Optimising acute non-critical inter-hospital transfers: A review of evidence, practice and patient perspectives

INTRODUCTION

Patients who present to hospital with an acute non-critical illness or injury, which is considered outside the capability framework of that hospital to treat, will require inter-hospital transfer (IHT) to a hospital with a higher level of capability for that condition. Delays in IHT can negatively impact patient care and patient outcomes.

OBJECTIVE

To review and synthesis academic evidence, practitioner insights and patient perspectives on ways to improve IHT from regional to metro hospitals.

DESIGN

A rapid review methodology identified one review and 14 primary studies. Twelve practitioner interviews identified insights into practice and implementation, and the patient perspectives were explored through a citizen panel with 15 participants.

FINDINGS

The rapid review found evidence relating to clinician and patient decision factors, protocols, communication practices and telemedicine. Practitioner interviews revealed challenges in making the initial decision, determining appropriate destinations and dealing with pushback. Adequate support and communication were raised as important to improve IHT. The citizen panel found that the main concern with IHT was delays. Citizen panel participants suggested dedicated transfer teams, education and information transfer systems to improve IHT.

DISCUSSION AND CONCLUSION

Common challenges in IHT include making the initial decision to transfer and communicating with other health services and patients and families. In identifying the appropriateness of transferring acute non-critical patients, clear and effective communication is central to appropriate and timely IHT; this evidence review indicates that education, protocols and information management could make IHT processes smoother.

Retired Orthopedic Surgeons' Reflections on Their Lives and Careers: A Cross-Sectional Study

Background: Retired surgeons often have limited opportunities to disseminate their wisdom and expertise in a structured manner to their younger colleagues. In addition, when asked to reflect on their personal and professional lives, many physicians say they wish they had done something differently. The extent to which this is true of retired orthopedic surgeons is not known. Purpose: We sought to determine the percentage of retired orthopedic surgeons who say that they would like to have changed something in their life/career and delineate the most commonly desired changes. Methods: We conducted a cross-sectional study of retired orthopedic surgeons, by emailing a Qualtrics survey to 5864 emeritus members of the American Academy of Orthopaedic Surgeons (AAOS), with 1 initial email invitation in April 2021 followed by 2 reminders in May 2021. The survey employed a branching logic, with up to 16 questions designed to determine whether they would have done anything differently in their life/career. Results: The survey was completed by 1165 of 5864 emeritus AAOS members, for a response rate of nearly 20%. The 3 most represented surgical subspecialties were general orthopedics, adult reconstruction, and hand and upper extremity surgery. Respondents' average age was 74.9 years and age at retirement was 67.8 years; nearly half worked part-time before retiring. More than 80% of the participants said that they had retired at the appropriate time, and 28.5% said they wished they had done something differently. The wished-for changes most often noted were spending more time with family, spending more time on personal wellness, and selecting better practice partners. Conclusion: The results of our survey of retired orthopedic surgeons show that while most were satisfied with their lives and careers, some had regrets. These findings suggest that there may be factors in the work lives of current surgeons that could be altered to reduce regret. Further study is warranted.

The impact of formal and informal support on emotional stress among non-co-resident caregivers of persons with dementia

OBJECTIVES

The purpose of this study was to examine the prevalence of formal and informal support between non-co-resident and co-resident family caregivers of persons with dementia and to investigate the impact of receiving formal or informal assistance on family caregivers' residential status and their perceived emotional stress.

METHOD

We used secondary data from the 2018 National Survey of Older American Act conducted by the Administration for Community Living. We selected 751 primary family caregivers of persons with dementia and conducted regression analyses to explore our research questions.

RESULTS

Non-co-resident caregivers of persons with dementia were younger, racially and ethnically diverse, employed, and had higher income than co-resident caregivers. They were less likely to utilize formal support, such as caregiver training or education (p = .005) and respite care (p = .019) but more likely to rely on informal support in their social networks (p = .002), compared to co-resident caregivers. Non-co-resident caregivers who had better informal support systems showed less emotional stress than co-resident caregivers (p = .024).

CONCLUSION

Findings from our study suggest the importance of engaging informal networks to alleviate emotional stress of non-co-resident caregivers of persons with dementia. Furthermore, it is critical to help them utilize adequate caregiver training and education as well as respite care before their loved ones experience dramatic functional and health declines.

Challenges Experienced by Italian Nursing Home Staff in End-of-Life Conversations with Family Caregivers during COVID-19 Pandemic: A Qualitative Descriptive Study

End-of-life conversations are among the most challenging of all communication scenarios and on the agenda of several healthcare settings, including nursing homes (NHs). They may be also difficult for experienced healthcare professionals (HCPs). This study explores the difficulties experienced by Italian NH staff in end-of-life conversations with family caregivers (FCs) during COVID-19 pandemic to uncover their educational needs. A qualitative descriptive study based on inductive thematic analysis was performed. Twenty-one HCPs across six Italian NHs were interviewed. Four themes described their experiences of end-of-life conversations: (1) communicating with FCs over the overall disease trajectory; (2) managing challenging emotions and situations; (3) establishing a partnership between HCPs and FCs; (4) addressing HCPs' communication skills needs. HCPs had to face multiple challenging situations that varied across the care period as well as complex emotions such as anxiety, guilt, uncertainty, fear, anger, or suffering, which required tailored answers. COVID-19 pandemic increased FCs' aggressive behaviors, their distrust, and uncertainty due to visitation restrictions. HCPs had to overcome this by developing a set of strategies, including adoption of an active-listening approach, supportive communication, and explicit acknowledgement of FCs' emotions. Since communication needs were mostly practical in nature, HCPs valued practical communication training.

Reducing Waste in Healthcare through Occupational Safety and Health Measures: A Study of Manufacturing Industries in Taiwan

Occupational accidents and diseases cause the loss of valuable workers and lead to high healthcare expenses. Because occupational accidents and diseases are ascribed to inadequate working conditions and work environments, they can be prevented through a well-established occupational safety and health management system, which can ensure workers' health and reduce the expense of healthcare. The study investigated the shortage of work-related occupational safety and health (OSH) measures in medium-sized manufacturing industries. This study mainly focused on qualitative interviews with 15 labor inspectors and 25 business executives from OSH participating to investigate the problems of occupational safety and health in the manufacturing industries in Taiwan. The results of a qualitative study show that the most important problems with OSH management are employers' negligence and workers' insufficient knowledge about OSH management. The research results revealed the following eighteen significant shortcomings of OSH management: employers care mostly about production profit and do not care much for OSH; OSH data collection and OSH planning are not suitable for the workplace; many managers of OSH affairs are not qualified, in terms of their professional or academic backgrounds; and the repair of workplaces' roofs often results in falling accidents, especially before or after a typhoon, because of workers' failure to use safety belts and/or to follow OSH guidelines. In order to address the shortcomings and bottlenecks, the study also presented recommendations for how to implement and revise the OSH Act and how to research and enhance OSH management. The results of this study will not only supply the Ministry of Labor (Taiwan) with data to plan the strategy of OSH management but also will allow employers and workers to improve OSH management in the workplace in order to prevent the occurrence of occupational accidents.

Next steps for drowning prevention in rural and remote Australia: A systematic review of the literature

OBJECTIVE

To examine unintentional drowning by remoteness in Australia.

DESIGN

A systematic review of both peer-reviewed and grey literature published between January 1990 and December 2019 (inclusive).

METHOD

Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, MEDLINE (Ovid), PubMed, EMBASE, Scopus, PsycINFO (ProQuest), SPORTDiscus and Google Scholar were searched for studies exploring fatal and non-fatal unintentional drowning by remoteness. Epidemiological data, common factors and prevention strategies were extracted and mapped to Australian standard geographical classifications (major cities, inner regional, outer regional, remote and very remote). Level of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation and prevention strategies aligned to the hierarchy of control.

RESULT

Thirty-two studies satisfied inclusion criteria (66% reporting epidemiology; 59% risk factors; and 44% prevention strategies). All (100%) included studies were assessed very low against Grading of Recommendations Assessment, Development and Evaluation. Findings indicate rural populations (ie, excluding major cities) have higher rates of drowning positively correlated with increasing remoteness. Common factors included age (child), natural water bodies, undertaking boating and watercraft activities and alcohol consumption. While a range of prevention strategies has been proposed, only one study outlined a rural drowning prevention strategy which had been implemented and evaluated. Strategies were generally low on the hierarchy of control.

CONCLUSION

Rural populations are proportionately overrepresented in drowning statistics. Proposed prevention strategies have unknown efficacy. Greater research into rural drowning of Australians is needed especially exploring behavioural motivations, program delivery, cost-effectiveness and evaluation. Development and use of a standard definition for remoteness are recommended. Rural populations use water extensively; therefore, there is an urgent need to keep them safe.

What students and new graduates perceive supports them to think, feel and act as a health professional in a rural setting

OBJECTIVE

Clinical placements in rural locations are perceived by students to provide positive learning experiences to support their transition to practice. This study explores how clinical placements in a rural health setting might influence students and new graduates to think, feel and act as a health professional.

DESIGN

A qualitative study comprising focus group discussions was conducted.

SETTING

The study was conducted in a rural health service in Queensland, Australia.

PARTICIPANTS

Allied health students (n = 12) on placement and new graduates (n = 11) working in a regional health service.

MAIN OUTCOME MEASURES

This study identified allied health student and new graduate perspectives on clinical placement factors which support them to think, feel and act as a health professional.

RESULTS

Thematic analysis was used to understand student and new graduate perceptions of how rural placements support thinking, feeling and acting as a health professional. Suggestions for supporting learning included the following: Development of learning partnerships between students and clinical educators with inbuilt expectations and opportunities for reflection and supervision. Creating a culture where students are welcomed, valued and encouraged to take meal breaks with the team supported connectedness. The importance of balancing student autonomy with educating and grading support to increase independence.

CONCLUSIONS

Findings show clinical placement experiences identified by allied health students and new graduates which support them to begin to think, feel and act as a health professional. Suggestions provided by students and new graduates can be used to inform implementation of clinical placement experiences.

The Changing Nature of Palliative Care: Implications for Allied Health Professionals' Educational and Training Needs

CareSearch is an Australian Government Department of Health funded repository of evidence-based palliative care information and resources. The CareSearch Allied Health Hub was developed in 2013 to support all allied health professionals working with palliative care clients in all clinical settings. This cross-sectional online survey sought to elicit allied health professionals palliative care experiences and subsequent considerations for educational and clinical practice needs. The survey was disseminated nationally via a range of organisations. Data was collected about palliative care knowledge, experience working with palliative care clients and professional development needs. Data were evaluated by profession, experience and practice setting. In total, 217 respondents answered one or more survey questions (94%). Respondents (65%) reported seeing >15 palliative care clients per month with 84% seen in hospital and community settings. Undergraduate education underprepared or partially prepared allied health professionals to work with these clients (96%) and 67% identified the need for further education. Access to postgraduate professional development was limited by available backfill and funding. Study findings support the importance of free, accessible, relevant educational and professional development resources to support clinical practice. This is particularly relevant for allied health professionals who have limited opportunities to attend formal professional development sessions.

Rural competencies in emerging medical practitioners: Beyond clinical skills

PROBLEM

Recruitment and retention of rural doctors remains a challenge in Australia. The Queensland Rural Generalist Program was developed to address this challenge and provides a range of tailored professional development opportunities to support rural medical training, recruitment and retention. The Rural Generalist Vocational Preparation Workshop was developed to maintain connection with trainees during a known attrition risk period and address a gap in training that focused on competencies required for rural practice.

DESIGN

The Rural Generalist Vocational Preparation Workshop, designed using adult learning principles, includes an optimal balance between theory, scenario-based learning and facilitated group discussions. A cross-sectional survey design was employed to evaluate the workshops delivered between 2015 and 2017.

SETTING

The workshops were attended by Queensland Rural Generalist Program trainees in the year prior to undertaking a vocational training position in a rural hospital or general practice. Participants were from 10 Hospital and Health Services in the Queensland public health sector at the time of attendance.

KEY MEASURES FOR IMPROVEMENT

An evaluation survey captured participant feedback about the workshop, its value, impact and their intention to implement changes in practice.

STRATEGIES FOR CHANGE

Fifty-one trainees attended the workshops across four locations.

EFFECTS OF CHANGE

Eight-eight per cent of participants reported intentions to implement changes to practice in: pursuit of career options and enhanced team work, leadership skills and networking.

LESSONS LEARNT

Evaluation results indicated that Rural Generalist Vocational Preparation Workshop was a highly valued opportunity. It provided future rural medical practitioners with professional support and networking opportunities, promoted identity formation and stimulated rural career planning.

Internal Structure Analysis of a Tobacco Control Network on the U.S.-México Border

Tobacco control (TC) networks (in which multiple agencies collaborate) are essential components within comprehensive TC efforts. The aim of this study was to assess the internal coalition outcomes hierarchy model (via the Internal Coalition Effectiveness [ICE] scale) in the present sample. Participants (members of a TC Network on the U.S.-México border; independent Waves 1 [N = 30] and 2 [N = 33; at a 1-year subsequent assessment]) completed a background questionnaire and an adapted version of the ICE scale. Mean values for ICE subscales suggested a strong enthusiasm of Network members and recognition of the importance of a cohesive social vision, employment of efficient practices, a need for improved and maintained knowledge/training, and stable social relationships among members. However, no significant differences were observed between data waves in the ICE subscales, multivariate analysis of variance: λ = .97, F(4, 43) = 0.31, p > .86. Considering a multifaceted assessment may enhance the understanding of the dynamics and strengths of the Network. Finally, including an assessment of the leadership's perspective regarding internal coalition outcome hierarchy model constructs to compare them with members' perspective is warranted.

Is the National Registration website (Australian Health Practitioner Regulation Agency) effective in tracking Australian medical graduates' rural work?

OBJECTIVE

This study compared rural location identified through the National Registration (AHPRA) registry with location obtained through labour-intensive personal contact.

DESIGN

Longitudinal cohort study with two methods to identify the work locations of medical graduates from The Rural Clinical School of Western Australia (RCSWA).

PARTICIPANTS

Consenting alumni from the University of Western Australia and the University of Notre Dame Fremantle participating in RCSWA between 2002 and 2009 inclusive and available to contact in 2011.

MAIN OUTCOME MEASURE

Percentage location matches between two contact methods.

RESULTS

There was 80% agreement for principal suburb, 92% agreement for principal city and 94% agreement for principal state between RCSWA personal contact and the AHPRA registry. AHPRA identified nearly two times as many graduate locations. However, there was only 31% agreement for a rural placement location (of any length). In more detail, for year-long rural placement, personal contact was 88% concordant with AHPRA; work six months or more were less concordant (44% agreement); work less than six months were not concordant (4% agreement).

CONCLUSIONS

AHPRA data matched RCSWA alumni data only for graduates in full-time rural work. Since medical alumni spend up to 10 years in pre-vocational and vocational training, which includes many rural options, personal contact was able to pick up the myriad of rural choices, whereas the AHPRA database was not sensitive enough to identify them. Until graduates have stably finished training, the optimal method to identify rural work is through personal contact but statistical correction for missing data needs to be considered.

Getting the news

Modern medical care is a 2-edged sword. Technical advances have improved our ability to diagnosis and treat disease, but they can also create a frightening, painful and bewildering environment for the patient seeking care. In this essay, the author shares his recent encounter with a life-threatening disease, emphasizing the unique contributions of the family physician to patient care, and pointing out some of the pitfalls of new communication tools such as e-mail.