Do delays in radiology lead to breaches in the 4-hour rule?

AIM: To assess trends in medical imaging requests before and after the 4-hour rule commenced and to assess the imaging time component of emergency department (ED) length of stay (LOS). MATERIALS AND METHODS: Retrospective analysis of ED patients and imaging requests 1 year prior to and 3 years after implementation of the 4-hour rule (April to December for 2011-2014) was performed at a single adult tertiary referral Level 1 trauma hospital with Level 6 ED. Logistic regression was used to evaluate trends in the number of ED patient presentations, patient triage categories, and imaging requests for these patients. The imaging component of the total ED LOS was compared for patients who met the 4-hour target and patients who did not. RESULTS: Compared to 2011 (before the 4-hour rule), ED presentations increased 4.74% in 2012, 12.7% in 2013, 21.28% in 2014 (p<0.01). Total imaging requests increased 23.05% in 2012, 48.04% in 2013, 60.77% in 2014 (p<0.01). For patients breaching the 4-hour rule, the mean time before radiology request was 2.4-2.8 hours; mean time from imaging request to completion was 1.2-1.3 hours; mean time from imaging completion to discharge from ED was the longest component of ED LOS (4.9-5.9 hours). CONCLUSIONS: There has been a significant increase in imaging requests, with a trend towards more CT and less radiography requests. Imaging requests for patients who breached the 4-hour target were made on average 2.4-2.8 hours after triage and average time after imaging in itself, exceeded 4 hours. Imaging is not likely a causative factor for patients breaching the 4-hour target.

Validation of self-reported hearing loss. The Blue Mountains Hearing Study.

PURPOSE: Large-scale epidemiological studies have often used self-report to estimate prevalence of age-related hearing loss. However, few large population-based studies have validated self-report against measured hearing loss. Our study aimed to assess the performance of a single question and a brief hearing handicap questionnaire in identifying individuals with hearing loss, against the gold standard of pure-tone audiometry. METHODS: We examined 2015 residents, aged 55-99 years, living in the west of Sydney, Australia, who participated in the Blue Mountains Hearing Study during 1997-1999. Audiologists administered a comprehensive questionnaire, including the question: 'Do you feel you have a hearing loss?' The Shortened Hearing Handicap Inventory for Elderly (HHIE-S) was also administered during the hearing examination, which included pure-tone audiometry. The single question and HHIE-S were compared with measured losses at levels >25, >40 and >60 decibels hearing level (dBHL) to indicate mild, moderate and marked hearing impairment, for pure-tone averages (PTA) of responses to 500, 1000, 2000 and 4000 Hz. RESULTS: The single question yielded reasonable sensitivity and specificity for hearing impairment, and was minimally affected by age and gender. HHIE-S scores >8 had lower sensitivity but higher specificity and positive predictive value. The HHIE-S performed slightly better in younger than older subjects and performed better for moderate hearing impairment. CONCLUSIONS: In this older population with a high prevalence of hearing loss (39.4%), both a question about hearing and the HHIE-S appeared sufficiently sensitive and specific to provide reasonable estimates of hearing loss prevalence. Both could be recommended for use in epidemiological studies that aim to assess the magnitude of the burden caused by age-related sensory impairment but cannot measure hearing loss by audiometry.

Risk factors for colonization with vancomycin-resistant enterococci in a Melbourne hospital.

OBJECTIVE: To determine risk factors for colonization with vancomycin-resistant enterococci (VRE) in a hospital outbreak. DESIGN: Outbreak investigation and case-control study. SETTING: A referral teaching hospital in Melbourne, Australia. PARTICIPANTS: Cases were inpatients colonized (with or without clinical disease) with VRE between July 26 and November 28, 1998; controls were hospitalized patients without VRE. METHODS: Five cases of VRE were identified between July 26 and November 8, 1998, by growth of VRE from various sites. Active case finding by cultures of rectal swabs from patients surveyed in wards was commenced on July 26, after the first isolate of VRE. RESULTS: There were 19 cases and 66 controls. All the VRE identified were vanB, and all were Enterococcus faecium. One molecular type predominated (18/19 cases). In a logistic-regression model, being on the same ward as a VRE case was the highest risk factor (odds ratio [OR], 82; 95% confidence interval [CI95], 5.7-1,176; P=.001). Having more than five antibiotics (OR, 11.9; CI95 1.1-129.6; P<.05), use of metronidazole (OR, 10.9; CI95, 1.7-69.8; P=.01), and being a medical patient (OR, 8.1; CI95, 1.4-47.6; P<.05) also were significant. Intensive care unit admission was associated with decreased risk (OR, 0.1; CI95, 0.01-0.8; P<.05). CONCLUSION: Our findings are consistent with an acute hospital outbreak. Monitoring and control of antibiotic use, particularly metronidazole, may reduce VRE in our hospital. Ongoing surveillance and staff education also are necessary.

Do work-place smoking bans cause smokers to smoke "harder"? Results from a naturalistic observational study.

The purpose of this study was to investigate whether smokers outside buildings with work-place smoking bans smoke "harder" than those smoking in social settings. An unobtrusive random observational study of smokers followed by structured interview was used, with 143 smokers taking smoking breaks outside their office buildings and 113 smokers in social settings. The main outcome measurements were number of puffs per cigarette and cigarette smoking duration. The mean number of puffs per cigarette for the office building group was 18.7% greater than that for the social settings group (10.7 +/- 3.2 vs. 8.7 +/- 2.7, t = 5.58, df = 253, p < 0.001); 74.8% of smokers outside offices took more than the mean number of puffs for the group compared to 42.5% of smokers in social settings (chi 2 df 1 = 26.31, p < 0.0001). Mean cigarette smoking duration was 30.4% shorter for the work-place group than the social settings group (3.9 +/- 1.2 minutes vs. 5.6 +/- 2.6 minutes). Of smokers outside offices, 55.2% had a cigarette smoking duration between 3 and 4.59 minutes, while 53.1% of smokers in social settings took > or = 5 minutes to smoke the observed cigarette (chi 2 df 2 = 31.55, p < 0.0001). Smokers who scored at the 75th percentile on the Fagerstrom Tolerance Scale took a mean 9.5 +/- 2.6 puffs per cigarette compared to 9.3 +/- 2.7 puffs by those who scored in the 25th percentile on the scale (t = 0.34, df = 145, p = 0.73). Regardless of degree of nicotine dependency, smokers leaving work-stations to smoke outside buildings smoked their cigarettes nearly 19% "harder" than cigarettes smoked in social settings. The individual and public health benefits of reduced smoking frequency engendered by work-place smoking bans may be lessened by policies which allow smokers to take smoking breaks.

Folate fortification: potential impact on folate intake in an older population.

OBJECTIVE: To examine the potential impact of different models of folate fortification of Australian foods on the folate intakes of older Australians. DESIGN: Dietary data were collected using a food frequency questionnaire from people attending a population-based health study. SETTING: Two postcode areas west of Sydney, Australia. SUBJECTS: A total of 2895 people aged over 49 y, obtained from a door knock census (79% of 3654 subjects examined). MAIN OUTCOME MEASURES: The folate intake in this population was estimated using four different models: (1) pre-fortification folate values; (2) current voluntary folate fortification in Australia; (3) universal fortification of all foods permitted to add folate, at 25% recommended dietary intake (RDI) per reference serve; and (4) universal fortification of all foods permitted to add folate, at 50% RDI per reference serve. The increased bioavailability of synthetic folic acid (SFA) was included in the analysis. RESULTS: At current voluntary folate fortification, approximately 65% of this population consume 320 microg dietary folate equivalents (DFE) or more per day from diet and supplements, and 0.4% (n=10) consume greater than the recommended upper safety level of 1000 microg from SFA. More than 95% of this older population would be expected to consume more than 320 microg DFE from diet and supplements with universal fortification at 50% of the RDI, and 0.5% (n=14) may consume greater than 1000 microg/day of SFA. CONCLUSIONS: There is unlikely to be a large increase in the proportion of older persons who are likely to consume more than the upper safety level of intake with universal folate fortification. As most of those who currently or are predicted to consume over 1000 microg SFA take supplements containing folic acid, it is highly recommended that vitamin B12 be included in any vitamin supplements containing folate. SPONSORSHIP: This study was supported by the Australian National Health and Medical Research Council (NHMRC).

Progression of periodontal disease in HIV seropositive patients.

Data from cross-sectional studies suggest that periodontitis in HIV-infected patients is a more destructive form of disease in contrast to the slowly progressing form of adult periodontitis in the general population. We studied prospectively over an 18-month period 30 HIV infected, but asymptomatic, patients and compared the rate of periodontal attachment loss with that of a healthy control group (n = 10) matched for age and plaque index. Every 6 months, each subject was assessed for their clinical status by a physician and CD4+ cell count determined. The proliferative response of peripheral blood lymphocytes was determined by in vitro cultures with PHA and Con A. The periodontal health status was assessed by scoring with plaque index (PI), gingival index (GI), and periodontal disease index (PDI). The control subjects were assessed for periodontal status only. Of the 30 HIV-positive patients whose data were analyzed 14 received Zidovudine (AZT) while the remaining 16 did not. There was no correlation between any clinical parameter measured and periodontal status as determined by PI or GI. However, a significant difference in the change of periodontal disease index (PDI) was observed between the HIV-infected and control groups (P = 0.005). We concluded that HIV-infected patients with pre-existing periodontitis tend to experience a greater rate of attachment loss over time compared with controls.

Cross-infection from periodontitis sites to failing implant sites in the same mouth.

Twenty-five tooth and implant sites in nine patients were investigated for the presence of putative periodontopathic organisms, using specific DNA probes for Actinobacillus actinomycetemcomitans, Porphromonas gingivalis, Prevotella intermedia, Eikenella corrodens, Fusobacterium nucleatum, Treponema denticola, and Campylobacter recta. Five of nine patients showed a likelihood of transmission from tooth to implant sites. These patients also showed a high number of putative periodontopathic organisms present in the tooth sites tested. A significant risk was found of transmitting putative periodontopathic organisms from periodontitis sites to implant sites in the same mouth. An appropriate clinical protocol needs to be developed to address this issue.

Effect of peer led programme for asthma education in adolescents: cluster randomised controlled trial.

OBJECTIVE: To determine the effect of a peer led programme for asthma education on quality of life and related morbidity in adolescents with asthma. DESIGN: Cluster randomised controlled trial. SETTING: Six high schools in rural Australia. PARTICIPANTS: 272 students with recent wheeze, recruited from a cohort of 1515 students from two school years (mean age 12.5 and 15.5 years); 251 (92.3%) completed the study. INTERVENTION: A structured education programme for peers comprising three steps (the "Triple A Program"). MAIN OUTCOME MEASURES: Quality of life, school absenteeism, asthma attacks, and lung function. RESULTS: When adjusted for year and sex, mean total quality of life scores showed significant improvement in the intervention than control group. Clinically important improvement in quality of life (>0.5 units) occurred in 25% of students with asthma in the intervention group compared with 12% in the control group (P=0.01). The number needed to treat was 8 (95% confidence interval 4.5 to 35.7). The effect of the intervention was greatest in students in year 10 and in females. Significant improvements occurred in the activities domain (41% v 28%) and in the emotions domain (39% v 19%) in males in the intervention group. School absenteeism significantly decreased in the intervention group only. Asthma attacks at school increased in the control group only. CONCLUSION: The triple A programme leads to a clinically relevant improvement in quality of life and related morbidity in students with asthma. Wider dissemination of this programme in schools could play an important part in reducing the burden of asthma in adolescents.

A prospective cohort study of health outcomes following whiplash associated disorders in an Australian population.

OBJECTIVE: To define health outcomes of whiplash associated disorders (WAD) at three months, six months, and two years after injury and to examine predictors of these outcomes. DESIGN: Prospective cohort study. SETTING: New South Wales, Australia. SUBJECTS: People with compensable motor crash injuries who reported whiplash as one of their injuries. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Functional Rating Index (FRI), Short Form 36 (SF-36) at three months, six months, and two years after injury, ascertained by telephone interview. RESULTS: At three months, 33.6% of the cohort was recovered (as defined by FRI

Modelling strategies for reducing pharmaceutical costs in hospital.

OBJECTIVE: To describe drug utilization and cost in a large hospital and to compare the impact of different strategies on cost associated with drug prescribing. DESIGN: Retrospective data on drug utilization and cost, linked to patient clinical data and prescriber data from November 1998 were analyzed and modelled. MAIN OUTCOME MEASURES: Impact of different strategies for cost control. SETTING: A large hospital in Sydney, Australia. RESULTS: The mean cost of drugs per episode of care was 28 Australian dollars. Of all drug costs, 79% was incurred by medical units and 14% by surgical units. Oncology accounted for 42% and inpatients for 91% of drug costs. Although section-100 (S-100) drugs incurred a high cost (640 dollars) per episode of care, there were only 41 episodes where S-100 drugs (expensive, restricted drugs) were used, and the total cost of S-100 drugs was only 3.7% of the total cost to the hospital. Antibiotics were the most commonly prescribed drug category, prescribed in 14% of all hospital episodes, and accounting for 14% of total drug costs. Anti-ulcer drugs were the next most costly group, accounting for 7% of total drug costs. A 20% reduction in use of antibiotics would save four times that (233,832 dollars pa) of a 20% reduction in use of S-100 drugs (61,392 dollars pa). DISCUSSION: Our study suggests that reducing inappropriate use of high volume drugs such as antibiotics could be more effective in optimising health facility drug budgets than attempts concentrating solely on reducing use of high cost drugs alone. Moreover our study suggests that systematic measurement of drug utilisation patterns is a key element of drug cost control strategies.

Attitudes of Australian nurses toward the implementation of a clinical information system.

A computerized clinical information system (CIS) used for the majority of patient charting and medical records was installed in six of 15 beds in the intensive care unit (ICU) of a large Australian hospital in November 1993. Staff acceptance was identified as integral to the success of the system. A survey was issued to all nursing staff of the ICU to identify factors that affected attitude toward computers in the critical care environment. Factors resulting in negative attitudes then could be targeted through training and support for users. The factors considered that potentially could influence attitudes were age, nursing experience, intensive care nursing experience, and education. The study showed that nursing experience had a statistically significant effect on motivation to use computers. A strong relation was evident between the concepts of beliefs, attitudes, and motivation. A less apparent association was present between knowledge and the other concepts. Orientation and in-service education programs should provide appropriate and applied information to optimize the motivation, beliefs, and computer literacy of nurses using CIS frameworks.

A comparison of nursing activities associated with manual and automated documentation in an Australian intensive care unit.

This article describes a comparative study that examined the frequencies of nursing activities, when using a clinical information system (CIS) and a paper-based documentation system in an Australian intensive care unit. The study unit had half the beds equipped with a CIS, and the remaining beds used paper documentation. Work sampling methodology was used to observe nurses working with both systems. Though there were differences for all activities between the environments and the directions of the differences were logical, none were statistically significant using a chi-square test (P = .11-0.65), probably because of the small sample size. This study established that work sampling methodology using a random timer is a valid and relatively easy method to capture work activity in the clinical area. Although this article does not provide definitive information regarding the benefits of a CIS over manual documentation, a number of important methodological issues are discussed, including the study design, procedure, use of dedicated observers, and the distinction between basic versus fully optioned systems. Future research should evaluate the efficiency, impact on patient outcomes and nursing practice, and cost effectiveness of fully optioned systems.