Risk factors associated with 31-day unplanned hospital readmission in newborns: a systematic review.

The purpose of this study is to synthesize evidence on risk factors associated with newborn 31-day unplanned hospital readmissions (UHRs). A systematic review was conducted searching CINAHL, EMBASE (Ovid), and MEDLINE from January 1st 2000 to 30th June 2021. Studies examining unplanned readmissions of newborns within 31 days of discharge following the initial hospitalization at the time of their birth were included. Characteristics of the included studies examined variables and statistically significant risk factors were extracted from the inclusion studies. Extracted risk factors could not be pooled statistically due to the heterogeneity of the included studies. Data were synthesized using content analysis and presented in narrative and tabular form. Twenty-eight studies met the eligibility criteria, and 17 significant risk factors were extracted from the included studies. The most frequently cited risk factors associated with newborn readmissions were gestational age, postnatal length of stay, neonatal comorbidity, and feeding methods. The most frequently cited maternal-related risk factors which contributed to newborn readmissions were parity, race/ethnicity, and complications in pregnancy and/or perinatal period. CONCLUSION: This systematic review identified a complex and diverse range of risk factors associated with 31-day UHR in newborn. Six of the 17 extracted risk factors were consistently cited by studies. Four factors were maternal (primiparous, mother being Asian, vaginal delivery, maternal complications), and two factors were neonatal (male infant and neonatal comorbidities). Implementation of evidence-based clinical practice guidelines for inpatient care and individualized hospital-to-home transition plans, including transition checklists and discharge readiness assessments, are recommended to reduce newborn UHRs. WHAT IS KNOWN: • Attempts have been made to identify risk factors associated with newborn UHRs; however, the results are inconsistent. WHAT IS NEW: • Six consistently cited risk factors related to newborn 31-day UHRs. Four maternal factors (primiparous, mother being Asian, vaginal delivery, maternal complications) and 2 neonatal factors (male infant and neonatal comorbidities). • The importance of discharge readiness assessment, including newborn clinical fitness for discharge and parental readiness for discharge. Future research is warranted to establish standardised maternal and newborn-related variables which healthcare providers can utilize to identify newborns at greater risk of UHRs and enable comparison of research findings.

Integrated clinical pathways for lower limb orthopaedic surgeries: An updated systematic review.

OBJECTIVE: The objective of the study was to comprehensively synthesise the components of integrated clinical pathways (ICPs) and post-operative outcomes of patients undergone total hip and knee arthroplasty (THA & TKA) and hip fracture surgeries. BACKGROUND: Previous systematic reviews examined components and effectiveness of ICPs for lower limb joint replacement and hip fracture surgeries. DESIGN AND METHODS: An updated systematic review guided by the Whittemore and Knafl (2005) framework. Electronic databases, Ovid MEDLINE, EBSCOhost-CINAHL, the Cochrane Reviews and Trails, EMBASE and PubMed, were searched from 2007 to 31 January 2021. Due to the heterogeneity of the methods and data collection tools of included studies, pooling of the quantitative data was not possible. Therefore, the included studies were synthesised and presented narratively under subthemes of arthroplasty and hip fracture surgeries. The PRISMA checklist for systematic reviews was used. RESULTS: Twenty-four studies met selection criteria with 11 examined ICPs for hip fracture and 13 for the THA and TKA. Twenty-one ICPs were reviewed, and 33 components were extracted. The most frequently included components for hip fracture subgroup were 'discharge disposition arrangement' and 'dedicated personnel and resources'. 'Exercise plan' and 'pain management' were for the arthroplasty subgroup. A significant reduction in the length of stay and post-operative complications were associated with the ICPs. Results were mixed for the effectiveness of ICPs in reducing unplanned hospital admissions, mortality rates, post-operative complications and hospital costs. CONCLUSION: The number of ICP components varied across studies. This review could not recommend a one size-fits-all ICP that could be adapted for use for patients undergoing hip fracture and joint replacement surgeries. RELEVANCE FOR CLINICAL PRACTICE: This review identified research evidence-based components considered as essential for the inclusion in ICP's for hip fracture and arthroplasty surgeries. Further research is suggested to determine the patient experience and healthcare providers' acceptance of ICPs.

Nurse-Caregiver Communication of Hospital-To-Home Transition Information at a Tertiary Pediatric Hospital in Western Australia: A Multi-Stage Qualitative Descriptive Study.

PURPOSE: To observe and describe nurse-caregiver communication of hospital-to-home transition information at the time of discharge at a tertiary children's hospital of Western Australia. DESIGN AND METHODS: A multi-stage qualitative descriptive design involved 31 direct clinical observations of hospital-to-home transition experiences, and semi-structured interviews with 20 caregivers and 12 nurses post-discharge. Eleven caregivers were re-interviewed 2-4 weeks post-discharge. Transcripts of audio recordings and field notes were analyzed using content analysis. Medical records were examined to determine patients' usage of hospital services within 30 days of discharge. RESULTS: Four themes emerged from the content analysis: structure of hospital-to-home transition information; transition information delivery; readiness for discharge; and recovery experience post-hospital discharge. Examination of medical records found seven patients presented to the Emergency Department within 2-19 days post-discharge, of which three were readmitted. Primary caregivers of three readmitted patients all had limited English proficiency. CONCLUSION: The study affirmed the complexity of transitioning pediatric patients from hospital to home. Inconsistent content and delivery of information impacted caregivers' perception of readiness for discharge and the recovery experience. PRACTICE IMPLICATIONS: Nurses need to assess readiness for discharge to identify individual needs using a validated tool. Inclusion of education on hospital-to-home transition information and discharge planning/process is required in the orientation program for junior and casual staff to ensure consistency of information delivery. Interpreter services should be arranged for caregivers with limited language proficiency throughout the hospital stay especially when transition information is being provided. Nurses should apply teach-back techniques to improve caregivers' comprehension of information.

Risk factors associated with 30-day all-cause unplanned hospital readmissions at a tertiary children's hospital in Western Australia.

AIM: To identify risk factors associated with 30-day all-cause unplanned hospital readmission at a tertiary children's hospital in Western Australia. METHODS: An administrative paediatric inpatient dataset was analysed retrospectively. Patients of all ages discharged between 1 January 2010 and 31 December 2014 were included. Demographic and clinical information at the index admission was examined using multivariate logistic regression analysis. RESULTS: A total of 3330 patients (4.55%) experienced at least one unplanned readmission after discharge. Readmission was more likely to occur in patients who were either older than 16 years (odds ratio (OR) = 1.46; 95% confidence interval (CI) 1.07-1.98), utilising private insurance as an inpatient (OR = 1.16; 95% CI 1.00-1.34), with greater socio-economic advantage (OR = 1.20; 95% CI 1.02-1.41), admitted on Friday (OR = 1.21; 95% CI 1.05-1.39), discharged on Friday/Saturday/Sunday (OR = 1.26, 95% CI 1.10-1.44; OR = 1.34, 95% CI 1.15-1.57; OR = 1.24, 95% CI 1.05-1.47, respectively), with four or more diagnoses at the index admission (OR = 2.41; 95% CI 2.08-2.80) or hospitalised for 15 days or longer (OR = 2.39; 95% CI 1.88-2.98). Area under receiver operating characteristic curve of the predictive model is 0.645. CONCLUSIONS: A moderate discriminative ability predictive model for 30-day all-cause same hospital readmission was developed. A structured discharge plan is suggested to be commenced from admission to ensure continuity of care for patients identified as being at higher risk of readmission. A recommendation is made that a designated staff member be assigned to co-ordinate the plan, including assessment of patients' and primary carers' readiness for discharge. Further research is required to establish comprehensive paediatric readmission rates by accessing linkage data to capture different hospital readmissions.

A prospective multicentre study testing the diagnostic accuracy of an automated cough sound centred analytic system for the identification of common respiratory disorders in children.

BACKGROUND: The differential diagnosis of paediatric respiratory conditions is difficult and suboptimal. Existing diagnostic algorithms are associated with significant error rates, resulting in misdiagnoses, inappropriate use of antibiotics and unacceptable morbidity and mortality. Recent advances in acoustic engineering and artificial intelligence have shown promise in the identification of respiratory conditions based on sound analysis, reducing dependence on diagnostic support services and clinical expertise. We present the results of a diagnostic accuracy study for paediatric respiratory disease using an automated cough-sound analyser. METHODS: We recorded cough sounds in typical clinical environments and the first five coughs were used in analyses. Analyses were performed using cough data and up to five-symptom input derived from patient/parent-reported history. Comparison was made between the automated cough analyser diagnoses and consensus clinical diagnoses reached by a panel of paediatricians after review of hospital charts and all available investigations. RESULTS: A total of 585 subjects aged 29 days to 12 years were included for analysis. The Positive Percent and Negative Percent Agreement values between the automated analyser and the clinical reference were as follows: asthma (97, 91%); pneumonia (87, 85%); lower respiratory tract disease (83, 82%); croup (85, 82%); bronchiolitis (84, 81%). CONCLUSION: The results indicate that this technology has a role as a high-level diagnostic aid in the assessment of common childhood respiratory disorders. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry (retrospective) - ACTRN12618001521213 : 11.09.2018.

Roles and functions of enrolled nurses in Australia: Perspectives of enrolled nurses and registered nurses.

AIMS AND OBJECTIVES: To determine, from the perspectives of enrolled nurses and registered nurses, the current scope of enrolled nurse practice and to identify the activities that most enrolled nurses frequently performed in their workplace. BACKGROUND: Enrolled nurse scope of practice in Australia has evolved and expanded over the past decade. However, the unclear role, function and competency differentiation between enrolled nurse and registered nurse leads to role confusion and ongoing professional debate. DESIGN: Exploratory Descriptive Study. METHODS: A cross-sectional online survey of enrolled nurses and registered nurses across Australia was conducted examining their levels of agreement on statements related to the scope of practice and the clinical and nonclinical activities that enrolled nurses were required to perform in their workplace. RESULTS: Valid responses were received from 892 enrolled nurses and 1,198 registered nurses. Enrolled nurses mostly agreed that they understood their scope of practice; did not undertake roles for which they were unprepared; sometimes undertook activities other than direct patient care; and believed that they operated equally to many registered nurses. The majority of enrolled nurses reported that they performed tasks mostly related to basic patient care in their workplace. There were a number of significant differences between perspectives of registered nurses and enrolled nurses. CONCLUSIONS: Clarifying the roles and scope of practice between the registered nurse and the enrolled nurse is important, and explicit differences in responsibility and accountability between their roles must be clearly articulated to harmonise perceptions about role and capability. Health service providers, policymakers and education providers need to work collaboratively to ensure that facets of enrolled nurse education and scope of practice in line with regulation are affirmed by all concerned. RELEVANCE TO CLINICAL PRACTICE: Health service providers, policymakers and education providers need to work collaboratively to ensure that facets of enrolled nurse education and scope of practice in line with regulation are affirmed by all concerned.

Transitioning adolescent and young adults with chronic disease and/or disabilities from paediatric to adult care services - an integrative review.

AIMS AND OBJECTIVES: This paper aims to provide an updated comprehensive review of the research-based evidence related to the transitions of care process for adolescents and young adults with chronic illness/disabilities since 2010. BACKGROUND: Transitioning adolescent and young adults with chronic disease and/or disabilities to adult care services is a complex process, which requires coordination and continuity of health care. The quality of the transition process not only impacts on special health care needs of the patients, but also their psychosocial development. Inconsistent evidence was found regarding the process of transitioning adolescent and young adults. DESIGN: An integrative review was conducted using a five-stage process: problem identification, literature search, data evaluation, data analysis and presentation. METHODS: A search was carried out using the EBSCOhost, Embase, MEDLINE, PsycINFO, and AustHealth, from 2010 to 31 October 2014. The key search terms were (adolescent or young adult) AND (chronic disease or long-term illness/conditions or disability) AND (transition to adult care or continuity of patient care or transfer or transition). RESULTS: A total of 5719 records were initially identified. After applying the inclusion criteria a final 61 studies were included. Six main categories derived from the data synthesis process are Timing of transition; Perceptions of the transition; Preparation for the transition; Patients' outcomes post-transition; Barriers to the transition; and Facilitating factors to the transition. A further 15 subcategories also surfaced. CONCLUSIONS: In the last five years, there has been improvement in health outcomes of adolescent and young adults post-transition by applying a structured multidisciplinary transition programme, especially for patients with cystic fibrosis and diabetes. However, overall patients' outcomes after being transited to adult health care services, if recorded, have remained poor both physically and psychosocially. An accurate tracking mechanism needs to be established by stakeholders as a formal channel to monitor patients' outcomes post- transition.

Perspectives of clinical handover processes: a multi-site survey across different health professionals.

AIMS AND OBJECTIVES: To examine the perspectives of health professionals of different disciplines about clinical handover. BACKGROUND: Ineffective handovers can cause major problems relating to the lack of delivery of appropriate care. DESIGN: A prospective, cross-sectional design was conducted using a survey about clinical handover practices. METHODS: Health professionals employed in public metropolitan hospitals, public rural hospitals and community health centres were involved. The sample comprised doctors, nurses and allied health professionals, including physiotherapists, social workers, pharmacists, dieticians and midwives employed in Western Australia, New South Wales, South Australia and the Australian Capital Territory. The survey sought information about health professionals' experiences about clinical handover; their perceived effectiveness of clinical handover; involvement of patients and family members; health professionals' ability to confirm understanding and to clarify clinical information; role modelling behaviour of health professionals; training needs; adverse events encountered and possibilities for improvements. RESULTS: In all, 707 health professionals participated (response rate = 14%). Represented professions were nursing (60%), medicine (22%) and allied health (18%). Many health professionals reported being aware of adverse events where they noticed poor handover was a significant cause. Differences existed between health professions in terms of how effectively they gave handover, perceived effectiveness of bedside handover vs. nonbedside handover, patient and family involvement in handover, respondents' confirmation of understanding handover from their perspective, their observation of senior health professionals giving feedback to junior health professionals, awareness of adverse events and severity of adverse events relating to poor handovers. CONCLUSIONS: Complex barriers impeded the conduct of effective handovers, including insufficient opportunities for training, lack of role modelling, and lack of confidence and understanding about handover processes. RELEVANCE TO CLINICAL PRACTICE: Greater focus should be placed on creating opportunities for senior health professionals to act as role models. Sophisticated approaches should be implemented in training and education.

How has the profile of Australian nurse practitioners changed over time?

AIM: To examine longitudinal changes in the profile of Australian nurse practitioners surveyed in both 2007 and 2009 ('resurveyed respondents') and to determine differences between nurse practitioners who completed the census only in 2009 ('new respondents') and resurveyed respondents. BACKGROUND: The nurse practitioner role is integral to the development and sustainability of advanced practice roles in healthcare systems. However, its success depends upon support from policy makers, health services and nursing. A census of Australian nurse practitioners previously was conducted in 2007 to obtain national data on the role and scope of practice of nurse practitioners in Australia. DESIGN: A quantitative self-administered survey. METHODS: Questionnaires were sent to all authorised Australian nurse practitioners in 2009. RESULTS/FINDINGS: A total of 408 surveys were administered with 293 questionnaires completed (response rate 76.3%). Of these, 49% of participants also had completed the 2007 survey. There were no differences in the limitations and enablers identified in 2007 compared to 2009, indicating that perceived barriers had not been addressed over time, nor had there been substantial improvements. New respondents were more likely to have worked as a nurse practitioner in the previous week (p < 0.004). There was a significant increase in the number of nurse practitioners waiting on approval for some or all clinical protocols (p = 0.024). CONCLUSIONS: Conditions enabling work to full scope of practice continue to be perceived as suboptimal by Australian nurse practitioners. Supportive strategies are needed to enable the role to be effectively utilised.

Attributes for effective nurse management within the health services of Western Australia, Singapore and Tanzania.

OBJECTIVE: To identify the perceptions of nurse managers in Western Australia, Singapore and Tanzania regarding desirable attributes for effective management of their health services, and to identify and discuss the implications for health-management education provided by Australian universities. METHODS: Nurse managers completed a questionnaire covering four key dimensions: personality characteristics, knowledge and learning, skills, and beliefs and values. Each of 75 items were rated as to their effect on management effectiveness, according to a 5-point Likert scale. RESULTS: Skills were considered the most important for management effectiveness by each group. Tanzanian respondents rated knowledge and learning almost as highly, and significantly higher than Western Australian respondents. They also rated personality characteristics and beliefs and values significantly higher than Western Australian respondents. No significant differences were found between Singapore and Western Australia. CONCLUSIONS: Participants desired a different relative mix of attributes in their nurse managers, with Western Australian respondents most likely to indicate that transformational leadership contributed most to managerial effectiveness. Tanzanian nurse managers were most likely to advocate transactional leadership, whereas Singaporean nurse managers' views were located somewhere between. Given that these perceptions are valid, the content and curricula of management-development courses need to be cognisant of the cultural backgrounds of participants. WHAT IS KNOWN ABOUT THE TOPIC? Views differ as to the extent to which the criteria for management effectiveness are broadly universal or contingent on culture. This applies to the area of nurse management as it does to healthcare management in general. WHAT DOES THIS PAPER ADD? It is demonstrated that each of the three quite different countries or states considered identified a distinctive combination of attributes as desirable, with the nurse managers of Western Australia most likely to favour a transformational style of leadership, those from Tanzania a transactional leadership style and those from Singapore somewhere in between. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Given the country- or state-specific desire for a different relative mix of attributes in their nurse managers, management educators in Australia need to ensure that the content and curricula of their courses are cognisant of the cultural backgrounds of their students. There are also important lessons to be taken on board regarding recruitment of nurses into management positions in terms of each of the four dimensions considered, particularly in terms of desirable personality characteristics and beliefs and values.

Risk factors associated with 30-day unplanned hospital readmission for patients with mental illness.

Unplanned hospital readmission rate is up to 43% in mental health settings, which is higher than in general health settings. Unplanned readmissions delay the recovery of patients with mental illness and add financial burden on families and healthcare services. There have been efforts to reduce readmissions with a particular interest in identifying patients at higher readmission risk after index admission; however, the results have been inconsistent. This systematic review synthesized risk factors associated with 30-day unplanned hospital readmissions for patients with mental illness. Eleven electronic databases were searched from 2010 to 30 September 2021 using key terms of 'mental illness', 'readmission' and 'risk factors'. Sixteen studies met the selection criteria for this review. Data were synthesized using content analysis and presented in narrative and tabular form because the extracted risk factors could not be pooled statistically due to methodological heterogeneity of the included studies. Consistently cited readmission predictors were patients with lower educational background, unemployment, previous mental illness hospital admission and more than 7 days of the index hospitalization. Results revealed the complexity of identifying unplanned hospital readmission predictors for people with mental illness. Policymakers need to specify the expected standards that written discharge summary must reach general practitioners concurrently at discharge. Hospital clinicians should ensure that discharge summary summaries are distributed to general practitioners for effective ongoing patient care and management. Having an advanced mental health nurse for patients during their transition period needs to be explored to understand how this role could ensure referrals to the general practitioner are eventuated.

Accuracy, interpretability and usability study of a wireless self-guided fetal heartbeat monitor compared to cardiotocography.

Fetal Cardiography is usually performed using in-hospital Cardiotocographic (CTG) devices to assess fetal wellbeing. New technologies may permit home-based, self-administered examinations. We compared the accuracy, clinical interpretability, and user experience of a patient-administered, wireless, fetal heartbeat monitor (HBM) designed for home use, to CTG. Initially, participants had paired HBM and CTG examinations performed in the clinic. Women then used the HBM unsupervised and rated the experience. Sixty-three women had paired clinic-based HBM and CTG recordings, providing 6982 fetal heart rate measures for point-to-point comparison from 126 min of continuous recording. The accuracy of the HBM was excellent, with limits of agreement (95%) for mean fetal heart rate (FHR) between 0.72 and -1.78 beats per minute. The FHR was detected on all occasions and confirmed to be different from the maternal heart rate. Both methods were equally interpretable by Obstetricians, and had similar signal loss ratios. Thirty-four (100%) women successfully detected the FHR and obtained clinically useful cardiographic data using the device at home unsupervised. They achieved the required length of recording required for non-stress test analysis. The monitor ranked in the 96-100th percentile for usability and learnability. The HBM is as accurate as gold-standard CTG, and provides equivalent clinical information enabling use in non-stress test analyses conducted outside of hospitals. It is usable by expectant mothers with minimal training.

Consistency of pediatric pain ratings between dyads: an updated meta-analysis and metaregression.

Accurate assessment of pediatric pain remains a challenge, especially for children who are preverbal or unable to communicate because of their health condition or a language barrier. A 2008 meta-analysis of 12 studies found a moderate correlation between 3 dyads (child-caregiver, child-nurse, and caregiver-nurse). We updated this meta-analysis, adding papers published up to August 8, 2021, and that included intraclass correlation/weighted kappa statistics (ICC/WK) in addition to standard correlation. Forty studies (4,628 children) were included. Meta-analysis showed moderate pain rating consistency between child and caregiver (ICC/WK = 0.51 [0.39-0.63], correlation = 0.59 [0.52-0.65], combined = 0.55 [0.48-0.62]), and weaker consistency between child and health care provider (HCP) (ICC/WK = 0.38 [0.19-0.58], correlation = 0.49 [0.34-0.55], combined = 0.45; 95% confidence interval 0.34-0.55), and between caregiver and HCP (ICC/WK = 0.27 [-0.06 to 0.61], correlation = 0.49 [0.32 to 0.59], combined = 0.41; 95% confidence interval 0.22-0.59). There was significant heterogeneity across studies for all analyses. Metaregression revealed that recent years of publication, the pain assessment tool used by caregivers (eg, Numerical Rating Scale, Wong-Baker Faces Pain Rating Scale, and Visual Analogue Scale), and surgically related pain were each associated with greater consistency in pain ratings between child and caregiver. Pain caused by surgery was also associated with improved rating consistency between the child and HCP. This updated meta-analysis warrants pediatric pain assessment researchers to apply a comprehensive pain assessment scale Patient-Reported Outcomes Measurement Information System to acknowledge psychological and psychosocial influence on pain ratings.

The status of Australian nurse practitioners: the second national census.

OBJECTIVES: To profile Australian nurse practitioners and their practice in 2009 and compare results with a similar 2007 census. METHODS; Self-administered questionnaire. RESULTS: A total of 293 nurse practitioners responded (response rate 76.3%). The majority were female (n=229, 81.2%); mean age was 47.3 years (s.d.=8.1). As in 2007, emergency nurse practitioners represented the largest clinical specialty (n=63, 30.3%). A majority practiced in a metropolitan area (n=133, 64.3%); a decrease from 2007. Consistent with 2007, only 71.5% (n=208) were employed as a nurse practitioner and 22.8% (n=46) were awaiting approval for some or all of their clinical protocols. Demographic data, allocations of tasks, and patterns of practice remained consistent with 2007 results. 'No Medicare provider number' (n=182, 91.0%), 'no authority to prescribe using the Pharmaceutical Benefits Scheme' (n=182, 89.6%) and 'lack of organisational support' (n=105, 52.2%) were reported as 'limiting' or 'extremely limiting' to practice. CONCLUSIONS: Our results demonstrate less than satisfactory uptake of the nurse practitioner role despite authorisation. Barriers constraining nurse practitioner practice reduced but remained unacceptably high. Adequate professional and political support is necessary to ensure the efficacy and sustainability of this clinical role.

Diagnostic Errors Are Common in Acute Pediatric Respiratory Disease: A Prospective, Single-Blinded Multicenter Diagnostic Accuracy Study in Australian Emergency Departments.

Background: Diagnostic errors are a global health priority and a common cause of preventable harm. There is limited data available for the prevalence of misdiagnosis in pediatric acute-care settings. Respiratory illnesses, which are particularly challenging to diagnose, are the most frequent reason for presentation to pediatric emergency departments. Objective: To evaluate the diagnostic accuracy of emergency department clinicians in diagnosing acute childhood respiratory diseases, as compared with expert panel consensus (reference standard). Methods: Prospective, multicenter, single-blinded, diagnostic accuracy study in two well-resourced pediatric emergency departments in a large Australian city. Between September 2016 and August 2018, a convenience sample of children aged 29 days to 12 years who presented with respiratory symptoms was enrolled. The emergency department discharge diagnoses were reported by clinicians based upon standard clinical diagnostic definitions. These diagnoses were compared against consensus diagnoses given by an expert panel of pediatric specialists using standardized disease definitions after they reviewed all medical records. Results: For 620 participants, the sensitivity and specificity (%, [95% CI]) of the emergency department compared with the expert panel diagnoses were generally poor: isolated upper respiratory tract disease (64.9 [54.6, 74.4], 91.0 [88.2, 93.3]), croup (76.8 [66.2, 85.4], 97.9 [96.2, 98.9]), lower respiratory tract disease (86.6 [83.1, 89.6], 92.9 [87.6, 96.4]), bronchiolitis (66.9 [58.6, 74.5], 94.3 [80.8, 99.3]), asthma/reactive airway disease (91.0 [85.8, 94.8], 93.0 [90.1, 95.3]), clinical pneumonia (63·9 [50.6, 75·8], 95·0 [92·8, 96·7]), focal (consolidative) pneumonia (54·8 [38·7, 70·2], 86.2 [79.3, 91.5]). Only 59% of chest x-rays with consolidation were correctly identified. Between 6.9 and 14.5% of children were inappropriately prescribed based on their eventual diagnosis. Conclusion: In well-resourced emergency departments, we have identified a previously unrecognized high diagnostic error rate for acute childhood respiratory disorders, particularly in pneumonia and bronchiolitis. These errors lead to the potential of avoidable harm and the administration of inappropriate treatment.

Identifying acute exacerbations of chronic obstructive pulmonary disease using patient-reported symptoms and cough feature analysis.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are commonly encountered in the primary care setting, though the accurate and timely diagnosis is problematic. Using technology like that employed in speech recognition technology, we developed a smartphone-based algorithm for rapid and accurate diagnosis of AECOPD. The algorithm incorporates patient-reported features (age, fever, and new cough), audio data from five coughs and can be deployed by novice users. We compared the accuracy of the algorithm to expert clinical assessment. In patients with known COPD, the algorithm correctly identified the presence of AECOPD in 82.6% (95% CI: 72.9-89.9%) of subjects (n = 86). The absence of AECOPD was correctly identified in 91.0% (95% CI: 82.4-96.3%) of individuals (n = 78). The diagnostic agreement was maintained in milder cases of AECOPD (PPA: 79.2%, 95% CI: 68.0-87.8%), who typically comprise the cohort presenting to primary care. The algorithm may aid early identification of AECOPD and be incorporated in patient self-management plans.

Diagnosing community-acquired pneumonia via a smartphone-based algorithm: a prospective cohort study in primary and acute-care consultations.

BACKGROUND: Community-acquired pneumonia (CAP) is an essential consideration in patients presenting to primary care with respiratory symptoms; however, accurate diagnosis is difficult when clinical and radiological examinations are not possible, such as during telehealth consultations. AIM: To develop and test a smartphone-based algorithm for diagnosing CAP without need for clinical examination or radiological inputs. DESIGN AND SETTING: A prospective cohort study using data from participants aged >12 years presenting with acute respiratory symptoms to a hospital in Western Australia. METHOD: Five cough audio-segments were recorded and four patient-reported symptoms (fever, acute cough, productive cough, and age) were analysed by the smartphone-based algorithm to generate an immediate diagnostic output for CAP. Independent cohorts were recruited to train and test the accuracy of the algorithm. Diagnostic agreement was calculated against the confirmed discharge diagnosis of CAP by specialist physicians. Specialist radiologists reported medical imaging. RESULTS: The smartphone-based algorithm had high percentage agreement (PA) with the clinical diagnosis of CAP in the total cohort (n = 322, positive PA [PPA] = 86.2%, negative PA [NPA] = 86.5%, area under the receiver operating characteristic curve [AUC] = 0.95); in participants 22-<65 years (n = 192, PPA = 85.7%, NPA = 87.0%, AUC = 0.94), and in participants aged ≥65 years (n = 86, PPA = 85.7%, NPA = 87.5%, AUC = 0.94). Agreement was preserved across CAP severity: 85.1% (n = 80/94) of participants with CRB-65 scores 1 or 2, and 87.7% (n = 57/65) with a score of 0, were correctly diagnosed by the algorithm. CONCLUSION: The algorithm provides rapid and accurate diagnosis of CAP. It offers improved accuracy over current protocols when clinical evaluation is difficult. It provides increased capabilities for primary and acute care, including telehealth services, required during the COVID-19 pandemic.

The work of nurse practitioners.

AIM: This paper is a report of a study of variations in the pattern of nurse practitioner work in a range of service fields and geographical locations, across direct patient care, indirect patient care and service-related activities. BACKGROUND: The nurse practitioner role has been implemented internationally as a service reform model to improve the access and timeliness of health care. There is a substantial body of research into the nurse practitioner role and service outcomes, but scant information on the pattern of nurse practitioner work and how this is influenced by different service models. METHODS: We used work sampling methods. Data were collected between July 2008 and January 2009. Observations were recorded from a random sample of 30 nurse practitioners at 10-minute intervals in 2-hour blocks randomly generated to cover 2 weeks of work time from a sampling frame of 6 weeks. RESULTS: A total of 12,189 individual observations were conducted with nurse practitioners across Australia. Thirty individual activities were identified as describing nurse practitioner work, and these were distributed across three categories. Direct care accounted for 36.1% of how nurse practitioners spend their time, indirect care accounted for 32.0% and service-related activities made up 31.9%. CONCLUSION: These findings provide useful baseline data for evaluation of nurse practitioner positions and the service effect of these positions. However, the study also raises questions about the best use of nurse practitioner time and the influences of barriers to and facilitators of this model of service innovation.

The first Australian nurse practitioner census: A protocol to guide standardized collection of information about an emergent professional group.

Internationally, collection of reliable data on new and evolving health-care roles is crucial. We describe a protocol for design and administration of a national census of an emergent health-care role, namely nurse practitioners in Australia using databases held by regulatory authorities. A questionnaire was developed to obtain data on the role and scope of practice of Australian nurse practitioners. Our tool comprised five sections and included a total of 56 questions, using 28 existing items from the National Nursing and Midwifery Labour Force Census and nine items recommended in the Nurse Practitioner Workforce Planning Minimum Data Set. Australian Nurse Registering Authorities (n = 6) distributed the survey on our behalf. This paper outlines our instrument and methods. The survey was administered to 238 authorized Australian nurse practitioners (85% response rate). Rigorous collection of standardized items will ensure health policy is informed by reliable and valid data. We will re-administer the survey 2 years following the first survey to measure change over time.

Clients' understanding of the role of nurse practitioners.

Nurse practitioners (NPs) have an emerging role in the Australian health care system. However, there remains a dearth of data about public understanding of the NP role. The aim of this study was to evaluate clients' understanding of the role of the NP and their satisfaction with education received, quality of care and NP knowledge and skill. All authorised NPs working in a designated NP position in Western Australia and those working in three area health services in New South Wales were invited to recruit five consecutive clients to complete the self-administered survey. Thirty-two NPs (NP response rate 93%) recruited 129 clients (client response rate 90%). Two-thirds of clients (63%) were aware they were consulting an NP. The majority rated the following NP-related outcomes as 'excellent' or 'very good': education provided (89%); quality of care (95%); and knowledge and skill (93%). Less than half reported an understanding that NPs could prescribe medications (40.5%) or interpret X-rays (33.6%). Clients of NPs practising in a rural or remote setting were more likely than those in an urban setting to have previously consulted an NP (P = 0.005), and where applicable would to prefer to see an NP rather than a doctor (P = 0.022). Successful implementation and expansion of the NP role requires NP visibility in the community. Despite high levels of satisfaction, more awareness of the scope of the NP role is required.