregiving in recent years, little is known about caregiving among young people, particularly its global prevalence. The lack of information has important implications for health policy and management, resulting in the inability to form appropriate evidence-based policies and managerial decision making. This study aims to derive an estimate of the prevalence of caregiving among young people through a systematic review of the current literature. The results of this study revealed a prevalence of caregiving among younger adolescents of between 1.1% (1.06-1.14%) and 12.0% (11.02-12.98%). However, the assessment of caregiving varies across studies, and all were conducted in developed countries. These results provide information on the burden of caregiving in young people and reveal the lack of global information, calling for more research on and attention to this specific population.

A Web-Based and Mobile Intervention Program Using a Spaced Education Approach for Workplace Mental Health Literacy: Cluster Randomized Controlled Trial.

Background: Workplace mental health is an important global health concern. objectives: This unblinded, phase-III, wait-listed cluster randomized controlled trial aimed to examine the effectiveness of a mobile health (mHealth) psychoeducation program using a spaced education approach on mental health literacy (MHL) in the workplace. The main interest of this paper was the immediate and 3-month medium-term effect of the program on the MHL of workers. The purposely built mHealth platform was also evaluated as a health-related app. Methods: The mHealth platform was designed using the principle of spaced education as a psychoeducation intervention program, with various modules of web-based and mobile materials presented to the participant in a progressive manner. Short quizzes at the end of each module ensured adequate learning, and successful completion qualified the learner to progress to the next level. The trial recruited 456 employees of specific industries with high levels of work-related stress. Participants who were nested in different offices or units were allocated into the intervention and wait-listed control groups using a block randomization process, with the office or unit as the cluster. A separate sample of 70 individual raters were used for the evaluation of the mHealth platform. The Australian National MHL and Stigma Survey and the Mobile Apps Rating Scale were completed through a web-based self-reported survey to assess MHL and evaluate the app. The trial and follow-up data were analyzed by a generalized linear latent and mixed model with adjustments for the clustering effect of work sites and repeated measures. Results: Of the 456 participants in the trial, 236 (51.8%) responded to the follow-up survey. Most MHL outcomes obtained significant results immediately after the intervention and across time. After adjusting for the clustering effect, the postintervention weighted mean scores were significantly higher in the intervention group than the control group for correct recognition of a mental health problem, help seeking, and stigmatization by 0.2 (SE 0.1; P=.003), 0.9 (SE 0.2; P<.001), and 1.8 (SE 0.4; P<.001), respectively. After adjusting for the clustering effect, significant differences across time were found in help-seeking intention (P=.01), stigmatization (P<.001), and social distancing (P<.001). The evaluation of the mHealth program resulted in average scores of the 4 major domains ranging from 3.8 to 4.2, with engagement having the lowest score. Conclusions: The mHealth psychoeducation intervention program using this platform had immediate and 3-month medium-term effects of retaining and improving MHL. The platform was evaluated to have satisfactory performance in terms of functionality, aesthetics, information content, and utility in enhancing MHL. It is anticipated that ongoing development in digital health will provide great benefits in improving the mental health of the global population.

Successful and sustained implementation of a behaviour-change informed strategy for emergency nurses: a multicentre implementation evaluation.

BACKGROUND: Implementing evidence that changes practice in emergency departments (EDs) is notoriously difficult due to well-established barriers including high levels of uncertainty arising from undifferentiated nature of ED patients, resource shortages, workload unpredictability, high staff turnover, and a constantly changing environment. We developed and implemented a behaviour-change informed strategy to mitigate these barriers for a clinical trial to implement the evidence-based emergency nursing framework HIRAID® (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, communication, and reassessment) to reduce clinical variation, and increase safety and quality of emergency nursing care. AIM: To evaluate the behaviour-change-informed HIRAID® implementation strategy on reach, effectiveness, adoption, quality (dose, fidelity) and maintenance (sustainability). METHODS: An effectiveness-implementation hybrid design including a step-wedge cluster randomised control trial (SW-cRCT) was used to implement HIRAID® with 1300 + emergency nurses across 29 Australian rural, regional, and metropolitan EDs. Evaluation of our behaviour-change informed strategy was informed by the RE-AIM Scoring Instrument and measured using data from (i) a post HIRAID® implementation emergency nurse survey, (ii) HIRAID® Instructor surveys, and (iii) twelve-week and 6-month documentation audits. Quantitative data were analysed using descriptive statistics to determine the level of each component of RE-AIM achieved. Qualitative data were analysed using content analysis and used to understand the 'how' and 'why' of quantitative results. RESULTS: HIRAID® was implemented in all 29 EDs, with 145 nurses undertaking instructor training and 1123 (82%) completing all four components of provider training at 12 weeks post-implementation. Modifications to the behaviour-change informed strategy were minimal. The strategy was largely used as intended with 100% dose and very high fidelity. We achieved extremely high individual sustainability (95% use of HIRAID® documentation templates) at 6 months and 100% setting sustainability at 3 years. CONCLUSION: The behaviour-change informed strategy for the emergency nursing framework HIRAID® in rural, regional, and metropolitan Australia was highly successful with extremely high reach and adoption, dose, fidelity, individual and setting sustainability across substantially variable clinical contexts. TRIAL REGISTRATION: ANZCTR, ACTRN12621001456842 . Registered 25 October 2021.

Rethinking the tiered trauma team response: A case-series study in a regional trauma centre.

OBJECTIVE: To reduce perceived unnecessary resource use, we modified our tiered trauma response. If a patient was not physiologically compromised, surgical registrar attendance was not mandated. We investigated the effect of this change on missed injury, unplanned representation to ED, diagnostic imaging rates and staff satisfaction. METHODS: A retrospective case series study assessing the 3-month period before and after the intervention was conducted. Logistic regression analyses were used to examine the association between ordering of computerised tomography (CT) and ED length of stay (LOS), injury severity (ISS), age, surgical review and admission. A staff survey was conducted to investigate staff perceptions of the practice change. Free text data were analysed using inductive content analysis. RESULTS: There were 105 patients in the control and 166 in the intervention group and their mean (SD) ISS was the same (ISS [SD] = 4 [±4] [P = 0.608]). A higher proportion of the control group were admitted (56.3% vs 42.2% [P = 0.032]) and they had a shorter ED LOS (274 min [202-456] vs 326 min [225-560], P = 0.044). The rate of missed injury was unchanged. A surgical review resulted in a 26-fold increase in receipt of a whole-body CT scan (odds ratio = 26.89, 95% confidence interval = 3.31-218.17). Just over half of survey respondents felt the change was safe (54.4%), and more surgical (90%) than ED staff (69%) reported the change as positive. CONCLUSION: The removal of the surgical registrar from the initial trauma standby response did not result in any adverse events, reduced admissions, pathology and imaging, but resulted in an increased ED LOS and time to surgical review.

Child and adolescent mental well-being intervention programme: A systematic review of randomised controlled trials.

Background: There has been an increasing awareness and recognition of mental well-being as one of the main outcome measures in national mental health policy and service provision in recent years. Many systemic reviews on intervention programmes for mental health or general well-being in young people have been conducted; however, these reviews were not mental well-being specific. Objective: This study aims to examine the effectiveness of child and adolescent mental well-being intervention programmes and to identify the approach of effective intervention by reviewing the available Randomised Controlled Trials. Methods: This systematic review study followed the PRISMA guidelines for systematic reviews ensuring a methodical and structured approach for the literature search and the subsequent review processes. The systematic literature search utilised major medical and health databases. Covidence, an online application for conducting systematic reviews, was used to assemble the titles, abstracts and full articles retrieved from the initial literature search. To examine the quality of the included trials for determining the strength of the evidence provided, the JBI Critical Appraisal Tool for Randomised Controlled Trial was used. Results: There were 34 studies identified after an extensive search of the literature following the PRISMA guidelines. Seven (7) fulfilled all selection criteria and provided information on the effect of an intervention programme on mental well-being in adolescence. Data were extracted and analysed systematically with key information summarised. The results suggested that two (2) programmes demonstrated significant intervention effects, but with a small effect size. The quality of these trials was also assessed using the JBI Critical Appraisal Tool for Randomised Controlled Trials and identified some methodological issues. Conclusion: In conclusion, activity-based and psychoeducation are shown to be potentially effective approaches for future programme development. More research on a well-designed programme is urgently needed, particularly in developing countries, to provide good evidence in supporting the mental health policy through the enhancement of mental well-being in young people.

The Emergency nurse Protocols Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) trial: protocol for a stepped wedge implementation trial.

INTRODUCTION: Emergency department (ED) overcrowding is a global problem and a threat to the quality and safety of emergency care. Providing timely and safe emergency care therein is challenging. To address this in New South Wales (NSW), Australia, the Emergency nurse Protocol Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) was developed. EPIC-START is a model of care incorporating EPIC protocols, the START patient admission prediction tool, and a clinical deterioration tool to support ED flow, timely care, and patient safety. The aim of this study is to evaluate the impact of EPIC-START implementation across 30 EDs on patient, implementation, and health service outcomes. METHODS AND ANALYSIS: This study protocol adopts an effectiveness-implementation hybrid design (Med Care 50: 217-226, 2012) and uses a stepped-wedge cluster randomised control trial of EPIC-START, including uptake and sustainability, within 30 EDs across four NSW local health districts spanning rural, regional, and metropolitan settings. Each cluster will be randomised independently of the research team to 1 of 4 dates until all EDs have been exposed to the intervention. Quantitative and qualitative evaluations will be conducted on data from medical records and routinely collected data, and patient, nursing, and medical staff pre- and post-surveys. ETHICS AND DISSEMINATION: Ethical approval for the research was received from the Sydney Local Health District Research Ethics Committee (Reference Number 2022/ETH01940) on 14 December 2022. TRIAL REGISTRATION: Australian and New Zealand Clinical trial, ACTRN12622001480774p. Registered on 27 October 2022.

The study design and methodology for the ARCHER study--adolescent rural cohort study of hormones, health, education, environments and relationships.

BACKGROUND: Adolescence is characterized by marked psychosocial, behavioural and biological changes and represents a critical life transition through which adult health and well-being are established. Substantial research confirms the role of psycho-social and environmental influences on this transition, but objective research examining the role of puberty hormones, testosterone in males and oestradiol in females (as biomarkers of puberty) on adolescent events is lacking. Neither has the tempo of puberty, the time from onset to completion of puberty within an individual been studied, nor the interaction between age of onset and tempo. This study has been designed to provide evidence on the relationship between reproductive hormones and the tempo of their rise to adult levels, and adolescent behaviour, health and wellbeing. METHODS/DESIGN: The ARCHER study is a multidisciplinary, prospective, longitudinal cohort study in 400 adolescents to be conducted in two centres in regional Australia in the State of New South Wales. The overall aim is to determine how changes over time in puberty hormones independently affect the study endpoints which describe universal and risk behaviours, mental health and physical status in adolescents. Recruitment will commence in school grades 5, 6 and 7 (10-12 years of age). Data collection includes participant and parent questionnaires, anthropometry, blood and urine collection and geocoding. Data analysis will include testing the reliability and validity of the chosen measures of puberty for subsequent statistical modeling to assess the impact over time of tempo and onset of puberty (and their interaction) and mean-level repeated measures analyses to explore for significant upward and downward shifts on target outcomes as a function of main effects. DISCUSSION: The strengths of this study include enrollment starting in the earliest stages of puberty, the use of frequent urine samples in addition to annual blood samples to measure puberty hormones, and the simultaneous use of parental questionnaires.

The effect of e-health contents on health science students' attitude toward the efficiency of health ICT in care provision.

OBJECTIVE: This study aimed to examine the effects of e-health education content on the attitude of undergraduate health science students towards the efficiency of health ICT in healthcare provision. METHODS: A cross-sectional survey design was used. Participants were Health Sciences students attending The University of Sydney. Students were divided into three groups: junior students enrolled in a subject with non e-health content; senior students enrolled in a subject with non e-health content; and students enrolled in a subject with e-health content. Students' attitude towards the efficiency of ICT in healthcare provision was measured by a modified version of the Information Technology Attitude Scales for Health (ITASH). RESULTS: Students enrolled in the subject with e-health content had a significantly higher average baseline attitude score than the other two groups (T198=-3.47, p=0.001; T93=-2.43, p=0.017). The repeat measures analysis yielded a result with significant interaction between survey time and student group (F2, 267=4.99, p=0.007) suggesting that changes of score was dependent on student group status. CONCLUSION: Subjects rich in e-health content significantly enhanced student attitudes, even with a group of students with a rather positive initial attitude. To facilitate the uptake and utilisation of health ICT by the future health workforce, it is important for tertiary educational institutes to provide students with sufficient exposure to specific health-related ICT training, via specifically designed subjects delivering both generic and specific e-health content.

Factors Associated with Work-Related Burnout among Corporate Employees Amidst COVID-19 Pandemic.

Work-related burnout is common and has detrimental effects on employees in many industries. The current study aims to examine both environmental and personal factors that are associated with work-related burnout in a population of corporate employees who managed to retain their jobs amidst the global COVID-19 pandemic crisis. This cross-sectional survey served as the baseline data collection of a phase III wait-listed cluster randomised controlled trial (CRCT) of an intervention program on mental well-being at the workplace. Participants were recruited from six large-size corporations. Work-related burnout was assessed by the Maslach Burnout Inventory (MBI), and the Moos Work Environment Scale (WES) was used for evaluating the workers' perspective on the workplace. Information was also collected on demographics and health behaviours. Burnout in this sample was prevalent with 60% of participants rated at a moderate to a high level on emotional exhaustion. Results from the multiple linear regression analyses suggested that different factors were related to different components of burnout. For example, age, work involvement, co-worker cohesion, and work pressure were associated with emotional exhaustion and depersonalisation while others were related to professional accomplishment. The overall results suggested that the work environment is of influential importance to the burnout of employees. However, although the study was conducted during the peak of the COVID-19 pandemic, the factors identified as relating to workplace burnout do not differ much from those identified in a crisis time. Implications of the results were discussed.

Efficacy of a Workplace Intervention Program With Web-Based Online and Offline Modalities for Improving Workers' Mental Health.

Objective: This study aims to examine the efficacy of the Workplace Web-based blended psychoeducation mental health intervention program. Of particular interest is the short-term effect of the intervention on workplace burnout, stress, quality of life, and the mental health literacy of workers. Methods and Materials: The study focused on employees (n = 456) in specific industries with high levels of work-related stress, adopting a phase III wait-listed cluster randomized controlled trial. Work-related burnout was assessed by the Maslach Burnout Inventory (MBI) and stress was measured using the stress subscale of the Depression, Anxiety, and Stress scale (DASS). Quality of Life was evaluated by the European Quality of Life-5 Dimensions (EQ-5D-5L) and Mental Health Literacy was assessed using the Australian National Mental Health Literacy and Stigma Survey. Data were analyzed as a trial with intention-to-treat analysis and adjustment for the clustering effect of work sites. Results: Significant differences between intervention and control groups were found on all outcome measures except the self-rated quality of life. The intervention group displayed a significant reduction in the weighted mean score of about 1.0 units (s.e. = 0.4) on the stress scale (p = 0.015) and an increase in the weighted mean score of 1.9 units (s.e. = 0.9) in the professional accomplishment domain of the MBI (p = 0.035). Significant increases were found in the weighted mean scores in the intervention group for correct recognition of the mental problems, help-seeking, and stigmatization, in comparison to the control group who scored 0.2 (s.e. = 0.1), 0.9 (s.e. = 0.2), 1.8 (s.e. = 0.4), respectively. Conclusions: The results obtained from a comparison of the outcome measures between the intervention and control groups were statistically significant, indicating that the intervention group performed better on most measures. The study demonstrates that, in the short term. the on-and-offline modalities of the Web-based blended psychoeducation intervention program is efficacious in reducing workplace burnout and stress and promoting mental health literacy at the workplace.

Predictors of 12 month functional outcomes and length of stay of severely injured children in NSW, Australia. A longitudinal multi-centre study.

BACKGROUND: The majority of paediatric injury outcomes studies focus on mortality rather than the impact on long-term quality of life, health care use and other health-related outcomes. This study sought to determine predictors of 12-month functional and psychosocial outcomes for children sustaining major injury in NSW. METHODS: The study included all children < 16 years requiring intensive care or an injury severity score (ISS) ≥ 9 treated in NSW at a paediatric trauma centre (PTC). Children were identified through the three PTCs and NSW Trauma Registry. The paediatric Quality of Life Inventory (PedsQL) and EuroQol five-dimensional EQ-5D-Y were used to measure HRQoL post-injury, completed via parent/carer proxy recruited through NSW PTCs. RESULTS: There were 510 children treated at the three NSW PTCs during the 15-month study period. The mean (SD) age was 6.7 (6.0) years, with a median NISS (New Injury Severity Score) of 11 (IQR: 9-18). Regression analysis showed worse psychosocial health at twelve months was associated with hospital length of stay (LoS) and number of body regions injured (F2,65 = 5.85, p = 0.005). Physical outcome was associated with LoS and intensive care unit (ICU) admission (F2,66 = 13.48, p < 0.001). Hospital LoS was significantly associated with NISS and head injury (F2,398 = 51.5, p < 0.001). CONCLUSION: Hospital length of stay and polytrauma are independent factors that negatively influence psychological and physical outcomes of children with major injuries. Early intervention to enable emotional well-being, discharge home and long-term follow up such as dedicated family support and rehabilitation at home could reduce preventable poor outcomes.

Prescribing behavior of antidepressants for depressive disorders: A systematic review.

Objective: Guidelines for the prescription of antidepressants for Depressive Disorders (DD) have been in place for a long time. However, there is a lack of systematic information on the prescribing behavior of antidepressants in evidence-based clinical practice in psychopharmacotherapy of depressive disorders. This may suggest a lack of implementation of clinical guidelines by clinicians. Existing literature mainly focuses on specific issues or medications. To provide general information on the prescribing behavior of antidepressants for depressive disorders, a systematic review of available studies since 2013 was conducted. Methods and materials: To ensure a structured and systematic approach for the literature search and subsequent review process, the PRISMA guidelines for systematic reviews were followed. Major medical and health and psychological databases were used for the literature search. These included Ebsco Host, OVID, PubMed, Science Direct, Scopus, and Web of Science. The online application "Covidence" was employed to manage the titles collected and the full articles retrieved from the initial literature search. Upon finalizing the list of selected studies, data extraction was then conducted using a build-in function of the Covidence platform with the required information pre-set on a template for data extraction. The extracted information was tabulated and summarized in a table. Results: Forty-one studies were identified after an extensive search of the literature following the PRISMA guidelines. Of these, 37 quantitative studies providing useful information were systematically reviewed and information extracted. There was a high level of heterogeneity among these studies with different foci or characteristics. Most studies were conducted in or utilized data obtained from hospital and primary healthcare settings. SSRIs were the most commonly prescribed type of antidepressant in the past decade, particularly among younger patients. Among these studies, antidepressants were mainly prescribed by psychiatrists with some by other physicians and general practitioners. This might reflect differences in legislation regarding professional requirements for prescribers or clinical practices. Conclusions: A few themes that would be considered important in terms of the effect of prescription behavior on depression, specifically children/adolescents, special target populations, and off-label prescription. The results highlighted the need for more studies on a community-based approach and the role of GPs in the treatment of DD.

Pathways and factors that influence time to definitive trauma care for injured children in New South Wales, Australia.

BACKGROUND: Timely definitive paediatric trauma care influences patient and parental physical and emotional outcomes. New South Wales (NSW) covers a large geographical area with all three NSW paediatric trauma centres (PTC) located in two approximated major cities, meaning it is inevitable that some injured children receive initial treatment locally and then require transfer. Little is known about the factors that then impact timely arrival of injured children to definitive care. METHODS: This included children admitted between July 2015 and September 2016, <16 years with an injury severity (ISS) ≥9; or requiring intensive care admission; or deceased following injury. Children were identified through the three PTCs, NSW Trauma Registry and NSW Medical Retrieval Registry. RESULTS: There were 593 children admitted following injury and 46% required transfer to a PTC. There was no significant difference in age, ISS, ICU admission or head injury (AIS >2) between transferred and directly transported cohorts. There were significant differences in mechanism of injury between the two groups (χ2(9) = 45.9, p < 0.001). The median (IQR) time to book a transfer from arrival at the referring facility, was 146.5 (86-238) minutes. Time from injury to arrival at the PTC more than doubled for children transferred, with significant and unwarranted variability between transporting agencies resulting in unwarranted delays to surgical intervention. For example, time spent at the referring facility by Aeromedical Retrieval Service was less than half that of the Newborn & paediatric Emergency Transport Service [53 (IQR:47-61) vs 115 (84-155) minutes (p <0.001)]. CONCLUSION: Clinicians caring for paediatric trauma patients in facilities outside trauma centres require the capability and opportunity to identify and notify early those requiring transfer for ongoing management. The provision of a streamlined referral and transfer process for all paediatric trauma patients requiring treatment in NSW PTCs would reduce the burden on the referring facility, reduce variation amongst transport providers and improve time to definitive care.

Mapping quantitative trait loci (QTL) in sheep. IV. Analysis of lactation persistency and extended lactation traits in sheep.

BACKGROUND: In sheep dairy production, total lactation performance, and length of lactation of lactation are of economic significance. A more persistent lactation has been associated with improved udder health. An extended lactation is defined by a longer period of milkability. This study is the first investigation to examine the presence of quantitative trait loci (QTL) for extended lactation and lactation persistency in sheep. METHODS: An (Awassi × Merino) × Merino single-sire backcross family with 172 ewes was used to map QTL for lactation persistency and extended lactation traits on a framework map of 189 loci across all autosomes. The Wood model was fitted to data from multiple lactations to estimate parameters of ovine lactation curves, and these estimates were used to derive measures of lactation persistency and extended lactation traits of milk, protein, fat, lactose, useful yield, and somatic cell score. These derived traits were subjected to QTL analyses using maximum likelihood estimation and regression analysis. RESULTS: Overall, one highly significant (LOD > 3.0), four significant (2.0 < LOD < 3.0) and five suggestive (1.7 < LOD < 2.0) QTL were detected across all traits in common by both mapping methods. One additional suggestive QTL was identified using maximum likelihood estimation, and four suggestive (0.01 < P < 0.05) and two significant (P < 0.01) QTL using the regression approach only. All detected QTL had effect sizes in the range of 0.48 to 0.64 SD, corresponding to QTL heritabilities of 3.1 to 8.9%. The comparison of the detected QTL with results in cattle showed conserved linkage regions. Most of the QTL identified for lactation persistency and extended lactation did not coincide. This suggests that persistency and extended lactation for the same as well as different milk yield and component traits are not controlled by the same genes. CONCLUSION: This study identified ten novel QTL for lactation persistency and extended lactation in sheep, but results suggest that lactation persistency and extended lactation do not have a major gene in common. These results provide a basis for further validation in extended families and other breeds as well as targeting regions for genome-wide association mapping using high-density SNP arrays.

Sleep Disorders in Early Childhood and the Development of Mental Health Problems in Adolescents: A Systematic Review of Longitudinal and Prospective Studies.

The association between sleep problems, particularly sleep disorders, and mental health has long been studied and recognized. However, the causal relationship between sleep disorders, particularly during early childhood, on mental health problems in adolescence are yet to be established. From a preventive perspective, it is important to understand the causality of mental health problems in adolescents so that intervention measures can be derived and implemented as early as possible for maximum effectiveness. To provide more precise information on the effect of early childhood sleep disorders on mental health problems during adolescence, a systematic review was conducted on longitudinal and prospective studies reported in the literature. Following the PRISMA guidelines with an extensive search of the literature 26 studies were identified. Seven of these identified studies satisfied all selection criteria with sufficient data on the effect of early childhood sleep disorders and mental health problems in adolescence. Information was extracted and analyzed systematically from each study and tabulated. The overall results obtained from these studies indicate a significant and possible causal relationship between early childhood sleep disorders and the development of mental health problems, such as anxiety, depression, and ADHD in adolescence. These results are discussed with regards to the theoretical and practical implications as well as preventive strategies.

Emergency department management of severely injured children in New South Wales.

OBJECTIVE: Presentations to EDs for major paediatric injury are considerably lower than for adults. International studies report lower levels of critical intervention, including intubation, required in injured children. A New South Wales study demonstrated an adverse event rate of 7.6% in children with major injury. Little is known about the care and interventions received by children presenting to Australian EDs with major injury. METHODS: The ED care of injured children <16 years who ultimately received definitive care at a New South Wales Paediatric Trauma Centre between July 2015 and September 2016, and had an Injury Severity Score ≥9, required intensive care admission or died were included. RESULTS: There were 491 injured children who received treatment at 64 EDs, half (49.4%, n = 243) were treated initially in a Paediatric Trauma Centre. One third (32.8%) sustained an Injury Severity Score >12, more than half (n = 251, 51.1%) of children were classified as a triage category 1 or 2, and 38.3% received trauma team activation. Critical intervention was infrequent. Intubation was documented in 9.2% (n = 45), needle thoracostomy and activation of massive transfusion protocol in two (0.4%) and eight (1.6%) had intraosseous access established. Only a small proportion (14.7%, n = 63) had two or more observations outside the normal range. CONCLUSION: A small proportion of children arriving in the ED post-major trauma have deranged clinical observations and receive critical interventions. The limited exposure in the management of trauma in paediatric patients requires measures to ensure clinicians have adequate training, skills and confidence to manage these clinical presentations in all EDs.

Prehospital care and transport costs of severely injured children in NSW Australia.

BACKGROUND: Injury is the leading cause of childhood death and disability in Australia. Prehospital emergency services in New South Wales (NSW) are provided by NSW Ambulance. The incidence, pre-hospital care provided and outcomes of children suffering major injury in NSW has not previously been described. METHODS: This retrospective study was conducted between July 2015 and September 2016 and included children <16 years with an injury severity score (ISS) >9, or requiring intensive care admission, or deceased following injury and treated in NSW. Children were identified through the three NSW Paediatric Trauma Centres, the NSW Trauma Registry, NSW Medical Retrieval Registry (AirMaestro, Avinet, Australia). RESULTS: There were 359 majorly injured children treated by NSW-based emergency service providers, the majority were male (73.3%) with a mean (SD) age of 8.0 (5.2) years. The median (IQR) injury severity score (ISS) for those transported via NSW emergency medical services was 10 (9-17), with almost half (44.1%) treated prehospital having an ISS >12. The most common documented interventions were intravenous access (44.1%) and oxygen therapy (39.6%). Intubation and chest decompression were recorded in 15.3% and 3.1% of cases respectively. The calculated median (IQR) transport charges for NSW Emergency Services was AUD $942 ($841.3-$1184.6). CONCLUSION: Critical interventions are performed infrequently in children with major injuries in the pre-hospital environment. The monitoring of the incidence and success rates for staff performing these interventions is not readily available from all prehospital emergency medical services operating in NSW. The capacity and processes to monitor and audit all critical interventions in the paediatric population should be resourced and clearly defined.