A protocol for tracking outcomes post intensive care.

BACKGROUND: Critically ill patients are more likely to survive intensive care than ever before due to advances in treatment. However, a proportion subsequently experiences post-intensive care syndrome (PICS) incurring substantial personal, social, and economic costs. PICS is a debilitating set of physical, psychological, and cognitive sequelae but the size and characteristics of the affected population have been difficult to describe, impeding progress in intensive care rehabilitation. AIMS AND OBJECTIVES: The aim of this protocol is to describe recovery after admission to intensive care unit (ICU) and the predictors, correlates, and patient-reported outcomes for those experiencing PICS. The study will support the development of screening, diagnostic, and outcome measures to improve post-ICU recovery. DESIGN: A prospective, multi-site observational study in three ICUs in Brisbane, Australia. Following consent, data will be collected from clinical records and using validated self-report instruments from 300 patients, followed up at 6 weeks and 6 months post ICU discharge. METHODS: TOPIC is a prospective, multi-site observational study using self-report and clinical data on risk factors, including comorbidities, and outcomes. Data will be collected with consent from hospital records and participants 6 weeks and 6months post ICU discharge. RESULTS: The main outcome measures will be self-reported physical, cognitive, and psychological function 6 weeks and 6 months post-ICU discharge. RELEVANCE TO CLINICAL PRACTICE: This protocol provides a methodological framework to measure recovery and understand PICS. Data analysis will describe characteristics associated with recovery and PICS. The subsequent prediction and screening tools developed then aim to improve the effectiveness of post-ICU prevention and rehabilitation through more targeted screening and prediction and found a program of research developing a more tailored approach to PICS.

Paramedic occupational violence mitigation: a comprehensive systematic review of emergency service worker prevention strategies and experiences for use in prehospital care.

Occupational violence is a significant issue within the context of prehospital healthcare with the majority of paramedics reporting some form of abuse, intimidation, physical or sexual assault during their career. Though the paramedic literature acknowledges the severity of this issue, there is limited literature examining occupational violence mitigation strategies. Despite this, the operational and environmental similarities that exist between paramedics and other emergency service workers such as the police and firefighters, provide an opportunity to review relatable occupational violence mitigation strategies and experiences.This review used Joanna Briggs Institute guidance for systematic reviews of both qualitative evidence and effectiveness. Studies included in this review incorporated those published in English from 1990 to January 2020.Two qualitative studies met the criteria for review. From these, a total of 22 findings were extracted and combined to form four categories from which two syntheses were developed. Twenty-four quantitative studies, encompassing six unique fields, met the criteria for review.Mitigation strategies for emergency service worker occupational violence are not easily defined. They are dynamic, multilayered and encompass a variety of complex social, medical and psychological influences. In spite of this, there are clear benefits to their application in regard to the approaches and training of violence mitigation. The paramedic environment would benefit from strategies that are flexible to the ongoing needs of the workers and the specific cultural, environmental and social factors that encompass the paramedic organisation.

Exploration of the health risk-based definition for heatwave: A multi-city study.

BACKGROUND: As heatwaves are expected to be more frequent, longer, and more intense in the future, it is imperative to understand how heatwaves affect health. However, it is intensely debated about how a heatwave should be defined. OBJECTIVES: This study explored the possibility of developing a health risk-based definition for heatwave, and assessed the heat-related mortality in the three largest Australian cities. METHODS: Daily data on climatic variables and non-accidental deaths for Brisbane, Melbourne and Sydney during the period 1988-2009 were obtained from relevant government agencies. Several local heatwave definitions were tested by using percentiles (e.g., from the 75th to 99th centile) of mean temperature with duration ≥2 days across these cities. We examined the relative risks of mortality associated with heatwaves in each city using Poisson generalised additive model, after controlling for long-term trend, within-season variation, day of the week, and relative humidity. Then, Bayesian hierarchical model with segment-spline was used to examine the threshold for the heatwave-related impacts. RESULTS: A consistent and significant increase in mortality during heatwaves was observed in all three cities. The pooled data show that the relative risk of mortality started to increase around the 95th centile of temperature, increased sharply at the 97th centile and rose alarmingly at the 99th centile. Based on research findings, we proposed tiered health risk-based metrics to define a heatwave. CONCLUSIONS: Our findings provide supportive evidence for developing health risk-based metrics to assess the impacts of heatwave. These findings may have important implications for assessing and reducing the burden of heat-related mortality.

Development of health risk-based metrics for defining a heatwave: a time series study in Brisbane, Australia.

BACKGROUND: This study attempted to develop health risk-based metrics for defining a heatwave in Brisbane, Australia. METHODS: Poisson generalised additive model was performed to assess the impact of heatwaves on mortality and emergency hospital admissions (EHAs) in Brisbane. RESULTS: In general, the higher the intensity and the longer the duration of a heatwave, the greater the health impacts. There was no apparent difference in EHAs risk during different periods of a warm season. However, there was a greater risk for mortality in the 2nd half of a warm season than that in the 1st half. While elderly (≥75 years) were particularly vulnerable to both the EHA and mortality effects of a heatwave, the risk for EHAs also significantly increased for two other age groups (0-64 years and 65-74 years) during severe heatwaves. Different patterns between cardiorespiratory mortality and EHAs were observed. Based on these findings, we propose the use of a tiered heat warning system based on the health risk of heatwave. CONCLUSIONS: Health risk-based metrics are a useful tool for the development of local heatwave definitions. This tool may have significant implications for the assessment of heatwave-related health consequences and development of heatwave response plans and implementation strategies.

Enhancing paramedics procedural skills using a cadaveric model.

BACKGROUND: Paramedic education has evolved in recent times from vocational post-employment to tertiary pre-employment supplemented by clinical placement. Simulation is advocated as a means of transferring learned skills to clinical practice. Sole reliance of simulation learning using mannequin-based models may not be sufficient to prepare students for variance in human anatomy. In 2012, we trialled the use of fresh frozen human cadavers to supplement undergraduate paramedic procedural skill training. The purpose of this study is to evaluate whether cadaveric training is an effective adjunct to mannequin simulation and clinical placement. METHODS: A multi-method approach was adopted. The first step involved a Delphi methodology to formulate and validate the evaluation instrument. The instrument comprised of knowledge-based MCQs, Likert for self-evaluation of procedural skills and behaviours, and open answer. The second step involved a pre-post evaluation of the 2013 cadaveric training. RESULTS: One hundred and fourteen students attended the workshop and 96 evaluations were included in the analysis, representing a return rate of 84%. There was statistically significant improved anatomical knowledge after the workshop. Students' self-rated confidence in performing procedural skills on real patients improved significantly after the workshop: inserting laryngeal mask (MD 0.667), oropharyngeal (MD 0.198) and nasopharyngeal (MD 0.600) airways, performing Bag-Valve-Mask (MD 0.379), double (MD 0.344) and triple (MD 0.326,) airway manoeuvre, doing 12-lead electrocardiography (MD 0.729), using laryngoscope (MD 0.726), using Magill® forceps to remove foreign body (MD 0.632), attempting thoracocentesis (MD 1.240), and putting on a traction splint (MD 0.865). The students commented that the workshop provided context to their theoretical knowledge and that they gained an appreciation of the differences in normal tissue variation. Following engagement in/ completion of the workshop, students were more aware of their own clinical and non-clinical competencies. CONCLUSIONS: The paramedic profession has evolved beyond patient transport with minimal intervention to providing comprehensive both emergency and non-emergency medical care. With limited availability of clinical placements for undergraduate paramedic training, there is an increasing demand on universities to provide suitable alternatives. Our findings suggested that cadaveric training using fresh frozen cadavers provides an effective adjunct to simulated learning and clinical placements.

Expanding emergency department capacity: a multisite study.

OBJECTIVES: The aims of the present study were to identify predictors of admission and describe outcomes for patients who arrived via ambulance to three Australian public emergency departments (EDs), before and after the opening of 41 additional ED beds within the area. METHODS: The present study was a retrospective comparative cohort study using deterministically linked health data collected between 3 September 2006 and 2 September 2008. Data included ambulance offload delay, time to see doctor, ED length of stay (LOS), admission requirement, access block, hospital LOS and in-hospital mortality. Logistic regression analysis was undertaken to identify predictors of hospital admission. RESULTS: Almost one-third of all 286037 ED presentations were via ambulance (n=79196) and 40.3% required admission. After increasing emergency capacity, the only outcome measure to improve was in-hospital mortality. Ambulance offload delay, time to see doctor, ED LOS, admission requirement, access block and hospital LOS did not improve. Strong predictors of admission before and after increased capacity included age >65 years, Australian Triage Scale (ATS) Category 1-3, diagnoses of circulatory or respiratory conditions and ED LOS >4h. With additional capacity, the odds ratios for these predictors increased for age >65 years and ED LOS >4h, and decreased for ATS category and ED diagnoses. CONCLUSIONS: Expanding ED capacity from 81 to 122 beds within a health service area impacted favourably on mortality outcomes, but not on time-related service outcomes such as ambulance offload time, time to see doctor and ED LOS. To improve all service outcomes, when altering (increasing or decreasing) ED bed numbers, the whole healthcare system needs to be considered.

Problems with a great idea: referral by prehospital emergency services to a community-based falls-prevention service.

BACKGROUND AND AIM: Falls are the leading cause of injury in older adults. Identifying people at risk before they experience a serious fall requiring hospitalisation allows an opportunity to intervene earlier and potentially reduce further falls and subsequent healthcare costs. The purpose of this project was to develop a referral pathway to a community falls-prevention team for older people who had experienced a fall attended by a paramedic service and who were not transported to hospital. It was also hypothesised that providing intervention to this group of clients would reduce future falls-related ambulance call-outs, emergency department presentations and hospital admissions. METHODS: An education package, referral pathway and follow-up procedures were developed. Both services had regular meetings, and work shadowing with the paramedics was also trialled to encourage more referrals. A range of demographic and other outcome measures were collected to compare people referred through the paramedic pathway and through traditional pathways. RESULTS: Internal data from the Queensland Ambulance Service indicated that there were approximately six falls per week by community-dwelling older persons in the eligible service catchment area (south west Brisbane metropolitan area) who were attended to by Queensland Ambulance Service paramedics, but not transported to hospital during the 2-year study period (2008-2009). Of the potential 638 eligible patients, only 17 (2.6%) were referred for a falls assessment. CONCLUSION: Although this pilot programme had support from all levels of management as well as from the service providers, it did not translate into actual referrals. Several explanations are provided for these preliminary findings.

Universal access to ambulance does not increase overall demand for ambulance services in Queensland, Australia.

OBJECTIVE: To determine the impact of the introduction of universal access to ambulance services via the implementation of the Community Ambulance Cover (CAC) program in Queensland in 2003-04. METHOD: The study involved a 10-year (2000-01 to 2009-10) retrospective analysis of routinely collected data reported by the Queensland Ambulance Service (QAS) and by the Council of Ambulance Authorities. The data were analysed for the impact of policy changes that resulted in universal access to ambulance services in Queensland. RESULTS: QAS is a statewide, publically funded ambulance service. In Queensland, ambulance utilisation rate (AUR) per 1000 persons grew by 41% over the decade or 3.9% per annum (10-year mean=149.8, 95% CI: 137.3-162.3). The AUR mean after CAC was significantly higher for urgent incidents than for non-urgent ones. However projection modelling demonstrates that URs after the introduction of CAC were significantly lower than the projected utilisation for the same period. CONCLUSIONS: The introduction of universal access under the Community Ambulance Cover program in Queensland has not had any significant independent long-term impact on demand overall. There has been a reduction in the long-term growth rate, which may have been contributed to by an 'appropriate use' public awareness program.

The impact of heatwaves on mortality and emergency hospital admissions from non-external causes in Brisbane, Australia.

OBJECTIVES: Heatwaves can have significant health consequences resulting in increased mortality and morbidity. However, their impact on people living in tropical/subtropical regions remains largely unknown. This study assessed the impact of heatwaves on mortality and emergency hospital admissions (EHAs) from non-external causes (NEC) in Brisbane, a subtropical city in Australia. METHODS: We acquired daily data on weather, air pollution and EHAs for patients aged 15 years and over in Brisbane between January 1996 and December 2005, and on mortality between January 1996 and November 2004. A locally derived definition of heatwave (daily maximum ≥37°C for 2 or more consecutive days) was adopted. Case-crossover analyses were used to assess the impact of heatwaves on cause-specific mortality and EHAs. RESULTS: During heatwaves, there was a statistically significant increase in NEC mortality (OR 1.46; 95% CI 1.21 to 1.77), cardiovascular mortality (OR 1.89; 95% CI 1.44 to 2.48), diabetes mortality in those aged 75+ (OR 9.96; 95% CI 1.02 to 96.85), NEC EHAs (OR 1.15; 95% CI 1.07 to 1.23) and EHAs from renal diseases (OR 1.41; 95% CI 1.09 to 1.83). The elderly were found to be particularly vulnerable to heatwaves (eg, for NEC EHAs, OR 1.24 for 65-74-year-olds and 1.39 for those aged 75+). CONCLUSIONS: Significant increases in NEC mortality and EHAs were observed during heatwaves in Brisbane where people are well accustomed to hot summer weather. The most vulnerable were the elderly and people with cardiovascular, renal or diabetic disease.

Pain catastrophising, body mass index and depressive symptoms are associated with pain severity in tertiary referral orthopaedic foot/ankle patients.

INTRODUCTION: Patients with chronic foot/ankle pain are often referred for orthopaedic assessment. Psychological vulnerabilities influence pain states (including foot and ankle), therefore this study aimed to establish the prevalence and relative importance of compromised psychological health to perceived foot/ankle pain severity in people referred to an orthopaedic foot and ankle clinic with non-urgent presentations. METHODS: Patients with triaged non-urgent foot/ankle referrals to the Department of Orthopaedics at Gold Coast University Hospital were recruited over a 12-month period and completed the Manchester-Oxford Foot and Ankle Questionnaire which was the primary measure. Participants also completed questionnaires assessing their anthropometric, demographic and health characteristics (Self-Administered Comorbidity Questionnaire) as well as measures of health-related quality of life (EuroQol-5-Dimensions-5-Level Questionnaire and EQ Visual Analogue Scale) and psychological health (Center for Epidemiological Studies-Depression scale, Pain Catastrophizing Scale and Central Sensitization Inventory). Descriptive statistics were used to summarise participant characteristics and a hierarchical multiple linear regression was employed to establish the extent to which psychological variables explain additional variance in foot/ankle pain severity beyond the effects of participant characteristics (age, sex, body mass index (BMI)). RESULTS: One hundred and seventy-two adults were recruited ((64.0% female), median (IQR) age 60.9 (17.7) years and BMI 27.6 (7.5) kg/m2). Specific psychological comorbidities were prevalent including depressive symptoms (48%), central sensitisation (38%) and pain catastrophising (24%). Age, sex and BMI accounted for 11.7% of the variance in MOXFQ-index and psychological variables accounted for an additional 28.2%. Pain catastrophising was the most significant independent predictor of foot/ankle pain severity (accounting for 14.4% of variance), followed by BMI (10.7%) and depressive symptoms (2.3%). CONCLUSIONS: This study demonstrated that specific psychological comorbidities and increased BMI are common in this cohort and that these factors are associated with the symptoms for which patients are seeking orthopaedic assessment. This knowledge should prompt clinicians to routinely consider the psychosocial components of patient presentations and develop non-operative and pre-operative treatment strategies which consider these factors with the goal of improving overall patient outcomes.

"I'd never have that operation again" - a mixed-methods study on how patients react to adverse outcomes following foot and ankle surgery.

BACKGROUND: Adverse outcomes arising from foot and ankle surgery, including lack of pain relief, increased disability and perioperative complications are infrequent but inevitable. This mixed-methods study aims to explore the impact of adverse outcomes on patients following nonemergent foot and ankle surgery. METHODS: Patients who underwent foot and ankle surgery over a two-year period were invited to participate in this study if they reported an adverse outcome. Qualitative assessment consisted of individual semi-structured interviews, designed to explore the decision they made to have surgery and the impact of the outcome after surgery. Quantitative assessment was performed using questionnaires on demographics, current analgesia, foot pain, health-related quality of life, psychological health, and regret. RESULTS: Twelve participants (eight women) consented for inclusion in this study. Current foot pain was high in 10 participants, five met the criteria for central sensitisation syndrome and two had clinically significant pain catastrophising. Most participants regretted their decision to have surgery. The three major themes identified were expectations, communication, and alternatives. CONCLUSIONS: Self-reported adverse outcomes following foot and ankle surgery were prevalent and participants in this study consistently complained of persistent pain. Regret was common and reasons cited for their adverse outcomes centred around the feelings of inadequate communication and failure to meet expectations.

The clinical journey of patients with a severe exacerbation of chronic obstructive pulmonary disease (COPD): from the ambulance to the emergency department to the hospital ward.

Background: Exacerbations of chronic obstructive pulmonary disease (COPD) are acute complications that often require emergency management by ambulance, emergency department (ED) and hospital services. Given the high mortality and morbidity of exacerbations, better understanding of the epidemiology of patients with COPD presenting to EDs is needed, as well as identification of predictive factors for adverse outcomes from exacerbations. Methods: This retrospective observational study involved patients who presented to an ED in the state of Queensland and received either an ED or hospital diagnosis of COPD in 2015 and 2016. Administrative data from ambulance, ED, hospital and death registry databases were linked to provide a comprehensive picture of the emergency healthcare pathway for these patients. Results: A total of 16,166 patients (49% female, 51% male) had 29,332 presentations to an ED in Queensland and received either an ED or hospital principal diagnosis of COPD during 2015 and 2016. These patients had a significant comorbidity burden with 54% having two or more comorbidities. Sixty-nine percent of ED presentations involved ambulance transport, and most of these (74%) involved administration of oxygen therapy and/or other medications by paramedics. Prehospital oxygen administration and ≥10 comorbidities were associated with >1 admission [odds ratio (OR) 1.3, 95% confidence interval (CI) 1.1-1.5; OR 4.3, 95% CI: 3.1-5.8, respectively], greater than average lengths of stay (OR 1.5, 95% CI: 1.3-1.6; OR 22.1, 95% CI: 18.1-27.2) and mortality (OR 1.6, 95% CI: 1.5-1.8; OR 5.3, 95% CI: 4.2-6.8). Of the ambulance presentations, 90% were admitted or received ongoing care. Conclusions: COPD places considerable burden on the emergency healthcare pathway including ambulances and EDs in Queensland. Patients with COPD most commonly present to the ED by ambulance and receive extensive pre-hospital management. These patients have significant comorbidity burden and experience high rates of admission and mortality. More research is required to investigate the emergency pathway to further identify reversible factors and enhance healthcare practice and policy for COPD management.

Linking ambulance, emergency department and hospital admissions data: understanding the emergency journey.

OBJECTIVE: To assess the accuracy of data linkage across the spectrum of emergency care in the absence of a unique patient identifier, and to use the linked data to examine service delivery outcomes in an emergency department (ED) setting. DESIGN: Automated data linkage and manual data linkage were compared to determine their relative accuracy. Data were extracted from three separate health information systems: ambulance, ED and hospital inpatients, then linked to provide information about the emergency journey of each patient. The linking was done manually through physical review of records and automatically using a data linking tool (Health Data Integration) developed by the CSIRO (Commonwealth Scientific and Industrial Research Organisation). Match rate and quality of the linking were compared. SETTING: 10,835 patient presentations to a large, regional teaching hospital ED over a 2-month period (August - September 2007). RESULTS: Comparison of the manual and automated linkage outcomes for each pair of linked datasets demonstrated a sensitivity of between 95% and 99%; a specificity of between 75% and 99%; and a positive predictive value of between 88% and 95%. CONCLUSIONS: Our results indicate that automated linking provides a sound basis for health service analysis, even in the absence of a unique patient identifier. The use of an automated linking tool yields accurate data suitable for planning and service delivery purposes and enables the data to be linked regularly to examine service delivery outcomes.

What are the true costs of major trauma?

BACKGROUND: This economic evaluation reports the results of a detailed study of the cost of major trauma treated at Princess Alexandra Hospital (PAH), Australia. METHODS: A bottom-up approach was used to collect and aggregate the direct and indirect costs generated by a sample of 30 inpatients treated for major trauma at PAH in 2004. Major trauma was defined as an admission for Multiple Significant Trauma with an Injury Severity Score>15. Direct and indirect costs were amalgamated from three sources, (1) PAH inpatient costs, (2) Medicare Australia, and (3) a survey instrument. Inpatient costs included the initial episode of inpatient care including clinical and outpatient services and any subsequent representations for ongoing-related medical treatment. Medicare Australia provided an itemized list of pharmaceutical and ambulatory goods and services. The survey instrument collected out-of-pocket expenses and opportunity cost of employment forgone. Inpatient data obtained from a publically funded trauma registry were used to control for any potential bias in our sample. Costs are reported in Australian dollars for 2004 and 2008. RESULTS: The average direct and indirect costs of major trauma incurred up to 1-year postdischarge were estimated to be A$78,577 and A$24,273, respectively. The aggregate costs, for the State of Queensland, were estimated to range from A$86.1 million to $106.4 million in 2004 and from A$135 million to A$166.4 million in 2008. CONCLUSIONS: These results demonstrate that (1) the costs of major trauma are significantly higher than previously reported estimates and (2) the cost of readmissions increased inpatient costs by 38.1%.

Disaster preparedness amongst pharmacists and pharmacy students: a systematic literature review.

OBJECTIVES: In the aftermath of a disaster, the services provided by pharmacists are essential to ensure the continued health and well-being of the local population. To continue pharmacy services, it is critical that pharmacists are prepared for disasters. A systematic literature review was conducted to explore pharmacists' and pharmacy students' preparedness for disasters and the factors that affect preparedness. METHODS: This review was conducted in April 2020 through electronic databases CINAHL, MEDLINE, Embase, PubMed, Scopus and PsycINFO, and two disaster journals. Search terms such as 'pharmacist*', 'disaster*' and 'prepared*' were used. The search yielded an initial 1781 titles. Articles were included if they measured pharmacists or pharmacy students' disaster preparedness. After screening and quality appraisal by two researchers, four articles were included in final analysis and review. Data were extracted using a data collection tool formulated by the researchers. Meta-analysis was not possible; instead, results were compared across key areas including preparedness ratings and factors that influenced preparedness. KEY FINDINGS: Three articles focused on pharmacy students' preparedness for disasters, and one on registered pharmacists' preparedness. Preparedness across both groups was poor to moderate with <18% of registered pharmacists found to be prepared to respond to a disaster. Factors that potentially influenced preparedness included disaster competency, disaster interventions and demographic factors. CONCLUSION: For pharmacists, the lack of research around their preparedness speaks volumes about their current involvement and expectations within disaster management. Without a prepared pharmacy workforce and pharmacy involvement in disaster management, critical skill and service gaps in disasters may negatively impact patients.

Evaluation of Disaster Preparedness and Preparedness Behaviors among Pharmacists: A Cross-Sectional Study in Australia.

INTRODUCTION: In a disaster aftermath, pharmacists have the potential to provide essential health services and contribute to the maintenance of the health and well-being of their community. Despite their importance in the health care system, little is known about the factors that affect pharmacists' disaster preparedness and associated behaviors. STUDY OBJECTIVE: The goal of this study was to determine the factors that influence disaster preparedness behaviors and disaster preparedness of Australian pharmacists. METHODS: A 70-question survey was developed from previous research findings. This survey was released online and registered Australian pharmacists were invited to participate. Multiple linear regression was used to determine the factors that influenced preparedness and preparedness behaviors among pharmacists. RESULTS: The final model of disaster preparedness indicated that 86.0% of variation in preparedness was explained by disaster experience, perceived knowledge and skills, colleague preparedness, perceived self-efficacy, previous preparedness behaviors, perceived potential disaster severity, and trust of external information sources. The final model of preparedness behaviors indicated that 71.1% of variation in previous preparedness behaviors can be explained by disaster experience, perceived institution responsibility, colleague preparedness, perceived likelihood of disaster, perceived professional responsibility, and years of practice as a pharmacist. CONCLUSION: This research is the first to explore the significant factors affecting preparedness behaviors and preparedness of Australian pharmacists for disasters. It begins to provide insight into potential critical gaps in current disaster preparedness behaviors and preparedness among pharmacists.

Attitudes to living and working in pandemic conditions among emergency prehospital medical care personnel.

INTRODUCTION: Little is known about the risk perceptions and attitudes of healthcare personnel, especially of emergency prehospital medical care personnel, regarding the possibility of an outbreak or epidemic event. PROBLEM: This study was designed to investigate pre-event knowledge and attitudes of a national sample of the emergency prehospital medical care providers in relation to a potential human influenza pandemic, and to determine predictors of these attitudes. METHODS: Surveys were distributed to a random, cross-sectional sample of 20% of the Australian emergency prehospital medical care workforce (n = 2,929), stratified by the nine services operating in Australia, as well as by gender and location. The surveys included: (1) demographic information; (2) knowledge of influenza; and (3) attitudes and perceptions related to working during influenza pandemic conditions. Multiple logistic regression models were constructed to identify predictors of pandemic-related risk perceptions. RESULTS: Among the 725 Australian emergency prehospital medical care personnel who responded, 89% were very anxious about working during pandemic conditions, and 85% perceived a high personal risk associated with working in such conditions. In general, respondents demonstrated poor knowledge in relation to avian influenza, influenza generally, and infection transmission methods. Less than 5% of respondents perceived that they had adequate education/training about avian influenza. Logistic regression analyses indicate that, in managing the attitudes and risk perceptions of emergency prehospital medical care staff, particular attention should be directed toward the paid, male workforce (as opposed to volunteers), and on personnel whose relationship partners do not work in the health industry. CONCLUSIONS: These results highlight the potentially crucial role of education and training in pandemic preparedness. Organizations that provide emergency prehospital medical care must address this apparent lack of knowledge regarding infection transmission, and procedures for protection and decontamination. Careful management of the perceptions of emergency prehospital medical care personnel during a pandemic is likely to be critical in achieving an effective response to a widespread outbreak of infectious disease.

Anticipated behaviors of emergency prehospital medical care providers during an influenza pandemic.

INTRODUCTION: Emergency prehospital medical care providers are frontline health workers during emergencies. However, little is known about their attitudes, perceptions, and likely behaviors during emergency conditions. Understanding these attitudes and behaviors is crucial to mitigating the psychological and operational effects of biohazard events such as pandemic influenza, and will support the business continuity of essential prehospital services. PROBLEM: This study was designed to investigate the association between knowledge and attitudes regarding avian influenza on likely behavioral responses of Australian emergency prehospital medical care providers in pandemic conditions. METHODS: Using a reply-paid postal questionnaire, the knowledge and attitudes of a national, stratified, random sample of the Australian emergency prehospital medical care workforce in relation to pandemic influenza were investigated. In addition to knowledge and attitudes, there were five measures of anticipated behavior during pandemic conditions: (1) preparedness to wear personal protective equipment (PPE); (2) preparedness to change role; (3) willingness to work; and likely refusal to work with colleagues who were exposed to (4) known and (5) suspected influenza. Multiple logistic regression models were constructed to determine the independent predictors of each of the anticipated behaviors, while controlling for other relevant variables. RESULTS: Almost half (43%) of the 725 emergency prehospital medical care personnel who responded to the survey indicated that they would be unwilling to work during pandemic conditions; one-quarter indicated that they would not be prepared to work in PPE; and one-third would refuse to work with a colleague exposed to a known case of pandemic human influenza. Willingness to work during a pandemic (OR = 1.41; 95% CI = 1.0-1.9), and willingness to change roles (OR = 1.44; 95% CI = 1.04-2.0) significantly increased with adequate knowledge about infectious agents generally. Generally, refusal to work with exposed (OR = 0.48; 95% CI = 0.3-0.7) or potentially exposed (OR = 0.43; 95% CI = 0.3-0.6) colleagues significantly decreased with adequate knowledge about infectious agents. Confidence in the employer's capacity to respond appropriately to a pandemic significantly increased employee willingness to work (OR = 2.83; 95% CI = 1.9-4.1); willingness to change roles during a pandemic (OR = 1.52; 95% CI = 1.1-2.1); preparedness to wear PPE (OR = 1.68; 95% CI = 1.1-2.5); and significantly decreased the likelihood of refusing to work with colleagues exposed to (suspected) influenza (OR = 0.59; 95% CI = 0.4-0.9). CONCLUSIONS: These findings indicate that education and training alone will not adequately prepare the emergency prehospital medical workforce for a pandemic. It is crucial to address the concerns of ambulance personnel and the perceived concerns of their relationship with partners in order to maintain an effective prehospital emergency medical care service during pandemic conditions.

Planning volunteer responses to low-volume mass gatherings: do event characteristics predict patient workload?

INTRODUCTION: Workforce planning for first aid and medical coverage of mass gatherings is hampered by limited research. In particular, the characteristics and likely presentation patterns of low-volume mass gatherings of between several hundred to several thousand people are poorly described in the existing literature. OBJECTIVES: This study was conducted to: 1. Describe key patient and event characteristics of medical presentations at a series of mass gatherings, including events smaller than those previously described in the literature; 2. Determine whether event type and event size affect the mean number of patients presenting for treatment per event, and specifically, whether the 1:2,000 deployment rule used by St John Ambulance Australia is appropriate; and 3. Identify factors that are predictive of injury at mass gatherings. METHODS: A retrospective, observational, case-series design was used to examine all cases treated by two Divisions of St John Ambulance (Queensland) in the greater metropolitan Brisbane region over a three-year period (01 January 2002-31 December 2004). Data were obtained from routinely collected patient treatment forms completed by St John officers at the time of treatment. Event-related data (e.g., weather, event size) were obtained from event forms designed for this study. Outcome measures include: total and average number of patient presentations for each event; event type; and event size category. Descriptive analyses were conducted using chi-square tests, and mean presentations per event and event type were investigated using Kruskal-Wallis tests. Logistic regression analyses were used to identify variables independently associated with injury presentation (compared with non-injury presentations). RESULTS: Over the three-year study period, St John Ambulance officers treated 705 patients over 156 separate events. The mean number of patients who presented with any medical condition at small events (less than or equal to 2,000 attendees) did not differ significantly from that of large (>2,000 attendees) events (4.44 vs. 4.67, F = 0.72, df = 1, 154, p = 0.79). Logistic regression analyses indicated that presentation with an injury compared with non-injury was independently associated with male gender, winter season, and sporting events, even after adjusting for relevant variables. CONCLUSIONS: In this study of low-volume mass gatherings, a similar number of patients sought medical treatment at small (<2,000 patrons) and large (>2,000 patrons) events. This demonstrates that for low-volume mass gatherings, planning based solely on anticipated event size may be flawed, and could lead to inappropriate levels of first-aid coverage. This study also highlights the importance of considering other factors, such as event type and patient characteristics, when determining appropriate first-aid resourcing for low-volume events. Additionally, identification of factors predictive of injury presentations at mass gatherings has the potential to significantly enhance the ability of event coordinators to plan effective prevention strategies and response capability for these events.

Do disasters predict international pharmacy legislation?

Objective The aim of this study was to explore whether a relationship exists between the number of disasters a jurisdiction has experienced and the presence of disaster-specific pharmacy legislation. Methods Pharmacy legislation specific to disasters was reviewed for five countries: Australia, Canada, UK, US and New Zealand. A binary logistic regression test using a generalised estimating equation was used to examine the association between the number of disasters experienced by a state, province, territory or country and whether they had disaster-specific pharmacy legislation. Results Three of six models were statistically significant, suggesting that the odds of a jurisdiction having disaster-specific pharmacy legislation increased as the number of disasters increased for the period 2007-17 and 2013-17. There was an association between the everyday emergency supply legislation and the presence of the extended disaster-specific emergency supply legislation . Conclusions It is evident from this review that there are inconsistencies as to the level of assistance pharmacists can provide during times of crisis depending on their jurisdiction and location of practice. It is not a question of whether pharmacists have the skills and capabilities to assist, but rather what legislative barriers are preventing them from being able to contribute further to the disaster healthcare team. What is known about the topic? The contributing factors to disaster-specific pharmacy legislation has not previously been explored in Australia. It can be postulated that the number of disasters experienced by a jurisdiction increases the likelihood of governments introducing disaster-specific pharmacy legislation based on other countries. What does this paper add? This study compared five countries and their pharmacy legislation specific to disasters. It identified that as the number of disasters increases, the odds of a jurisdiction having disaster-specific emergency supply or disaster relocation or mobile pharmacy legislation increases. However, this is likely to be only one of many factors affecting the political decisions of when and what legislation is passed in relation to pharmacists' roles in disasters. What are the implications for practitioners? Pharmacists are well situated in the community to be of assistance during disasters. However, their ability to help patients with chronic disease management or providing necessary vaccinations in disasters is limited by the legislation in their jurisdiction. Releasing pharmacists' full potential in disasters could alleviate the burden of low-acuity patients on other healthcare services. This could subsequently free up other healthcare professionals to treat high-acuity patients and emergencies.