Development of a comprehensive approach to adult hereditary cancer testing in Ontario.

BACKGROUND: Genetic testing for hereditary cancer susceptibility has advanced over time due to the discovery of new risk genes, improved technology and decreased cost. In the province of Ontario, testing eligibility criteria were initially developed to include hereditary breast, ovarian and colorectal cancer syndromes. The rapid evolution of genetic technologies has facilitated the ability to interrogate a large number of genes concurrently. This, coupled with new knowledge about risk genes, necessitated a coordinated approach to expanding the scope of genes and indications tested and synchronisation of access and test utilisation across the province as required in a publicly funded universal healthcare system. METHODS: Ontario Health-Cancer Care Ontario convened expert working groups to develop a standardised and comprehensive cancer gene list for adults and accompanying hereditary cancer testing (HCT) criteria using an evidence-based framework and broad laboratory and clinical genetics engagement. RESULTS: A standardised 76-cancer-gene panel, organised into 13 larger disease site panels and 25 single/small gene panels, was developed and endorsed by the working groups. Provincial genetic testing eligibility criteria were updated to align with the new panels and to guide clinical decision-making. In the first year following the implementation of these changes, 10 564 HCT panels were performed with an overall mutation detection rate of 12.2%. CONCLUSION: Using an evidence framework and broad clinical engagement to develop and endorse an updated guidance document, cancer genetic testing for adults in Ontario is now standardised and coordinated across the province.

Oncology stewardship practice in the United States: A Hematology/Oncology Pharmacy Association national survey.

INTRODUCTION: The treatment of cancer is associated with high risk for toxicity and high cost. Strategies to enhance the value, quality, and safety of cancer care are often managed independently of one another. Oncology stewardship is a potential framework to unify these efforts and enhance outcomes. This landscape survey establishes baseline information on oncology stewardship in the United States. METHODS: The Hematology/Oncology Pharmacy Association (HOPA) distributed a 38-item survey composed of demographic, institutional, clinical decision-making, support staff, metrics, and technology sections to 675 HOPA members between 9 September 2022 and 9 October 2022. RESULTS: Most organizations (78%) have adopted general pharmacy stewardship practices; however, only 31% reported having established a formalized oncology stewardship team. More than 70% of respondents reported implementation of biosimilars, formulary management, and dose rounding as oncology stewardship initiatives in both inpatient and outpatient settings. Frequently cited barriers to oncology stewardship included lack of clinical pharmacist availability (74%), lack of oncology stewardship training (62%), lack of physician/provider buy-in (32%), and lack of cost-saving metrics (33%). Only 6.6% of survey respondents reported their organization had defined "value in oncology." Lack of a formalized stewardship program was most often cited (77%) as the rationale for not defining value. CONCLUSIONS: Less than one-third of respondents have established oncology stewardship programs; however, most are providing oncology stewardship practices. This manuscript serves as a call to action for stakeholders to work together to formalize oncology stewardship programs that optimize value, quality, and safety for patients with cancer.

Doctors' pay in the United Kingdom: evaluating the broader impacts of change.

The United Kingdom's National Health Service (NHS) faces a mounting workforce crisis, with compensation being a focal point of discontent. This editorial explores the real-term erosion of doctors' salaries in the UK, using the Retail Price Index as a more comprehensive measure of inflation. Comparisons with international standards reveal significant disparities, contributing to the emigration of medical talent. The NHS's increased reliance on agency locum doctors poses financial strain and affects continuity of patient care. Economic considerations debunk common counterarguments against pay restoration, emphasising the broader implications for healthcare delivery and societal well-being. The editorial concludes by advocating for policy measures to address this pay disparity as both an economic imperative and a strategic necessity to sustain the NHS.

Escalating competition in NHS: implications for healthcare quality and workforce sustainability.

The UK's National Health Service (NHS) faces escalating competition ratios for specialty training positions, with application rates dramatically outpacing the growth in available posts. This trend contributes to systemic bottlenecks and challenges traditional career progression pathways within medicine. In this evolving landscape, the once-certain career progression within medicine is now increasingly uncertain. This commentary explores the complex dynamics of increased medical school admissions against stagnant specialty training placements and the broader strategic implications for workforce planning within the NHS. It critically evaluates the implications of current funding policies, which seem to prioritise an expansion of nondoctor healthcare roles over the development of specialist training, raising concerns about the long-term patient care quality and safety. Key recommendations include a reassessment of medical education expansion, a review of funding allocation, increased support for specialty training, and government accountability for healthcare workforce planning. The urgent need for strategic policy reform is underscored to ensure that NHS can sustain a high-quality, specialist-led healthcare provision in the face of rising competition and workforce pressures.

A recent surge of nitrous oxide misuse around London which merits a public health warning.

BACKGROUND: Use of nitrous oxide (N2O) gas for recreational purposes by young people is increasingly recognized as a public health hazard in the UK. METHODS: We looked at the hospital records of patients admitted over the last 4 years to a single neurological centre in Essex to determine the demographics, presentation, and management of patients presenting with symptoms of N2O toxicity from its recreational use. RESULTS: Of the 17 patients (mean age = 22.9 ± 3 years) admitted between September 2018 and October 2022, 70% were admitted between January and October 2022. All patients reported limb paraesthesiae and 16/17 reported (95%) imbalance; 11/17 (65%) showed objective limb weakness. Serum B12 concentration was low in 9/17 (53%). Plasma methylmalonic acid (n = 7) and homocysteine (n = 8) levels were elevated in all patients tested. Spinal cord Magnetic Resonance Imaging (MRI) imaging was abnormal in 10/17 (59%) patients. Nerve conduction studies were abnormal in 10/13 (77%) patients, with evidence of a symmetric, length-dependent, large fibre neuropathy. CONCLUSIONS: There has been a recent surge of cases with neurological complications of recreational N2O abuse in the UK, with a relatively greater rate in 2022. Greater awareness of this condition amongst clinicians and health regulators is urgently required to prevent harm from N2O misuse in young people.

30 years of youth system of care lessons learned - a qualitative study of Hawai'i's partnership with the Substance Abuse and Mental Health Services Administration.

BACKGROUND: The Hawai'i State Department of Health, Child and Adolescent Mental Health Division (CAMHD) has maintained a longstanding partnership with Substance Abuse and Mental Health Services Administration (SAMHSA) to enhance capacity and quality of community-based mental health services. The current study explored CAMHD's history of SAMHSA system of care (SOC) awards and identified common themes, lessons learned, and recommendations for future funding. METHODS: Employing a two-phase qualitative approach, the study first conducted content analysis on seven final project reports, identifying themes and lessons learned based on SOC values and principles. Subsequently, interviews were conducted with 11 system leaders in grant projects and SOC award projects within the state. All data from project reports and interview transcripts were independently coded and analyzed using rapid qualitative analysis techniques. RESULTS: Content validation and interview coding unveiled two content themes, interagency collaboration and youth and family voice, as areas that required long-term and consistent efforts across multiple projects. In addition, two general process themes, connection and continuity, emerged as essential approaches to system improvement work. The first emphasizes the importance of fostering connections in family, community, and culture, as well as within workforce members and child-serving agencies. The second highlights the importance of nurturing continuity throughout the system, from interagency collaboration to individual treatment. CONCLUSIONS: The study provides deeper understanding of system of care evaluations, offering guidance to enhance and innovate youth mental health systems. The findings suggest that aligning state policies with federal guidelines and implementing longer funding mechanisms may alleviate administrative burdens.

Can proactive support prevent unscheduled care? A controlled observational retrospective cohort study in cancer patients in Scotland.

INTRODUCTION: Preventative spend is a global health and social care strategy. Improving Cancer Journeys (ICJ) is a proactive, holistic, multidisciplinary project consistent with this agenda, currently being rolled out across Scotland and parts of UK. ICJ helps people with cancer access whatever support they need to mitigate their most pressing concerns. This study hypothesised that ICJ service users should subsequently use less unscheduled care than matched cohorts not using ICJ. METHODS: Retrospective observational cohort study using linked national datasets. N = 1,214 ICJ users in Glasgow were matched for age, sex, deprivation, cancer type, stage, and diagnosis year to two control groups: 1. Cancer patients from Glasgow before ICJ (pre-2014), 2. Cancer patients from rest of Scotland during study period (2014-2018). Cancer registrations were linked for 12-month baseline and study periods to: NHS24 calls, A&E admissions, inpatient hospital admissions, unscheduled care, number & cost of psychotropic prescriptions. Per-person mean service uses were compared between groups. RESULTS: There was a significant increase in NHS24 calls in the ICJ group (0.36 per person vs. -0.03 or 0.35), more and longer A&E attendances in ICJ (0.37 per person vs. 0.19 or 0.26; 2.19 h per person vs. 0.81-0.92 h), more and longer hospital admissions in ICJ (4.25 vs. 2.59 or 2.53; 12.05 days vs. 8.37 or 8.64), more care pathways involving more steps in ICJ (0.77 spells vs. 0.39 or 0.57; 1.88 steps vs. 1.56 or 1.21), more psychotropic drug prescriptions and higher costs in ICJ (1.88 prescription vs. 1.56 or 1.21; £9.51 vs. £9.57 or £6.95) in comparison to both control groups. DISCUSSION: ICJ users sourced significantly more unscheduled care than matched cohorts. These findings were consistent with much of the comparable literature examining the impact of non-health interventions on subsequent health spend. They also add to the growing evidence showing that ICJ reached its intended target, those with the greatest need. Together these findings raise the possibility that those choosing to use ICJ may also be self-identifying as a cohort of people more likely to use unscheduled care in future. This needs to be tested prospectively, because this understanding would be very helpful for health and social care planners in all countries where proactive holistic services exist.

Nurses' professional discretion in the purchaser-provider split in home care in Norway.

AIM: To explore how nurses' professional discretion is operationalized in home care services that follow a purchaser-provider organization in Norway. DESIGN: A qualitative descriptive study. METHODS: Semi-structured interviews with open-ended questions were used, and data were collected from in-depth interviews with 15 registered nurses working in home care in four Norwegian local authority areas between April and November 2020. Braun and Clark's six-step analysis was used to analyse the empirical data. RESULTS: The analysis yielded two main themes, namely 'The purchaser's instructions: facilitating and constraining care' and 'Professional discretion meets the purchaser-provider organisation of healthcare,' with five associated codes. CONCLUSION: Nurses are dependent on an organizational framework due to the complexity of health care services and the number of tasks involved. At the same time, they perform considerable compensatory work and need the ability to be flexible to enable this work and to perform actions related to the unforeseen needs of individual patients or those involving professional discretion. IMPACT: The purchaser-provider model both facilitates and constrains nursing practice and professional responsibility in home nursing. Home nursing services need to be well organized because of their complexity and the wide variety of tasks they involve. In this context, the element of constraint is associated with the need for flexibility and professional discretion. Despite a strict framework, the nurses perform additional and compensatory tasks. Reforms inspired by 'New Public Management,' such as the purchaser-provider split, limit the workload for nurses; however, there is still a need to exercise discretion. The findings of this study may help home care managers and health policy-makers understand the interaction between management logic and health care logic, leading to a more appropriate organization of health care services where the nurses, as actors, gain more trust. IMPLICATIONS: This study highlights home care nurses' opportunities to exercise discretion in an organizational framework that strives towards standardization. The nurses' ability to exercise discretion is important for individual and holistic patient care. At the same time, an organizational framework is needed because nurses cannot attend to all the needs the patients may have, as this will overload both home health services and the nurses.

The impact of evidence-based nursing leadership in healthcare settings: a mixed methods systematic review.

BACKGROUND: The central component in impactful healthcare decisions is evidence. Understanding how nurse leaders use evidence in their own managerial decision making is still limited. This mixed methods systematic review aimed to examine how evidence is used to solve leadership problems and to describe the measured and perceived effects of evidence-based leadership on nurse leaders and their performance, organizational, and clinical outcomes. METHODS: We included articles using any type of research design. We referred nurses, nurse managers or other nursing staff working in a healthcare context when they attempt to influence the behavior of individuals or a group in an organization using an evidence-based approach. Seven databases were searched until 11 November 2021. JBI Critical Appraisal Checklist for Quasi-experimental studies, JBI Critical Appraisal Checklist for Case Series, Mixed Methods Appraisal Tool were used to evaluate the Risk of bias in quasi-experimental studies, case series, mixed methods studies, respectively. The JBI approach to mixed methods systematic reviews was followed, and a parallel-results convergent approach to synthesis and integration was adopted. RESULTS: Thirty-one publications were eligible for the analysis: case series (n = 27), mixed methods studies (n = 3) and quasi-experimental studies (n = 1). All studies were included regardless of methodological quality. Leadership problems were related to the implementation of knowledge into practice, the quality of nursing care and the resource availability. Organizational data was used in 27 studies to understand leadership problems, scientific evidence from literature was sought in 26 studies, and stakeholders' views were explored in 24 studies. Perceived and measured effects of evidence-based leadership focused on nurses' performance, organizational outcomes, and clinical outcomes. Economic data were not available. CONCLUSIONS: This is the first systematic review to examine how evidence is used to solve leadership problems and to describe its measured and perceived effects from different sites. Although a variety of perceptions and effects were identified on nurses' performance as well as on organizational and clinical outcomes, available knowledge concerning evidence-based leadership is currently insufficient. Therefore, more high-quality research and clinical trial designs are still needed. TRAIL REGISTRATION: The study was registered (PROSPERO CRD42021259624).

Work engagement among nurses in the context of the COVID-19 pandemic: A systematic review.

BACKGROUND: Despite nurses receiving education on how to respond during crises, the stress and demands arising from unprecedented situations, such as the COVID-19 pandemic, may affect their work engagement. AIM: To appraise and synthesize studies examining work engagement among nurses in the context of the COVID-19 pandemic. METHODS: It is a systematic review in which three databases were searched. Critical appraisal tools and PRISMA guidelines were used. Content analysis was performed. ETHICAL CONSIDERATIONS: Ethical approval was not required for this systematic review. FINDINGS: A total of 21 studies were included. The results were classified into three categories: (1) levels and meanings of work engagement, (2) the relationship of work engagement with various factors, and (3) measures to enhance work engagement. CONCLUSION: The review revealed that nurses' work engagement varied from moderate to high. Factors such as education level and work schedule flexibility influenced their engagement. Positive associations were found between work engagement and job satisfaction, intention to stay, and organizational support, while stress and workload showed negative relationships. The crucial role of health policymakers, hospital administrators, and nurse managers in acting ethically, creating favorable working conditions and fostering nurses' work engagement was emphasized.

How do health system factors (funding and performance) impact on access to healthcare for populations experiencing homelessness: a realist evaluation.

BACKGROUND: People experiencing long-term homelessness face significant difficulties accessing appropriate healthcare at the right time and place. This study explores how and why healthcare performance management and funding arrangements contribute to healthcare accessibility or the lack thereof using long-term homeless adults as an example of a population experiencing social exclusion. METHODS: A realist evaluation was undertaken. Thirteen realist interviews were conducted after which data were transcribed, coded, and analysed. RESULTS: Fourteen CMOCs were created based on analysis of the data collected. These were then consolidated into four higher-level CMOCs. They show that health systems characterised by fragmentation are designed to meet their own needs above the needs of patients, and they rely on practitioners with a special interest and specialised services to fill the gaps in the system. Key contexts identified in the study include: health system fragmentation; health service fragmentation; bio-medical, one problem at a time model; responsive specialised services; unresponsive mainstream services; national strategy; short health system funding cycles; and short-term goals. CONCLUSION: When health services are fragmented and complex, the needs of socially excluded populations such as those experiencing homelessness are not met. Health systems focus on their own metrics and rely on separate actors such as independent NGOs to fill gaps when certain people are not accommodated in the mainstream health system. As a result, health systems lack a comprehensive understanding of the needs of all population groups and fail to plan adequately, which maintains fragmentation. Policy makers must set policy and plan health services based on a full understanding of needs of all population groups.

Concurrent Validation of the Inpatient Rehabilitation Facility Patient Assessment Instrument Version 1.4; Sections GG, B, and C.

OBJECTIVE: To validate Sections GG (Self-Care and Mobility Assessment), B (Hearing, Speech, and Vision), and C (Cognitive Patterns) of the Centers for Medicare and Medicaid Services Inpatient Rehabilitation Facility Patient Assessment Instrument (CMS-IRF PAI) Version 1.4 in comparison with Functional Independence Measure (FIM) motor subscale (FIMm) and cognitive subscale (FIMc). DESIGN: Retrospective cohort. SETTING: Single inpatient rehabilitation facility. PARTICIPANTS: Cohort of 1296 patients admitted for rehabilitation after stroke, between October 1, 2016, and October 1, 2019. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sections GG, B, and C scores were compared with FIMm and FIMc using Spearman's and Bland-Altman Analyses. RESULTS: Sections GG and FIMm were highly correlated on admission (ρ=0.919, P<.001) and discharge (ρ=0.929, P<.001). Ceiling effects at discharge were more pronounced for Section GG (8.6%). Bland-Altman analyses revealed a bias toward higher scores on Section GG vs FIMm on admission (Bias=2.3%, P<.001), and discharge (Bias=6.2%, P<.001). Section GG showed bias toward greater gains in function (Bias=3.9%, P<.001), particularly in walking and stairs (bias=3.71%, P<.001). Comparable self-care items accounted for a smaller percentage of the Section GG gains compared with FIMm (bias=-7.5%, P<.001). The internal validity of a scale consisting of Section B and C (B+C scale) was good, (Cronbach's alpha=0.868) and was highly correlated with FIMc (ρ=0.745), but rated patients at a higher level of cognition (bias=20.0%, P<.001) and had a greater ceiling effect (20.4%) on admission compared with the FIMc (0.6%). CONCLUSION: The B+C scale and Section GG were correlated with FIMc and FIMm subscales but biased toward higher ratings of ability. Ceiling effects may limit discrimination at higher level of cognition/functional independence. The clinical acceptability of Section GG total scores as an outcome measure and predictor of long-term outcomes requires further study.

British doctors' work-life balance and home-life satisfaction: a cross-sectional study.

PURPOSE: To assess British doctors' work-life balance, home-life satisfaction and associated barriers. STUDY DESIGN: We designed an online survey using Google Forms and distributed this via a closed social media group with 7031 members, exclusively run for British doctors. No identifiable data were collected and all respondents provided consent for their responses to be used anonymously. The questions covered demographic data followed by exploration of work-life balance and home-life satisfaction across a broad range of domains, including barriers thereto. Thematic analysis was performed for free-text responses. RESULTS: 417 doctors completed the survey (response rate: 6%, typical for online surveys). Only 26% reported a satisfactory work-life balance; 70% of all respondents reported their work negatively affected their relationships and 87% reported their work negatively affected their hobbies. A significant proportion of respondents reported delaying major life events due to their working patterns: 52% delaying buying a home, 40% delaying marriage and 64% delaying having children. Female doctors were most likely to enter less-than-full-time working or leave their specialty. Thematic analysis revealed seven key themes from free-text responses: unsocial working, rota issues, training issues, less-than-full-time working, location, leave and childcare. CONCLUSIONS: This study highlights the barriers to work-life balance and home-life satisfaction among British doctors, including strains on relationships and hobbies, leading to many doctors delaying certain milestones or opting to leave their training position altogether. It is imperative to address these issues to improve the well-being of British doctors and improve retention of the current workforce.

Reliability of patient-reported comorbidities: a systematic review and meta-analysis.

Self-reported questionnaires have become a widely adopted method of reviewing patients in clinical practice. This systematic review aimed to determine the reliability of patient-reported comorbidities and to identify which patient factors influence the reliability. Included studies assessed the reliability of at least one patient-reported comorbidity against their medical record or clinical assessment as gold standard. Twenty-four eligible studies were included in the meta-analysis. Only endocrine diseases (Cohen's Kappa Coefficient (CKC) 0.81 (95% CI 0.76 to 0.85)), consisting of diabetes mellitus (CKC 0.83 (95% CI 0.80 to 0.86)) and thyroid disease (CKC 0.68 (95% CI 0.50 to 0.86)), showed good-to-excellent reliability. Factors most frequently reported to influence concordance included age, sex and educational level. This systematic review demonstrated poor-to-moderate reliability for most systems, except for endocrine which showed good-to-excellent reliability. Although patient self-reporting can be a useful guide to clinical management, several patient factors were demonstrated to affect reliability therefore it should be avoided as a standalone measure.

The importance of embedding an inclusive culture within healthcare teamwork education; an evaluation of implementation methods.

Teamworking is a fundamental concept within most organisations and healthcare is no different. It is at the core of everything we do as professionals and has a multitude of impacts including on patient safety, the quality of care that we provide, and staff morale. This paper looks at why we should prioritize advancing teamwork education; argues the advantages of developing an all-encompassing, inclusive team training approach; and summarizes the different methods of how to implement teamwork education within your organisation. Key messages Good teamworking processes have significant effects on patient safety and staff well-being. Inclusive training has wide-reaching benefits for staff morale, fostering colleague relationships and breaking down hierarchies. Teamwork education should be embedded within all healthcare organisations with the method used depending on organisational culture, hierarchy gradient and learners' starting knowledge.

Addressing non-response data for standardized post-acute functional items.

BACKGROUND: The post-acute patient standardized functional items (Section GG) include non-response options such as refuse, not attempt and not applicable. We examined non-response patterns and compared four methods to address non-response functional data in Section GG at nation-wide inpatient rehabilitation facilities (IRF). METHODS: We characterized non-response patterns using 100% Medicare 2018 data. We applied four methods to generate imputed values for each non-response functional item of each patient: Monte Carlo Markov Chains multiple imputations (MCMC), Fully Conditional Specification multiple imputations (FCS), Pattern-mixture model (PMM) multiple imputations and the Centers for Medicare and Medicaid Services (CMS) approach. We compared changes of Spearman correlations and weighted kappa between Section GG and the site-specific functional items across impairments before and after applying four methods. RESULTS: One hundred fifty-nine thousand six hundred ninety-one Medicare fee-for-services beneficiaries admitted to IRFs with stroke, brain dysfunction, neurologic condition, orthopedic disorders, and debility. At discharge, 3.9% (self-care) and 61.6% (mobility) of IRF patients had at least one non-response answer in Section GG. Patients tended to have non-response data due to refused at discharge than at admission. Patients with non-response data tended to have worse function, especially in mobility; also improved less functionally compared to patients without non-response data. Overall, patients coded as 'refused' were more functionally independent in self-care and patients coded as 'not applicable' were more functionally independent in transfer and mobility, compared to other non-response answers. Four methods showed similar changes in correlations and agreements between Section GG and the site-specific functional items, but variations exist across impairments between multiple imputations and the CMS approach. CONCLUSIONS: The different reasons for non-response answers are correlated with varied functional status. The high proportion of patients with non-response data for mobility items raised a concern of biased IRF quality reporting. Our findings have potential implications for improving patient care, outcomes, quality reporting, and payment across post-acute settings.

Differences in the Patterns of Care Between Emergency Department Visits with and Without a Physician.

BACKGROUND: A variety of clinicians practice in emergency departments (EDs). Although most ED patients prefer seeing physicians, a subset sees no physician. OBJECTIVES: We sought to determine the factors that predict when an ED patient is seen by at least one physician and compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician. METHODS: We used 11 years of cross-sectional data from the National Hospital Ambulatory Medical Care Survey and focused on the sample of ED patient visits seen by at least one physician and those seen by no physician. We used bivariate statistics to compare characteristics between samples and used multivariate logistic regression analysis to identify the factors that predicted being seen by a physician. Finally, we compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician. RESULTS: Approximately 10% of the sample was not seen by any physician. Patients seen by at least one physician had, on average, 0.8 more diagnostic services ordered/provided and 0.1 more procedures provided compared with patients who were not seen by any physician. Patients seen by at least one physician had longer visits by 29.4 min, on average, and had increased odds of being hospitalized (adjusted odds ratio 3.9, 95% confidence interval 2.9-5.2). CONCLUSIONS: A variety of patient and hospital characteristics influenced whether ED patients were seen by physicians. Diagnostic services, procedures, visit length, and hospital admission differed by physician presence. Findings have implications for ED practice and future research.

The emergence of custodial health nursing as a specialty whose time has come: An Australian experience.

BACKGROUND: Nurses provide healthcare in prisons worldwide. Working within security restraints, in environments not designed for nursing care, custodial health nurses (CHNs) use specialist nursing skills and knowledge to do essential work. Rapid increases in prisoner age, infirmity and ill-health of prisoners mandate their access to these nurses. AIM: To raise awareness of the CHNs struggle for specialty status within the nursing profession, public health frameworks and prisons. SOURCES OF EVIDENCE: Publicly available information is organised and analysed through the author's lens of 20 years working in the Australian prison system as a general nurse and nurse practitioner. DISCUSSION: CHNs efforts towards becoming a specialty within nursing, public health and prisons are ongoing. Overcoming barriers and maximising facilitators to effective CHN practice would be indicators of successful incorporation of nursing models that assist prisoner patients. Prison healthcare contexts are unique regarding prisoner health and funding that impacts the CHNs resourcing, their scope of practice and acceptance of nursing in prison systems and the broader healthcare sectors. CONCLUSION: Greater visibility of the CHNs will help promote policy reforms regarding nursing services within a changing prisoner demographic. Changes to educational and professional support for CHNs are needed. Policy restrictions on funding for CHN models in Australia fall short of international standards for prison healthcare; however, political and organisational commitment in this area will be necessary to attain community-equivalent healthcare standards across the custodial setting. IMPLICATIONS FOR NURSING AND OTHER POLICIES: Professional structures, competencies and specialty policy frameworks are required to promote CHNs as advocates for prisoners needing care and their professional development. CHNs at the forefront of policy development and review will benefit all stakeholders in custodial health.

The COVID Positive Pathway: a collaboration between public health agencies, primary care, and metropolitan hospitals in Melbourne.

OBJECTIVES: To assess the capacity of the COVID Positive Pathway, a collaborative model of care involving the Victorian public health unit, hospital services, primary care, community organisations, and the North Western Melbourne Primary Health Network, to support people with coronavirus disease 2019 (COVID-19) isolating at home. DESIGN, SETTING, PARTICIPANTS: Cohort study of adults in northwest Melbourne with COVID-19, 3 August - 31 December 2020. MAIN OUTCOME MEASURES: Demographic and clinical characteristics, and social and welfare needs of people cared for in the Pathway, by care tier level. RESULTS: Of 1392 people referred to the Pathway by the public health unit, 858 were eligible for enrolment, and 711 consented to participation; 647 (91%) remained in the Pathway until they had recovered and isolation was no longer required. A total of 575 participants (81%) received care in primary care, mostly from their usual general practitioners; 155 people (22%) received care from hospital outreach services, and 64 (9%) needed high tier care (hospitalisation). Assistance with food and other basic supplies was required by 239 people in the Pathway (34%). CONCLUSIONS: The COVID Positive Pathway is a feasible multidisciplinary, tiered model of care for people with COVID-19. About 80% of participants could be adequately supported by primary care and community organisations, allowing hospital services to be reserved for people with more severe illness or with risk factors for disease progression. The principles of this model could be applied to other health conditions if regulatory and funding barriers to information-sharing and care delivery by health care providers can be overcome.

Decreased in-hospital mortality rate following implementation of a comprehensive electronic medical record system.

AIM: To evaluate changes in in-hospital mortality rate following implementation of a comprehensive electronic medical record (EMR) system. METHODS: Before and after study of 355,709 hospital discharges, over an 8-year period, at a paediatric teaching hospital. The major outcome measures were crude number of in-hospital deaths, deaths per 1000 discharges, and standardised mortality ratio. RESULTS: Primary analysis of data from 2 years before and 2 years after EMR go-live showed a reduction in absolute mortality of 33 deaths, a reduction in the mortality rate of 0.48 per 1000 discharges (95% CI 0.09, 0.88 per 1000): and a relative 22% decrease (95% CI: 4%, 36%, P = 0.02) in deaths per 1000 discharges from 2.20 to 1.72. There was also a reduction in standardised mortality ratio of 47% (95% CI: 18%, 66%, P = 0.004). Post-hoc analysis of mortality rates for an additional 2-year pre-intervention period indicated that these changes in the mortality rate were not part of a pre-existing downward trend. Further analysis of an additional 20-month post-intervention period suggests that the reduced mortality rate has been sustained. CONCLUSION: We documented evidence of a clinically important decrease in in-hospital mortality rate following the implementation of a modern comprehensive EMR system in an Australian paediatric teaching hospital. The study does not prove a causal relationship, and it is possible that other factors explain some, or all, of this difference, but no changes in the hospital population or other major interventions were identified as alternative explanations for this observed change.