Hospital Experiences of Carers in Relation to the Comprehensive Care Standard: A Mixed Method Study.

AIMS: To explore the care experiences of informal carers of people with chronic conditions in hospitals and identify areas for improvement in the context of comprehensive care delivery. DESIGN: A explanatory sequential mixed-method study. METHODS: This study was conducted, involving a survey with 182 carers and interviews with 31 carers of individuals who attended an Australian hospital. Descriptive analysis of quantitative data was performed using RStudio, while thematic analysis of qualitative data was conducted using NVivo. RESULTS: The findings revealed seven overarching components of care that influenced carers' hospital experiences and their perceptions of care quality. Areas requiring improvement were identified within these categories. CONCLUSION: This review identifies common perspectives of informal carers of people with chronic conditions in hospital settings and highlights important areas that require attention to improve carers' hospital care experiences. Carers should be welcomed, involved, informed and supported during hospital attendance to foster the most positive care experiences. IMPLICATIONS: Healthcare professionals should involve carers in assessment, shared decision-making and the care process and recognise and address carers' needs. IMPACT: The findings revealed the carer's hospital experiences in the context of comprehensive care delivery and identified areas requiring improvement. REPORTING METHOD: The CROSS and the COREQ guidelines were followed. PATIENT OR PUBLIC CONTRIBUTION: The study protocol was presented to stakeholders from two hospitals in Australia, a Patient and Carer Advisory Board (attached to the parent project: evaluating Quality of Care (eQC)) and the Australian Commission on Safety and Quality in Health Care, and discussions were held to assess the relevance and significance of this study to clinical practice and health policy.

Identification of implementation enhancement strategies for national comprehensive care standards using the CFIR-ERIC approach: a qualitative study.

BACKGROUND: Comprehensive care is important for ensuring patients receive coordinated delivery of healthcare that aligns with their needs and preferences. While comprehensive care programs are recognised as beneficial, optimal implementation strategies in the real world remain unclear. This study utilises existing implementation theory to investigate barriers and enablers to implementing the Australian National Safety and Quality Health Service Standard 5 - Comprehensive Care Standard in acute care hospitals. The aim is to develop implementation enhancement strategies for work with comprehensive care standards in acute care. METHODS: Free text data from 256 survey participants, who were care professionals working in acute care hospitals across Australia, were coded using the Consolidated Framework for Implementation Research (CFIR) using deductive content analysis. Codes were then converted to barrier and enabler statements and themes using inductive theme analysis approach. Subsequently, CFIR barriers and enablers were mapped to the Expert Recommendations for Implementing Change (ERIC) using the CFIR-ERIC Matching Tool, facilitating the development of implementation enhancement strategies. RESULTS: Twelve (n = 12) CFIR barriers and 10 enablers were identified, with 14 barrier statements condensed into 12 themes and 11 enabler statements streamlined into 10 themes. Common themes of barriers include impact of COVID-19 pandemic; heavy workload; staff shortage, lack of skilled staff and high staff turnover; poorly integrated documentation system; staff lacking availability, capability, and motivation; lack of resources; lack of education and training; culture of nursing dependency; competing priorities; absence of tailored straties; insufficient planning and adjustment; and lack of multidisciplinary collaboration. Common themes of enablers include leadership from CCS committees and working groups; integrated documentation systems; established communication channels; access to education, training and information; available resources; culture of patient-centeredness; consumer representation on committees and working groups; engaging consumers in implementation and in care planning and delivery; implementing changes incrementally with a well-defined plan; and regularly collecting and discussing feedback. Following the mapping of CFIR enablers and barriers to the ERIC tool, 15 enhancement strategies were identified. CONCLUSION: This study identified barriers, enablers, and recommended strategies associated with implementing a national standard for comprehensive care in Australian acute care hospitals. Understanding and addressing these challenges and strategies is not only crucial for the Australian healthcare landscape but also holds significance for the broader international community that is striving to advance comprehensive care.

The implementation and impacts of the Comprehensive Care Standard in Australian acute care hospitals: a survey study.

BACKGROUND: Comprehensive care (CC) is becoming a widely acknowledged standard for modern healthcare as it has the potential to improve health service delivery impacting both patient-centred care and clinical outcomes. In 2019, the Australian Commission on Safety and Quality in Health Care mandated the implementation of the Comprehensive Care Standard (CCS). However, little is known about the implementation and impacts of the CCS in acute care hospitals. Our study aimed to explore care professionals' self-reported knowledge, experiences, and perceptions about the implementation and impacts of the CCS in Australian acute care hospitals. METHODS: An online survey using a cross-sectional design that included Australian doctors, nurses, and allied health professionals in acute care hospitals was distributed through our research team and organisation, healthcare organisations, and clinical networks using various methods, including websites, newsletters, emails, and social media platforms. The survey items covered self-reported knowledge of the CCS and confidence in performing CC, experiences in consumer involvement and CC plans, and perceptions of organisational support and impacts of CCS on patient care and health outcomes. Quantitative data were analysed using Rstudio, and qualitative data were analysed thematically using Nvivo. RESULTS: 864 responses were received and 649 were deemed valid responses. On average, care professionals self-reported a moderate level of knowledge of the CCS (median = 3/5) and a high level of confidence in performing CC (median = 4/5), but they self-reported receiving only a moderate level of organisational support (median = 3/5). Only 4% (n = 17) of respondents believed that all patients in their unit had CCS-compliant care plans, which was attributed to lack of knowledge, motivation, teamwork, and resources, documentation issues, system and process limitations, and environment-specific challenges. Most participants believed the CCS introduction improved many aspects of patient care and health outcomes, but also raised healthcare costs. CONCLUSION: Care professionals are confident in performing CC but need more organisational support. Further education and training, resources, multidisciplinary collaboration, and systems and processes that support CC are needed to improve the implementation of the CCS. Perceived increased costs may hinder the sustainability of the CCS. Future research is needed to examine the cost-effectiveness of the implementation of the CCS.

Outcomes of medically retrieved infants with bronchiolitis in high-income countries: A scoping review.

INTRODUCTION: Bronchiolitis is the most common respiratory infection and reason for hospitalisation in infancy; however, outcomes of infants with bronchiolitis who require interhospital transfer by specialist medical retrieval services are poorly understood. OBJECTIVES: The objective of this study was to summarise current evidence of the rate, therapy, and outcomes of infants with bronchiolitis who required medical retrieval for ongoing management. REVIEW METHOD: A scoping literature review informed by the Joanna Briggs Institute methodology was used including published studies in any language covering the period 1996 to December 2022 and grey literature sources comprised of reports from retrieval services in high-income countries with comparable healthcare systems. DATA SOURCES: Medline, CINAHL, and the Cochrane Database of Systematic Reviews electronic databases were the sources for published studies. Grey literature sources were retrieval service web pages/social media sites from Australia, Canada, New Zealand, the United Kingdom, and the United States of America. RESULTS: Searching identified 12 677 records, with 12 069 ineligible records and 286 duplicates excluded at screening. Of the 72 papers included for title and abstract review, 16 were selected for full-text review. Six papers fulfilled inclusion criteria. Infants with bronchiolitis were the primary focus of three studies. Transfer rate was reported in four studies, ranging from 4.3% to 18.5%. Use of respiratory therapy was variably reported and was associated with prematurity. Outcomes following retrieval such as respiratory therapies, days on therapies, length of stay in the intensive care unit, and hospital length of stay were only reported in two studies. Of 103 identified medical retrieval services and data registries, no reports were found that included information on the number of transfers or outcomes for infants with bronchiolitis. CONCLUSIONS: Up to one in five infants with bronchiolitis require medical retrieval. Only two published studies and no reports reported on the number and outcomes of infants. Given the frequency and severity of bronchiolitis, understanding indications for medical retrieval and outcomes of those infants may help to better target care and interventions for this common illness. Benefits could include diminishing the costly burden to families and the healthcare system of avoidable medical retrieval and interhospital transfer.

The implementation and impacts of national standards for comprehensive care in acute care hospitals: An integrative review.

Objectives: To synthesise current evidence addressing implementation approaches, challenges and facilitators, and impacts of national standards for comprehensive care in acute care hospitals. Methods: Using Whittemore & Knafl's five-step method, a systematic search was conducted across five databases, including Medline (EBSCO), CINAHL (EBSCO), Cochrane Library, Web of Science, and Scopus, to identify primary studies and reviews. In addition, grey literature (i.e., government reports and webpages) was also searched via Google and international government/organisation websites. All searches were limited to January 1, 2000 to January 31, 2023. Articles relevant to the implementation or impacts of national standards for comprehensive care in acute care hospitals were included. Included articles underwent a Joanna Briggs Institute quality review, followed by qualitative content analysis of the extracted data adhering to PRISMA reporting guidelines. Results: A total of 16 articles were included in the review (5 primary studies, 5 government reports, and 6 government webpages). Three countries (Australia, Norway, and the United Kingdom [UK]) were identified as having a national standard for comprehensive care. The Australian standard contains a unique component of minimising patient harm. Norway does not have a defined implementation framework for the standard, whereas Australia and the UK do. Limited research suggests that challenges in implementing a national standard for comprehensive care in acute care hospitals include difficulties in implementing governance processes, end-of-life care actions, minimising harms actions, and developing comprehensive care plans with multidisciplinary teams, the absence of standardised care plans and patient-centred goals in documentation, and excessive paperwork. Implementation facilitators include a new care plan template using the Identify, Situation, Background, Assessment and Recommendation framework for handover, promoting efficient documentation, clinical decision-making and direct patient care, and proactivity among patients and care professionals with collaboration skills. Limited research suggests introducing the Australian standard demonstrated some positive effects on patient outcomes. Conclusion: The components and implementation approaches of the national standards for comprehensive care in Australia, Norway and the UK were slightly different. The scarcity of studies found during the review highlights the need for further research to evaluate the implementation challenges and facilitators, and impacts of national standards for comprehensive care in acute care hospitals.

Use of Social Determinants of Health Screening among Primary Health Care Nurses of Developed Countries: An Integrative Review.

The aims of the study are to evaluate and synthesise research that has investigated social determinants of health screening by primary healthcare nurses; how and when primary health care nurses perform social determinants of health screening; and implications for advancing nursing practice. Systematic searches in electronic databases identified fifteen published studies which met the inclusion criteria. Studies were synthesised using reflexive thematic analysis. This review found little evidence of primary health care nurses using standardised social determinants of health screening tools. Eleven subthemes were identified and collapsed into three main themes: organisation and health system supports are required to enable primary health care nurses; primary health care nurses are often reluctant to perform social determinants of health screening; and the importance of interpersonal relationships for social determinants of health screening. The social determinants of health screening practices of primary health care nurses are poorly defined and understood. Evidence suggests that primary health care nurses are not routinely using standardised screening tools or other objective methods. Recommendations are made for valuing therapeutic relationships, social determinants of health education and the promotion of screening by health systems and professional bodies. Overall, further research examining the best social determinant of health screening method is required.

Developing the Occupational Communion Scale: Belonging-Based Social Connections Are Vital for Work Engagement, Self-Efficacy, and Positive Affect in Aged Care Workforces.

BACKGROUND AND OBJECTIVES: A multifaceted construct called occupational communion (OC), defined as a sense of belonging based on social interaction at work, has been proposed to understand why care workers were positively engaged in their jobs over time, even though they were very demanding. Rich qualitative data on the multiple aspects of OC in care work exist, but a valid measure does not. RESEARCH DESIGN AND METHODS: We applied a mixed-method systematic scale development process to measure OC. Aged and dementia care workers in Australia (76%) and other countries participated in a focus group and online surveys (N = 2,451). We also used interview data from our prior study. The study involved 3 components: (1) scale development and design; (2) pilot test validation with exploratory factor analysis; and (3) confirmatory validation via confirmatory factor analysis. The third component assessed convergent and discriminant validity using measures of communion, self-efficacy, work engagement, job and life satisfaction, intention to leave, positive and negative affect, and mood. RESULTS: We developed a 28-item Occupational Communion Scale (OCS) with good internal consistency (composite reliability = 0.75-0.91) across 6 factors: (1) "natural" carer, (2) psychological need to care, (3) connection with clients, (4) connection with coworkers, (5) desire for more connection, and (6) blurred boundaries. All validity measures correlated with OC and work engagement, self-efficacy, and positive affect showed the strongest association. DISCUSSION AND IMPLICATIONS: The OCS can be used to design and evaluate interventions addressing aged care workforce engagement, social connections and well-being, and care outcomes.

The precarious resilience of aged care employees enrolled in an Australian online dementia course: A cross-sectional study of occupational health and well-being.

OBJECTIVE: Australian aged care workforce surveys offer limited information about those who engage in online dementia education regarding their occupational health and well-being. A salutogenic approach was applied to an aged care context to quantitatively assess both positive and negative aspects of health at work to inform the development of workplace interventions tailored to those interested in self-development. METHODS: Physical, psychological and occupational health were measured in an online cross-sectional survey of general health, chronic conditions, psychological distress, positive and negative affect, job satisfaction, access to workplace amenities and turnover intentions of aged care workers undertaking an online dementia course in October 2014. RESULTS: Participants (N = 662) rated their general physical health as good and a minority experienced chronic conditions such as obesity. Overall, workers had average levels of positive and negative affect and low distress. However, 25% were likely to have a mental health condition. While most were employed on a permanent basis (80%) and reported moderate job satisfaction, 18% were likely to leave their job. There were some gaps in workplace amenities to support health and well-being: for example, 13% reported no access to lunch break areas. CONCLUSIONS: Results suggest precarious resilience in aged care workers enrolled in an Australian online dementia course. Workplace interventions that focus on preventative health strategies are required to address the health risks associated with higher than national averages of obesity and mental health, and reduce exposure of workers to physical and psychological harms.

What are the Clinical and Social Outcomes of Integrated Care for Older People? A Qualitative Systematic Review.

Introduction: Older people with multiple chronic conditions have most to gain from successful integrated care models but there is a need to understand current evidence of outcomes for older people. Methods: A qualitative meta-aggregation method was used for the review. Systematic searching of CINAHL, PubMed (Medline), Web of Science, PsycINFO, Scopus and Cochrane identified an initial 93 papers, of which 27 were reviewed. Studies were selected according to the pre-defined protocol and quality assessed using The Joanna Briggs Institute Critical Appraisal Tools (JBIQARI). Eleven, peer-reviewed, English-language papers published between 2000 to 2020 were included. Results: Thirty-three findings were extracted and aggregated into six categories. Three synthesised statements were identified denoting outcomes of integrated care for older people. These indicate social participation and connectedness for older people and their families; the older person feeling motivated to engage in health goals when their preferences were taken into consideration; and older people experiencing support and wellbeing when a therapeutic relationship with a key worker is established. Discussion and conclusion: There was scant evidence of the older person's voice within included studies and a limited focus on outcomes. Stronger evidence is needed to provide meaningful and robust evaluation of outcomes within integrated care models for the older person.

Barriers and facilitators to more timely treatment of aneurysmal subarachnoid haemorrhage across two tertiary referral centres in Australia: A thematic analysis.

BACKGROUND: Delays in treatment of aSAH appear to be common but the causes are not well understood. We explored facilitators and barriers to timely treatment of aSAH. METHODS: We used a multiple case study with cases of aSAH surviving> 1 day identified prospectively. We conducted semi-structured interviews with the patient, their next-of-kin and health professionals involved in the case. Within-case analysis identified barriers and facilitators in 4 phases (pre-hospital, presentation, transfer, in-hospital) followed by thematic analysis across cases using a case-study matrix. RESULTS: Twenty-seven cases with 90 interviewees yielded five themes related to facilitators or barriers of timely treatment. "Early recognition" led to urgent response. "Accessibility to health care" depended on patient's location, transport, and environmental conditions. Good "Coordination" between and within health services was a key facilitator. "Complexity" of patient's condition affected time to treatment in multiple time periods. "Availability of resources" was identified most frequently during the diagnostic and treatment phases as both barrier and facilitator. CONCLUSIONS: The identified themes may be modifiable at the patient/health professional level and health system level and may improve timely treatment of aSAH through targeted interventions, subsequently contributing to improve morbidity and mortality of patients with aSAH.

Association of Onset-to-Treatment Time With Discharge Destination, Mortality, and Complications Among Patients With Aneurysmal Subarachnoid Hemorrhage.

Importance: Rapid access to specialized care is recommended to improve outcomes after aneurysmal subarachnoid hemorrhage (SAH), but understanding of the optimal onset-to-treatment time for aneurysmal SAH is limited. Objective: To assess the optimal onset-to-treatment time for aneurysmal SAH that maximized patient outcomes after surgery. Design, Setting, and Participants: This cohort study assessed 575 retrospectively identified cases of first-ever aneurysmal SAH occurring within the referral networks of 2 major tertiary Australian hospitals from January 1, 2010, to December 31, 2016. Individual factors, prehospital factors, and hospital factors were extracted from the digital medical records of eligible cases. Data analysis was performed from March 1, 2020, to August 31, 2021. Exposures: Main exposure was onset-to-treatment time (time between symptom onset and aneurysm surgical treatment in hours) derived from medical records. Main Outcomes and Measures: Clinical characteristics, complications, and discharge destination were extracted from medical records and 12-month survival obtained from data linkage. The associations of onset-to-treatment time (in hours) with (1) discharge destination of survivors (home vs rehabilitation), (2) 12-month survival, and (3) neurologic complications (rebleed, delayed cerebral ischemia, meningitis, seizure, hydrocephalus, and delayed cerebral injury) were investigated using natural cubic splines in multivariable Cox proportional hazards and logistic regression models. Results: Of the 575 patients with aneurysmal SAH, 482 patients (mean [SD] age, 55.0 [14.5] years; 337 [69.9%] female) who received endovascular coiling or neurosurgical clipping were studied. A nonlinear association of treatment delay was found with the odds of being discharged home vs rehabilitation (effective df = 3.83 in the generalized additive model, χ2 test P = .002 for the 4-df cubic spline), with a similar nonlinear association remaining significant after adjustment for sex, treatment modality, severity, Charlson Comorbidity Index, history of hypertension, and hospital transfer (likelihood ratio test: df = 3, deviance = 9.57, χ2 test P = .02). Both unadjusted and adjusted cox regression models showed a nonlinear association between time to treatment and 12-month mortality with the lowest hazard of death with receipt of treatment at 12.5 hours after symptom onset, although the nonlinear term became nonsignificant upon adjustment. The odds of being discharged home were higher with treatment before 20 hours after onset, with the probability of being discharged home compared with rehabilitation or other hospital increased by approximately 10% when treatment was received within the first 12.5 hours after symptom onset and increased by an additional 5% from 12.5 to 20 hours. Time to treatment was not associated with any complications. Conclusions and Relevance: This cohort study found evidence that more favorable outcomes (discharge home and survival at 12 months) were achieved when surgical treatment occurred at approximately 12.5 hours. These findings provide more clarity around optimal timelines of treatment with people with aneurysmal SAH; however, additional studies are needed to confirm the findings.

Adherence to evidence-based processes of care reduces one-year mortality after aneurysmal subarachnoid hemorrhage (aSAH).

BACKGROUND: There is limited research on the provision of evidence-based care and its association with outcomes after aneurysmal subarachnoid hemorrhage (aSAH). AIMS: We examined adherence to evidence-based care after aSAH and associations with survival and discharge destination. Also, factors associated with evidence-based care including age, sex, Charlson comorbidity index, severity scores, and delayed cerebral ischemia and infarction were examined for association with survival and discharge destination. METHODS: In a retrospective cohort (2010-2016) of all aSAH cases across two comprehensive cerebrovascular centres, we extracted 3 indicators of evidence-based aSAH care from medical records: (1) antihypertensives prior to aneurysm treatment, (2) nimodipine, and (3) aneurysm treatment (coiling/clipping). We defined 'optimal care' as receiving all eligible processes of care. Survival at 1 year was obtained by data linkage. We estimated (1) proportion of patients and characteristics associated with receiving processes of care, (2) associations between processes of care with 1-year mortality using cox-proportional hazard model and discharge destination with log binomial regression adjusting for age, sex, severity of aSAH, delayed cerebral ischemia and/or cerebral infarction and comorbidities. Sensitivity analyses explored effect modification of the association between processes of care and outcome by management type (active versus comfort measures). RESULTS: Among 549 patients (69% women), 59% were managed according to the guidelines. Individual indicators were associated with lower 1-year mortality but not discharge destination. Optimal care reduced mortality at 1 year in univariable (HR 0.24 95% CI 0.17-0.35) and multivariable analyses (HR 0.51 95% CI 0.34-0.77) independent of age, sex, severity, comorbidities, and hospital network. CONCLUSION: Adherence to processes of care reduced 1-year mortality after aSAH. Many patients with aSAH do not receive evidence-based care and this must be addressed to improve outcomes.

Are We Improving? Update and Critical Appraisal of the Reporting of Decision Process and Quality Measures in Trials Evaluating Patient Decision Aids.

BACKGROUND: In 2014, a systematic review found large gaps in the quality of reporting of measures used in 86 published trials evaluating the effectiveness of patient decision aids (PtDAs). The purpose of this study was to update that review. METHODS: We examined measures of decision making used in 49 randomized controlled trials included in the 2014 and 2017 Cochrane Collaboration systematic review of PtDAs. Data on development of the measures, reliability, validity, responsiveness, precision, interpretability, feasibility, and acceptability were independently abstracted by 2 paired reviewers. RESULTS: Information from 273 measures was abstracted, and 109 of these covered the core domains of decision processes (n = 55) and decision quality including informed choice/knowledge (n = 48) and values-choice concordance (n = 12). Very few studies reported data on the performance and clinical sensibility of measures, with reliability (23%) and validity (6%) being the most common. Studies using new measures were less likely to include information about their psychometric performance compared with previously published measures. LIMITATIONS: The review was limited to reporting of measures in studies included in the Cochrane review and did not consult prior publications. CONCLUSION: There continues to be very little reported about the development or performance of measures used to evaluate the effectiveness of PtDAs in published trials. Minimum reporting standards have been published, and efforts to require investigators to use them are needed.

Care of frail and older adults: A content analysis of paramedic operational clinical practice guidelines.

INTRODUCTION: Frailty rates are increasing with population ageing. In paramedicine, Clinical Practice Guidelines (CPGs) are essential documents that support decision making, yet little evidence exists regarding the support CPGs provide paramedics in the care of frail and older adults. AIM: To investigate how CPGs support paramedics' care of frail and older adults. METHODS: CPGs from nine Australasian paramedic services were collected in 2019. Content analysis was used to explore two hundred and thirty-seven individual CPGs for decision support information regarding frail and older adults. RESULTS: Evidence-based content relating to older adults was sparse compared to paediatric content. Two overarching decision support domains were identified, patient assessment and management. Inconsistent age descriptors were widespread, particularly in pharmacological guidelines. Five service providers' CPGs contained validated assessment instruments for use with older adults. CONCLUSION: Decision support documentation regarding frail and older adults varies across Australasian paramedic services. Frailty and older adult specific CPGs, and validated assessment instruments suitable to the paramedicine environment could improve paramedic decision making and minimise patient risk. A collaborative approach encompassing service providers and educational institutions is crucial to develop consistent, evidence-based CPGs relevant to older adults.

Time and predictors of time to treatment for aneurysmal subarachnoid haemorrhage (aSAH): a systematic review.

BACKGROUND: Aneurysmal subarachnoid haemorrhage (aSAH) is a serious form of stroke, for which rapid access to specialist neurocritical care is associated with better outcomes. Delays in the treatment of aSAH appear to be common and may contribute to poor outcomes. We have a limited understanding of the extent and causes of these delays, which hinders the development of interventions to reduce delays and improve outcomes. The aim of this systematic review was to quantify and identify factors associated with time to treatment in aSAH. METHODS: This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and was registered in PROSPERO (Reg. No. CRD42019132748). We searched four electronic databases (MEDLINE, EMBASE, Web of Science and Google Scholar) for manuscripts published from January 1998 using pre-designated search terms and search strategy. Main outcomes were duration of delays of time intervals from onset of aSAH to definitive treatment and/or factors related to time to treatment. RESULTS: A total of 64 studies with 16 different time intervals in the pathway of aSAH patients were identified. Measures of time to treatment varied between studies (e.g. cut-off timepoints or absolute mean/median duration). Factors associated with time to treatment fell into two categories-individual (n = 9 factors, e.g. age, sex and clinical characteristics) and health system (n = 8 factors, e.g. pre-hospital delay or presentation out-of-hours). Demographic factors were not associated with time to treatment. More severe aSAH reduced treatment delay in most studies. Pre-hospital delays (patients delay, late referral, late arrival of ambulance, being transferred between hospitals or arriving at the hospital outside of office hours) were associated with treatment delay. In-hospital factors (patients with complications, procedure before definitive treatment, slow work-up and type of treatment) were less associated with treatment delay. CONCLUSIONS: The pathway from onset to definitive treatment of patients with aSAH consists of multiple stages with multiple influencing factors. This review provides the first comprehensive understanding of extent and factors associated with time to treatment of aSAH. There is an opportunity to target modifiable factors to reduce time to treatment, but further research considering more factors are needed.

The 'fallacy of normalcy': A content analysis of women's online post-childbirth health-related support.

BACKGROUND: Online forums have changed traditional sources of seeking help because they provide an anonymous and non-judgemental environment particularly suited for women with post-childbirth problems. QUESTION: What support is given to mothers who have posted questions about post-childbirth morbidities? METHODS: A total of 333 messages posted on a post-childbirth online forum were loaded into NVIVO 12 Pro and were analysed using content and thematic analysis. Content analysis identified the major health problems, and thematic analysis was used for identifying motivations and the support offered. FINDINGS: Seventeen different health problems were discussed on posts, with a strong emphasis on pelvic problems, followed by mental health concerns. The key motivation for seeking online help identified using 'typology of advice solicitation' was request for opinion or information (48.85%). The two main support themes were: peer to peer support (82%) and normalisation (not always appropriate) of post-childbirth problems (18%). Most of the support offered was emotional (56.9%) followed by practical (22.7%) and informational support (20.4%). DISCUSSION: Postpartum adjustment of post-childbirth experiences can be supportive but if ill-informed may provide a barrier to safe and reliable health care. CONCLUSION: We recommend women have access to online forums moderated by healthcare providers who can notify participants when a problem requires support from a relevant health professional opinion.

Associations between socioeconomic status and place of residence with survival after aneurysmal subarachnoid haemorrhage.

BACKGROUND/AIM: This study aims to understand early (<24 h post ictus) and late (up to 12 months) survival post aneurysmal subarachnoid haemorrhage (aSAH), with a focus on rurality and socioeconomic status. METHODS: A statewide population-based cohort of aSAH cases in Tasmania, Australia, was established from 2010 to 2014 using multiple overlapping sources. Clinical data were collected from medical records and the Tasmanian Death Registry, with area-level rurality and socioeconomic status geocoded to participants' residential address. RESULTS: From a cohort of 237 (70% women, 36% disadvantaged, 38% rural) individuals over a 5-year period, 12-month mortality was 52.3% with 54.0% of these deaths occurring within 24 h post ictus. In univariable analysis of 12-month survival, outcome was not influenced by socioeconomic status, but rural geographical location was associated with a non-significant increase in death (hazard ratio (HR) 1.22; 95% confidence interval (CI) 0.85-1.75) along with hypertension (HR 1.78; 95% CI 1.07-2.98) and hypercholesterolaemia (HR 1.70; 95% CI 0.99-2.91). Multivariable analysis demonstrated a statistically significant increase in death to 12 months after aSAH for both hypertension (HR 1.81; 95% CI 1.08-3.03) and hypercholesterolaemia (HR 1.71; 95% CI 1.00-2.94) but not socioeconomic status or geographic location. CONCLUSION: We found high early death in this population-based aSAH Australian population. Survival to 12 months after aSAH was not related to either geographical location or socioeconomic status but modifiable risk factors increased the risk of death.

What Works in Implementing Patient Decision Aids in Routine Clinical Settings? A Rapid Realist Review and Update from the International Patient Decision Aid Standards Collaboration.

BACKGROUND: Decades of effectiveness research has established the benefits of using patient decision aids (PtDAs), yet broad clinical implementation has not yet occurred. Evidence to date is mainly derived from highly controlled settings; if clinicians and health care organizations are expected to embed PtDAs as a means to support person-centered care, we need to better understand what this might look like outside of a research setting. AIM: This review was conducted in response to the IPDAS Collaboration's evidence update process, which informs their published standards for PtDA quality and effectiveness. The aim was to develop context-specific program theories that explain why and how PtDAs are successfully implemented in routine healthcare settings. METHODS: Rapid realist review methodology was used to identify articles that could contribute to theory development. We engaged key experts and stakeholders to identify key sources; this was supplemented by electronic database (Medline and CINAHL), gray literature, and forward/backward search strategies. Initial theories were refined to develop realist context-mechanism-outcome configurations, and these were mapped to the Consolidated Framework for Implementation Research. RESULTS: We developed 8 refined theories, using data from 23 implementation studies (29 articles), to describe the mechanisms by which PtDAs become successfully implemented into routine clinical settings. Recommended implementation strategies derived from the program theory include 1) co-production of PtDA content and processes (or local adaptation), 2) training the entire team, 3) preparing and prompting patients to engage, 4) senior-level buy-in, and 5) measuring to improve. CONCLUSIONS: We recommend key strategies that organizations and individuals intending to embed PtDAs routinely can use as a practical guide. Further work is needed to understand the importance of context in the success of different implementation studies.