Findings from three methods to identify falls in hospitals: Results from the Ambient Intelligent Geriatric Management system fall prevention trial.

OBJECTIVE: To (a) compare characteristics of patients who fall with those of patients who did not fall; and (b) characterise falls (time, injury severity and location) through three fall reporting methods (incident system reports, medical notes and clinician reports). METHODS: A substudy design within a stepped-wedge clinical trial was used: 3239 trial participants were recruited from two inpatient Geriatric Evaluation and Management Units and one general medicine ward in two Australian states. To compare the characteristics of patients who had fallen with those who had not, descriptive tests were used. To characterise falls through three reporting methods, bivariate logistic regressions were used. RESULTS: Patients who had fallen were more likely than patients who had not fallen to be cognitively impaired (51% vs. 29%, p < 0.01), admitted with falls (38% vs. 28%, p = 0.01) and have poor health outcomes such as prolonged length of stay (24 [16-34] vs. 12 [8-19] days [IQR], p < 0.01) and less likely to be discharged directly to the community (62% vs. 47%, p < 0.01). Most falls were captured from medical notes (93%), with clinician (71%) and incident reports (68%) missing 21%-25% of falls. The proportion of injurious falls identified through incident reports was higher than medical records or clinician reports (40% vs. 34% vs. 37%). CONCLUSIONS: This study reaffirms the need to improve reporting falls in incident systems and at clinical handover to the team leader. Research should continue to use more than one method of identifying falls, but include data from medical records. Many falls cause injury, resulting in poor health outcomes.

Older Adults' Perceptions of the Built Environment and Associations with Frailty: A Feasibility and Acceptability Study.

It is essential to evaluate frail older adults understanding and execution of survey tools to improve data quality and accurate representation in research. The study tested the feasibility and acceptability of a survey that assesses various measures of functional status in frail older people. The study evaluated: 1) recruitment rate; 2) time to complete questionnaires and difficulties encountered; and 3) acceptability by participants. Validated tools including: FRAIL Scale, EuroQoL 5D-5L, Charlson's Comorbidities Index, Baecke's Physical Activity Questionnaire, Life-Space Assessment, Katz and Lawton ADL and NEWS Walkability Scale were assessed. Twenty-five older patients (63% recruitment rate) of a post-acute restorative program (residential Transition Care Program) in Adelaide, South Australia were interviewed. Although not statistically different, time to complete the overall questionnaire differed between robust, pre-frail and frail participants. Overall, the survey was considered acceptable and feasible, with consideration with NEWS and Life-Space assessment regarding length, phrasing and layout.

Older People Who Are Frequent Users of Acute Care: A Symptom of Fragmented Care? A Case Series Report on Patients' Pathways of Care.

Older frequent users of acute care can experience fragmented care. There is a need to understand the issues in a local context before attempting to address fragmented care. 0.5% (n=61) of the population in a defined local government area were identified as having ≥4 unplanned emergency department (ED) presentations/ admissions to an acute-care hospital over 13 months. A retrospective case-series study was conducted to examine detailed pathways of care for 17 patients within the identified population. The two dominant presentation reasons were clinical symptoms associated with a declining/significant loss of capacity in fundamental self-care activities and chronic cardiac/respiratory conditions. Of patients discharged home, 21% of discharge letters were delayed >7 days and only 19% received a written discharge plan. Half of community dwelling patients received home nursing and/or assistance. Frequent users of acute care can experience untimely hospital communication and may require more coordinated care provided in the community to assist self-care and manage chronic conditions.

Management of Musculoskeletal Conditions in Rural South Australia: A Randomised Controlled Trial.

With age, the prevalence of musculoskeletal conditions increases markedly. This rural-based study determined the benefits of two approaches for managing musculoskeletal conditions: a multiple-component 'Self-management Plus' intervention, and usual care. The intervention combined self-management education with physical activity and health professional support. 6-month outcomes included: Clinical Global Impression-Improvement Scale (CGI-IS) and Quality of Life (QoL). A total of 145 people were recruited; mean (SD) age was 66.1 (11.1) and 63.3 (10.9) years for intervention and control groups respectively. The intervention resulted in greater improvements in global functioning (CGI-IS mean (SD) = 3.2 (1.3)) than usual care (CGI-IS mean (SD) = 4.2 (1.5)). There was no difference in QoL improvement between study groups. A multiple-component 'Self-management Plus' intervention had a positive effect on physical functioning for older adults with musculoskeletal conditions. However, recruitment and retention of participants was problematic, which raises questions about the intervention's feasibility in its current form.

Cardiac syndrome X in Ireland: incidence and phenotype.

BACKGROUND: Cardiac syndrome X (CSX) is typical angina pectoris with objective signs of myocardial ischaemia despite a normal coronary angiogram and may be due to microvascular dysfunction. The incidence of CSX has not been greatly investigated worldwide and its incidence in Ireland is unknown. AIMS: We aimed to determine the incidence of CSX in Cork University Hospital (CUH) and to establish the phenotype of the typical Irish CSX patient. METHODS: All patients undergoing coronary angiography in CUH during regular working hours over a 3-month period were investigated. CSX was diagnosed using standard criteria. An extended recruitment period of 14 months allowed enrolment of a sufficient number of CSX patients to enable phenotyping. RESULTS: Only 5 of 372 (1.3 %) patients undergoing angiography to investigate chest pain met the diagnostic criteria for CSX. None were given a discharge diagnosis of CSX or received cardiology follow-up. Irish CSX patients were predominantly female (88 %) with a mean age of 59.2 ± 6.6 years. Although they were significantly less functionally limited than patients with obstructive CAD, they had an equally substantial impairment in quality of life. CONCLUSIONS: CSX is relatively uncommon in Ireland and is most frequently seen in middle-aged women with hyperlipidaemia. It has significant impacts on patients' quality of life. None of the CSX patients were diagnosed as such, highlighting the lack of awareness or acceptance of this condition in Ireland. These patients require diagnosis and active cardiology follow-up to effectively manage their symptoms.

Evidence-based rural general practice: barriers and solutions in South Australia.

INTRODUCTION: This paper reports on research to ascertain the views of general practitioners (GPs) practising in rural and remote areas of South Australia, on evidence-based medicine (EBM). It follows our previous paper that identified, through a literature search, the key issues in moving towards EBM in general practice in these areas1. The objective of the paper was to identify perceived barriers and potential solutions to evidence-based general practice in rural and remote South Australia. METHODS: An interview survey was conducted in the year 2000 at 89 of 104 GPs' (86%) surgeries in three rural Divisions of General Practice in South Australia. RESULTS: EBM was viewed positively by 85%, and 94% reported practising EBM. However, barriers to EBM were identified by 84% and four key themes were identified. GP-related barriers identified by 60% included difficulty finding, appraising and applying evidence and lack of time to read, reflect and update practice. Patient related barriers (23%) included an apparent conflict between some patients' expectations and evidence. Environmental barriers (43%) related to remoteness included high workload, limited information and poor resources for continued medical education. Resource related barriers included a lack of computer hardware and software and slow, unreliable and expensive Internet access (14%). Potential solutions were suggested by 82%. The most frequent was improved hardware, software and Internet access (41%). Only 19% suggested formal training for GPs, while 26% suggested improved clinical practice guidelines and 23% suggested non-Internet based dissemination of information including a service to provide evidence-based answers to clinical problems. CONCLUSION: EBM was viewed positively by the surveyed GPs and many believed they already practised it. Most identified barriers to full and effective use of EBM but also suggested solutions.

Contemporary management issues for Aboriginal Community Controlled Health Services.

Aboriginal Community Controlled Health Services face particular management issues as they adjust to the dominant Western paradigm of managerialism and the market model of health service provision. Their cultural orientation leads to distinctive organisational features which both advantage and disadvantages them in this environment. The holistic model of health used and community control enable the delivery of integrated, culturally appropriate health care. However, effective community control is difficult to achieve. Services may benefit from partnerships with collaborators such as hospitals, regional health services and university departments of rural health if the partnerships are based on mutual respect and ensure that community control is retained.