Malcolm R Masso

Why patients attend emergency departments for conditions potentially appropriate for primary care: Reasons given by patients and clinicians differ

Objectives:  To compare reasons identified by clinical staff for potential primary care attendances to the ED with those previously identified by patients.

Literature review to identify factors that support implementation of evidence-based practice in residential aged care

The aim was to undertake a review of the literature on change management, quality improvement, evidence-based practice and diffusion of innovations to identify key factors that might influence the uptake and continued use of evidence in residential aged care. The key factors will be used to shape and inform the evaluation of the Encouraging Best Practice in Residential Aged Care Program which commenced in Australia in 2007. MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews were searched using combinations of search terms. Searching focused on existing literature reviews, discussions of relevant conceptual and theoretical frameworks and primary studies that have examined the implementation of evidence-based practice in residential aged care. Keyword searching was supplemented with snowball searching (following up on the references cited in the papers identified by the search), searching by key authors in the field and hand searching of a small number of journals. In general, the period covered by the searches was from 2002 to 2008. The findings from the literature are often equivocal. Analysis and consolidation of factors derived from the literature that might influence the implementation of evidence-based practice resulted in the identification of eight factors: (i) a receptive context for change; (ii) having a model of change to guide implementation; (iii) adequate resources; (iv) staff with the necessary skills; (v) stakeholder engagement, participation and commitment; (vi) the nature of the change in practice; (vii) systems in place to support the use of evidence; and (viii) demonstrable benefits of the change. Most of the literature included in the review is from studies in healthcare and hence the generalisability to residential aged care is largely unknown. However, the focus of this research is on clinical care, within the context of residential aged care, hence the healthcare literature is relevant. The factors are relatively broad and cover the evidence itself, the process of implementation, the context within which evidence will be implemented and the systems and resources to support implementation. It is likely that the factors are not independent of each other. The set of factors will be refined over the course of the evaluation.

Palliative care phase : inter-rater reliability and acceptability in a national study

Background: The concept of palliative care consisting of five distinct, clinically meaningful, phases (stable, unstable, deteriorating, terminal and bereavement) was developed in Australia about 20 years ago and is used routinely for communicating clinical status, care planning, quality improvement and funding. Aim: To test the reliability and acceptability of revised definitions of Palliative Care Phase. Design: Multi-centre cross-sectional study involving pairs of clinicians independently rating patients according to revised definitions of Palliative Care Phase. Setting/participants: Clinicians from 10 Australian palliative care services, including 9 inpatient units and 1 mixed inpatient/community-based service. Results: A total of 102 nursing and medical clinicians participated, undertaking 595 paired assessments of 410 patients, of which 90.7% occurred within 2 h. Clinicians rated 54.8% of patients in the stable phase, 15.8% in the unstable phase, 20.8% in the deteriorating phase and 8.7% in the terminal phase. Overall agreement between clinicians’ rating of Palliative Care Phase was substantial (kappa = 0.67; 95% confidence interval = 0.61–0.70). A moderate level of inter-rater reliability was apparent across all participating sites. The results indicated that Palliative Care Phase was an acceptable measure, with no significant difficulties assigning patients to a Palliative Care Phase and a good fit between assessment of phase and the definition of that phase. The most difficult phase to distinguish from other phases was the deteriorating phase. Conclusion: Policy makers, funders and clinicians can be confident that Palliative Care Phase is a reliable and acceptable measure that can be used for care planning, quality improvement and funding purposes.

The Griffith Area Palliative Care Service (GAPS): an evaluation of an Australian rural palliative care model

Abstract Quantitative and qualitative data, including service utilisation, health records, a provider survey and participant observation, were used to describe the impact of a new model of palliative care on patients, carers and staff in rural Australia. A total of 95 patients were enrolled between October 2001 and February 2003, for an average of 147 days. Deaths per month averaged 3.5. Participating general practitioners were positive about the model. The experiences of 14 patients or carers and 3 people who had cared for a relative with terminal illness prior to the new model were also positive. As one illustration, patients and carers commented that trips to the emergency department prior to the GAPS programme often involved long waiting times and unnecessary investigations and that this had now improved. The elements of the model that worked most effectively were weekly case conferences, the on-call nursing roster, patient-held records and shared protocols and procedures. The model achieved its aim of improving palliative care services and still continues with some modifications. The generalisability of the model is now being tested in eight rural and remote communities across Australia.

Functional Assessment to Predict Capacity for Work in a Population of School‐leavers with Disabilities

This study reports on an assessment system for school‐leavers with disabilities to identify their capacity for work and the type of transition‐to‐work programme best suited to each person. Participants were 1,556 high school students in four cohorts who left school between 1999 and 2002. Each school‐leaver was assessed by rehabilitation counsellors for functional ability and capacity for work. In a supplementary study, the 2002 cohort was assessed by special transition teachers using a short screening tool. The results demonstrate that there is a predictable hierarchy of functional acquisition among school‐leavers with disabilities and that the single best predictor of future capacity for work and need for transition‐to‐work programmes among this group of young people is the capacity to manage activities of daily living. The results also demonstrate that a short screen used by teachers, together with a behavioural assessment, is sufficient to stream school‐leavers with a disability into a range of transition‐to‐work programmes.

Advance care planning in palliative care: a national survey of health professionals and service managers

OBJECTIVE To identify the attitudes, knowledge and practices regarding advance care planning (ACP) in palliative care. METHODS A nationwide online survey was distributed to Australian palliative care services associated with the Palliative Care Outcomes Collaboration (n=105). Seventy-three health professionals (HPs) and 59 service managers completed the survey. RESULTS Regarding ACP, 51% of service managers reported relevant policies and procedures were in place in their service and 44% included ACP in job descriptions. Most HPs were confident in undertaking ACP, including initiating discussions with patients and complying with documents; however, only 44% reported receiving ACP specific training. Although 58% of HPs reported having conversations about ACP with more than 11 patients in the past 6 months, only 44% of managers report that it is offered to most patients. Thirty per cent of HPs were aware of others not adhering to patient wishes in the past 6 months and only 43% of HPs (and 37% of managers) believed ACP is done well within their service. CONCLUSIONS This first national survey examining ACP in palliative care services demonstrates there is a need to improve systems to support ACP and to understand circumstances in which ACP wishes are not followed.

Palliative Care Problem Severity Score: Reliability and acceptability in a national study:

Background: The Palliative Care Problem Severity Score is a clinician-rated tool to assess problem severity in four palliative care domains (pain, other symptoms, psychological/spiritual, family/carer problems) using a 4-point categorical scale (absent, mild, moderate, severe). Aim: To test the reliability and acceptability of the Palliative Care Problem Severity Score. Design: Multi-centre, cross-sectional study involving pairs of clinicians independently rating problem severity using the tool. Setting/participants: Clinicians from 10 Australian palliative care services: 9 inpatient units and 1 mixed inpatient/community-based service. Results: A total of 102 clinicians participated, with almost 600 paired assessments completed for each domain, involving 420 patients. A total of 91% of paired assessments were undertaken within 2 h. Strength of agreement for three of the four domains was moderate: pain (Kappa = 0.42, 95% confidence interval = 0.36 to 0.49); psychological/spiritual (Kappa = 0.48, 95% confidence interval = 0.42 to 0.54); family/carer (Kappa = 0.45, 95% confidence interval = 0.40 to 0.52). Strength of agreement for the remaining domain (other symptoms) was fair (Kappa = 0.38, 95% confidence interval = 0.32 to 0.45). Conclusion: The Palliative Care Problem Severity Score is an acceptable measure, with moderate reliability across three domains. Variability in inter-rater reliability across sites and participant feedback indicate that ongoing education is required to ensure that clinicians understand the purpose of the tool and each of its domains. Raters familiar with the patient they were assessing found it easier to assign problem severity, but this did not improve inter-rater reliability.

Emergency department waiting times: do the raw data tell the whole story?

OBJECTIVE To determine whether there are real differences in emergency department (ED) performance between Australian states and territories. METHODS Cross-sectional analysis of 2009-10 attendances at an ED contributing to the Australian non-admitted patient ED care database. The main outcome measure was difference in waiting time across triage categories. RESULTS There were more than 5.8 million ED attendances. Raw ED waiting times varied by a range of factors including jurisdiction, triage category, geographic location and hospital peer group. All variables were significant in a model designed to test the effect of jurisdiction on ED waiting times, including triage category, hospital peer group, patient socioeconomic status and patient remoteness. When the interaction between triage category and jurisdiction entered the model, it was found to have a significant effect on ED waiting times (P<0.001) and triage was also significant (P<0.001). Jurisdiction was no longer statistically significant (P=0.248 using all triage categories and 0.063 using only Australian Triage Scale 2 and 3). CONCLUSIONS Although the Council of Australian Governments has adopted raw measures for its key ED performance indicators, raw waiting time statistics are misleading. There are no consistent differences in ED waiting times between states and territories after other factors are accounted for. WHAT IS KNOWN ABOUT THE TOPIC? The length of time patients wait to be treated after presenting at an ED is routinely used to measure ED performance. In national health agreements with the federal government, each state and territory in Australia is expected to meet waiting time performance targets for the five ED triage categories. The raw data indicate differences in performance between states and territories. WHAT DOES THIS PAPER ADD? Measuring ED performance using raw data gives misleading results. There are no consistent differences in ED waiting times between the states and territories after other factors are taken into account. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Judgements regarding differences in performance across states and territories for triage waiting times need to take into account the mix of patients and the mix of hospitals.

Assessment of need and capacity to benefit for people with a disability requiring aids, appliances and equipment

AIM To develop an equitable system for allocating equipment, aids and appliances to adults with disabilities based on assessment of need and capacity to benefit for use by occupational therapists, who are the main professional group involved in assessing and prioritising applications. METHODS An assessment tool was developed, pilot tested and field tested at four sites in New South Wales. Assessments were undertaken in parallel with existing systems. Feedback on use of the tool was obtained from those conducting the assessments and those making decisions to fund applications for equipment based on the assessments. RESULTS One hundred and six assessments were undertaken. Applications for bed, sleeping and seating equipment and equipment to assist with mobility, toileting, showering and transfers accounted for 94.2% of equipment requested. Provision of equipment was expected to have greatest impact on the physical effort and safety of carers and the safety and quality of life of applicants. Regression analysis identified assessment items that explain variation between applicants and that can avoid unnecessary data collection. CONCLUSIONS The assessment tool provides a standardised method for assessing requests for equipment based on the twin concepts of need and capacity to benefit. The results support the use of both concepts as the foundation of the assessment process. Further development is required, particularly to move to the next stage of using the assessment tool as the basis for prioritising applications for equipment.

Evolution of a multilevel framework for health program evaluation

A well-conceived evaluation framework increases understanding of a programs goals and objectives, facilitates the identification of outcomes and can be used as a planning tool during program development. Herein we describe the origins and development of an evaluation framework that recognises that implementation is influenced by the setting in which it takes place, the individuals involved and the processes by which implementation is accomplished. The framework includes an evaluation hierarchy that focuses on outcomes for consumers, providers and the care delivery system, and is structured according to six domains: program delivery, impact, sustainability, capacity building, generalisability and dissemination. These components of the evaluation framework fit into a matrix structure, and cells within the matrix are supported by relevant evaluation tools. The development of the framework has been influenced by feedback from various stakeholders, existing knowledge of the evaluators and the literature on health promotion and implementation science. Over the years, the framework has matured and is generic enough to be useful in a wide variety of circumstances, yet specific enough to focus data collection, data analysis and the presentation of findings.