Development and Evaluation of a Massive Open Online Course on Healthcare Redesign: A Novel Method for Engaging Healthcare Workers in Quality Improvement.

Healthcare workers are under increasing pressure to use limited resources more efficiently and improve patient outcomes. Healthcare redesign, a quality improvement methodology derived from the automotive industry, is a proven means of achieving these goals. Continuing Professional Development (CPD) opportunities for nurses seeking to build their capacity for healthcare redesign often come in the form of university courses, which can be costly and prohibitively time-consuming. We developed a Massive Open Online Course (MOOC) with a view to increasing the number of healthcare workers undertaking CPD in healthcare redesign and subsequently using these principles in their workplaces. The aim of the current study is to describe the development of our MOOC and its initial feedback from users. Materials and Methods: The theoretical and practical components of an existing postgraduate award course unit were made fit for purpose by being arranged into six weekly modules, before being transposed to an established learning management platform for MOOCs. Related quizzes, videos and interactive activities were then developed and included in each of these modules. Peer review of this content was completed by subject matter and teaching and learning experts prior to the MOOC being launched. Results: After running for nine months, 578 participants had enrolled in the MOOC, of whom 118 (20%) had followed through to completion. Participants were overwhelmingly from Australia (89%) and identified as female (78%). Preliminary feedback obtained from participants was positive, with 81% of respondents agreeing that they were satisfied with their experience, and 82% intending to apply their knowledge in practice. Conclusions: The MOOC has addressed a learning need by providing a brief and free form of education; learning from its development will help others seeking similar educational solutions. Initial feedback suggests the MOOC has been well-received and is likely to be translated into practice.

Evaluating a Novel Extended Scope of Occupational Therapy Service Aimed at Hospital Avoidance in Tasmania, Australia, from the Perspective of Stakeholders.

The Australian state of Tasmania has seen a spike in Emergency Department presentations in recent years, particularly among the elderly. A novel extended scope occupational therapy (ESOT) service was implemented by the Tasmanian Health Service, aimed at supporting hospital avoidance. Clients were referred to the ESOT service by other services after being assessed as having a high risk of imminent hospital presentation. Occupational Therapists provided short-term interventions related to falls, mobility, nutrition, and initiated onward referrals to other services. A convergent parallel mixed methods design was used to evaluate the ESOT service. Quantitative data from routinely collected administrative records and a purpose-built survey of referring clinicians were used alongside qualitative data from semi-structured interviews with clients/carers, to enable the triangulation of data. Quantitative data were analysed using descriptive statistics, while qualitative data collected in interviews were thematically analysed. A total of 104 extended scope interventions were provided to 100 clients. Most clients were able to stay at home. Qualitative data revealed that mobility, support, and facilitating access to support services were factors which added value to the client and carer experience. In conclusion, the ESOT program contributed to potentially avoiding hospital admissions and to improving the quality of life of participating clients.

Telehealth experiences of vulnerable clients living in Tasmania.

OBJECTIVE: To understand the experiences of vulnerable clients who used telehealth during the Coronavirus pandemic. DESIGN: The study employed a qualitative enquiry, utilising semi-structured interviews lasting 30-60 minutes with a thematic analysis approach to explore factors influencing client experience with telehealth. SETTING: A wide range of locations across Tasmania, Australia. PARTICIPANTS: Twelve participants who were considered to be vulnerable on a number of domains, including: health and human wellbeing factors, social risk factors, functional limitations, and individual behavioural factors. INTERVENTIONS: The provision of telehealth consultations to vulnerable clients. MAIN OUTCOME MEASURES: Four global themes were discovered: i) Telehealth saves time, money and energy; ii) User friendly technology facilitates care; iii) Rapport and confidentiality helps clients to feel safe; and iv) Fit for purpose telehealth provides a quality service. RESULTS: The discovered themes entailed the major finding that most participants were satisfied with the overall quality of the telehealth service they received and the convenience of this service. Concerns were raised regarding the limitations around social interaction, physical examination, and access to fit-for-purpose telehealth devices. CONCLUSION: This research with vulnerable clients, from Tasmania, supports the evidence that the utilisation of telehealth allows more convenient access to care. To optimise the service, however, concerns regarding the desire for social interaction, appropriate physical examination, and access to fit-for-purpose telehealth devices will need to be addressed.

Regional differences in the care and outcomes of acute stroke patients in Australia: an observational study using evidence from the Australian Stroke Clinical Registry (AuSCR).

OBJECTIVE: To compare the processes and outcomes of care in patients who had a stroke treated in urban versus rural hospitals in Australia. DESIGN: Observational study using data from a multicentre national registry. SETTING: Data from 50 acute care hospitals in Australia (25 urban, 25 rural) which participated in the Australian Stroke Clinical Registry during the period 2010-2015. PARTICIPANTS: Patients were divided into two groups (urban, rural) according to the Australian Standard Geographical Classification Remoteness Area classification. Data pertaining to 28 115 patients who had a stroke were analysed, of whom 8159 (29%) were admitted to hospitals located within rural areas. PRIMARY AND SECONDARY OUTCOME MEASURES: Regional differences in processes of care (admission to a stroke unit, thrombolysis for ischaemic stroke, discharge on antihypertensive medication and provision of a care plan), and survival analyses up to 180 days and health-related quality of life at 90-180 days. RESULTS: Compared with those admitted to urban hospitals, patients in rural hospitals less often received thrombolysis (urban 12.7% vs rural 7.5%, p<0.001) or received treatment in stroke units (urban 82.2% vs rural 76.5%, p<0.001), and fewer were discharged with a care plan (urban 61.3% vs rural 44.7%, p<0.001). No significant differences were found in terms of survival or overall self-reported quality of life. CONCLUSIONS: Rural access to recommended components of acute stroke care was comparatively poorer; however, this did not appear to impact health outcomes at approximately 6 months.

Health care providers' perceptions of factors that influence the provision of acute stroke care in urban and rural settings: A qualitative study.

OBJECTIVES: Individuals living in rural areas have comparatively less access to acute stroke care than their urban counterparts. Understanding the local barriers and facilitators to the use of current best practice for acute stroke may inform efforts to reduce this disparity. METHODS: A qualitative study featuring semi-structured interviews and focus groups was conducted in the Australian state of Tasmania. Clinical staff from a range of disciplines involved in acute stroke care were recruited from three of the state's four major public hospitals (one urban and two rural). A semi-structured interview guide based on the findings of an earlier quantitative study was used to elicit discussion about the barriers and facilitators associated with providing acute stroke care. An inductive process of thematic analysis was then used to identify themes and subthemes across the data set. RESULTS: Two focus groups and five individual interviews were conducted. Four major themes were identified from analysis of the data: systemic issues, clinician factors, additional support and patient-related factors. Acute stroke care within the study's urban hospital was structured and comprehensive, aided by the hospital's acute stroke unit and specialist nursing support. In contrast, care provided in the study's rural hospitals was somewhat less comprehensive, and often constrained by an absence of infrastructure or poor access to existing resources. CONCLUSION: The identified factors help to characterise acute stroke care within urban and rural hospitals and will assist quality improvement efforts in Tasmania's hospitals.

Regional differences in access to acute ischaemic stroke care and patient outcomes.

BACKGROUND: Advances in stroke management such as acute stroke units and thrombolysis are not uniformly distributed throughout our population, with rural areas being relatively disadvantaged. It remains unclear, however, whether such disparities have led to corresponding differences in patient outcomes. AIMS: To describe the regional differences in acute ischaemic stroke care and outcomes within the Australian state of Tasmania. METHODS: A retrospective case note audit was used to assess the care and outcomes of 395 acute ischaemic stroke patients admitted to Tasmania's four major public hospitals. Sixteen care processes were recorded, which covered time-critical treatment, allied health interventions and secondary prevention. Outcome measures were assessed using 30-day mortality and discharge destination, both of which were analysed for differences between urban and rural hospitals using logistic regression. RESULTS: No patients in rural hospitals were administered thrombolysis; these hospitals also did not have acute stroke units. With few exceptions, patients' access to the remaining care indicators was comparable between regions. After adjusting for confounders, there were no significant differences between regions in terms of 30-day mortality (odds ratio (OR) = 0.99, 95% confidence interval (CI) 0.46-2.18) or discharge destination (OR = 1.24, 95% CI 0.81-1.91). CONCLUSIONS: With the exception of acute stroke unit care and thrombolysis, acute ischaemic stroke care within Tasmania's urban and rural hospitals was broadly similar. No significant differences were found between regions in terms of patient outcomes. Future studies are encouraged to employ larger data sets, which capture a broader range of urban and rural sites and record patient outcomes at extended interval.

Sex differences in risk factors for aneurysmal subarachnoid haemorrhage: Systematic review and meta-analysis.

BACKGROUND: Aneurysmal subarachnoid haemorrhage (aSAH) disproportionally affects women. We conducted a systematic review and meta-analysis to explore sex differences in aSAH risk factors. METHODS: Case-control/cohort studies were searched to November 2017 with sex-specific risk factors for aSAH. Meta-analysis was performed when a risk factor was reported in ≥2 studies. RESULTS: Of 31 studies, 22 were eligible for meta-analysis. Female sex was associated with greater odds of aSAH (HRadjusted 1.90 [1.47-2.46]. There was no detectable difference between the sexes for hypertension (ORadjusted: men 3.13 [2.26-4.34]; women 3.65 [2.87-4.63], p = .18), smoking (ORadjusted: men 2.96 [1.68-5.21]; women 3.11 [1.21-7.97], p = .95), aSAH family history, systolic blood pressure, age and some genetic variations. Alcohol (ORadjusted: men 1.50 [1.04-2.17]; women 0.83 [0.48-1.45], p = .003), high alanine aminotransferase levels, and some gene variants increased the risk of aSAH in men. Reproductive factors, divorce and some genetic variations increased the risk in women. High aspartate aminotransferase levels in men and, diabetes (ORadjusted: men 0.57 [0.32-1.01]; women 0.24 [0.13-0.43], p = .01) and parity in women reduced aSAH risk. CONCLUSION: We recommend sex-specific re-analysis of existing studies of aSAH risk factors. Known aSAH risk factors (hypertension, smoking and alcohol consumption) should be targeted to prevent aSAH in men and women. Registration PROSPERO (ID: CRD42018091521).

Urban-rural differences in the care and outcomes of acute stroke patients: Systematic review.

OBJECTIVE: To describe literature pertaining to urban-rural differences in both the quality of care and outcomes of acute stroke patients. METHODS: We systematically searched CINAHL, PubMed, ProQuest Dissertations & Theses, and Scopus for published and unpublished literature until 9th December 2017. Studies were included if they compared the acute care provided to, or outcomes of, patients hospitalised for stroke in urban versus rural settings. Abstract, full-text review, and data extraction were conducted in duplicate. Findings are presented in the form of narrative syntheses. RESULTS: A total of 28 studies were included in the review (16 on care, 12 on outcomes). With few exceptions, studies addressing the provision of care suggested that rural patients have less access to most aspects of acute stroke care. Studies reporting urban-rural differences in patient outcomes were inconsistent in their findings, however, few of these studies were primarily focused on the issue of urban-rural disparities. Overall, study findings did not appear to differ in line with study quality ratings, stroke subtypes included, or how inter-facility patient transfers were accounted for. CONCLUSIONS: There is convincing, albeit not unanimous, evidence to suggest that stroke patients in rural areas receive less acute care than their urban counterparts. Despite this, the available data and methodology have largely not been used to study urban-rural differences in patient outcomes. PROSPERO registration information: URL: https://www.crd.york.ac.uk/prospero. Unique identifier: CRD42017073262.

Hospital length of stay variation and comorbidity of mental illness: a retrospective study of five common chronic medical conditions.

BACKGROUND: With the increasing burden of mental illness globally, it is becoming common for hospitalised patients with chronic medical conditions to have a comorbidity of mental illness. This combination could prolong length of stay (LOS) of this patient cohort. We conducted an investigation in Tasmania, Australian hospitals to characterise this cohort and assess if co-morbidity of mental illness is a distinguishing factor that generates LOS variation across different chronic medical conditions. METHODS: The retrospective study analysed 16,898 admissions of patients with a primary diagnosis of one of five chronic medical conditions: lung or colorectal cancer, chronic obstructive pulmonary disease (COPD), type II diabetes, ischaemic heart disease (IHD) and stroke. Data were from July 2010 to June 2015, across four hospitals that collectively cover 95% of public hospital admissions in Tasmania, Australia. Descriptive statistics were used to compare characteristics of patients between the scenarios of with and without co-morbidity of mental illness. We used negative binomial regression models to assess whether co-morbidity of mental illness, along with its sub-types, after adjustment for potential confounding variables, associated with LOS variation in patients of each medical condition. Based on the adjusted LOS variation, we estimated differences in bed days' use between patients with and without comorbidity of mental illness. RESULTS: Patients with co-morbidity of mental illness were significantly younger in comparison to patients without mental illness. With each medical condition, patients with comorbidity of mental illness had incurred higher bed days' use than for those without mental illness. In cancer and stroke cohorts, co-morbidity of mental illness unfavourably affected the LOS variation by as high as 97% (CI: 49.9%-159%) and 109% (78%-146%), respectively. Though mental and behavioural disorders due to psychoactive substances was a dominant sub-type of mental illness across the medical conditions, it contributed significant unfavourable LOS variation only in the stroke patients i.e. 36.3% (CI: 16.2%-59.9%). CONCLUSIONS: Mental illness consistently produced unfavourable LOS variation. Upskilling of healthcare teams and greater reporting and analysis of LOS variation for this patient cohort, and the sub-cohorts within it, are necessary to provide improved medical care and achieve system efficiencies.