Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system

OBJECTIVES

To compare medication errors identified at audit and via direct observation with medication errors reported to an incident reporting system at paediatric hospitals and to investigate differences in types and severity of errors detected and reported by staff.

METHODS

This is a comparison study at two tertiary referral paediatric hospitals between 2016 and 2020 in Australia. Prescribing errors were identified from a medication chart audit of 7785 patient records. Medication administration errors were identified from a prospective direct observational study of 5137 medication administration doses to 1530 patients. Medication errors reported to the hospitals' incident reporting system were identified and matched with errors identified at audit and observation.

RESULTS

Of 11 302 clinical prescribing errors identified at audit, 3.2 per 1000 errors (95% CI 2.3 to 4.4, n=36) had an incident report. Of 2224 potentially serious prescribing errors from audit, 26.1% (95% CI 24.3 to 27.9, n=580) were detected by staff and 11.2 per 1000 errors (95% CI 7.6 to 16.5, n=25) were reported to the incident system. Although the prescribing error detection rates varied between the two hospitals, there was no difference in incident reporting rates regardless of error severity. Of 40 errors associated with actual patient harm, only 7 (17.5%; 95% CI 8.7% to 31.9%) were detected by staff and 4 (10.0%; 95% CI 4.0% to 23.1%) had an incident report. None of the 2883 clinical medication administration errors observed, including 903 potentially serious errors and 144 errors associated with actual patient harm, had incident reports.

CONCLUSION

Incident reporting data do not provide an accurate reflection of medication errors and related harm to children in hospitals. Failure to detect medication errors is likely to be a significant contributor to low error reporting rates. In an era of electronic health records, new automated approaches to monitor medication safety should be pursued to provide real-time monitoring.

Developing a process to measure actual harm from medication errors in paediatric inpatients: From design to implementation

AIMS

The potential harm associated with medication errors is widely reported, but data on actual harm are limited. When actual harm has been measured, assessment processes are often poorly described, limiting their ability to be reproduced by other studies. Our aim was to design and implement a new process to assess actual harm resulting from medication errors in paediatric inpatient care.

METHODS

Prescribing errors were identified through retrospective medical record reviews (n = 26 369 orders) and medication administration errors through direct observation (n = 5137 administrations) in a tertiary paediatric hospital. All errors were assigned potential harm severity ratings on a 5-point scale. Multidisciplinary panels reviewed case studies for patients assigned the highest three potential severity ratings and determined the following: actual harm occurrence and severity level, plausibility of a link between the error(s) and identified harm(s) and a confidence rating if no harm had occurred.

RESULTS

Multidisciplinary harm panels (n = 28) reviewed 566 case studies (173 prescribing related and 393 administration related) and found evidence of actual harm in 89 (prescribing = 22, administration = 67). Eight cases of serious harm cases were found (prescribing = 1, administration = 7) and no cases of severe harm. The panels were very confident in 65% of cases (n = 302) where no harm was found. Potential and actual harm ratings varied.

CONCLUSIONS

This harm assessment process provides a systematic method for determining actual harm from medication errors. The multidisciplinary nature of the panels was critical in evaluating specific clinical, therapeutic and contextual considerations including care delivery pathways, therapeutic dose ranges and drug-drug and drug-disease interactions.

Risk Factors Associated with Medication Administration Errors in Children: A Prospective Direct Observational Study of Paediatric Inpatients

INTRODUCTION

Limited evidence exists regarding medication administration errors (MAEs) on general paediatric wards or associated risk factors exists.

OBJECTIVE

The aim of this study was to identify nurse, medication, and work-environment factors associated with MAEs among paediatric inpatients.

METHODS

This was a prospective, direct observational study of 298 nurses in a paediatric referral hospital in Sydney, Australia. Trained observers recorded details of 5137 doses prepared and administered to 1530 children between 07:00 h and 22:00 h on weekdays and weekends. Observation data were compared with medication charts to identify errors. Clinical errors, potential severity and actual harm were assessed. Nurse characteristics (e.g. age, sex, experience), medication type (route, high-risk medications, use of solvent/diluent), and work variables (e.g. time of administration, weekday/weekend, use of an electronic medication management system [eMM], presence of a parent/carer) were collected. Multivariable models assessed MAE risk factors for any error, errors by route, potentially serious errors, and errors involving high-risk medication or causing actual harm.

RESULTS

Errors occurred in 37.0% (n = 1899; 95% confidence interval [CI] 35.7-38.3) of administrations, 25.8% (n = 489; 95% CI 23.8-27.9) of which were rated as potentially serious. Intravenous infusions and injections had high error rates (64.7% [n = 514], 95% CI 61.3-68.0; and 77.4% [n = 188], 95% CI 71.7-82.2, respectively). For intravenous injections, 59.7% (95% CI 53.4-65.6) had potentially serious errors. No nurse characteristics were associated with MAEs. Intravenous route, early morning and weekend administrations, patient age ≥ 11 years, oral medications requiring solvents/diluents and eMM use were all significant risk factors. MAEs causing actual harm were 45% lower using an eMM compared with paper charts.

CONCLUSION

Medication error prevention strategies should target intravenous administrations and not neglect older children in hospital. Attention to nurses' work environments, including improved design and integration of medication technologies, is warranted.

Marked variations in medical provider and out-of-pocket costs for radical prostatectomy procedures in Australia

Objectives Unwarranted clinical variations in radical prostatectomy (RP) procedures are frequently reported, yet less attention is given to the variations in associated costs. This issue can further widen disparities in access to care and provoke questions about the overall value of the procedure. The present paper aimed to delve into the disparities in hospital, medical provider and out-of-pocket costs for RP procedures in Australia, discussing plausible causes and potential policy opportunities. Methods A retrospective cohort study using Medibank Private claims data for RP procedures conducted in Australian hospitals between 1 January 2015 and 31 December 2020 was undertaken. Results Considerable variations in both medical provider and out-of-pocket costs were observed across the country, with variations evident between different states or territories. Particularly striking were the discrepancies in the costs charged by medical providers, with a notable contrast between the 10th and 90th percentiles revealing a substantial difference of A$9925. Hospitals in Australia exhibited relatively comparable charges for RP procedures. Conclusions Initiatives such as enhancing transparency regarding individual medical provider costs and implementing fee regulations with healthcare providers may be useful in curbing the variations in RP procedure costs.

Stepped-Wedge Cluster RCT to Assess the Effects of an Electronic Medication System on Medication Administration Errors

Medication errors are a leading cause of preventable harm in hospitals. Electronic medication systems (EMS) have shown success in reducing the risk of prescribing errors, but considerable less evidence is available about whether these systems support a reduction in medication administration errors in paediatrics. Using a stepped wedge cluster randomized controlled trial we investigated changes in medication administration error rates following the introduction of an EMS in a paediatric referral hospital in Sydney, Australia. Direct observations of 284 nurses as they prepared and administered 4555 medication doses was undertaken and observational data compared against patient records to identify administration errors. We found no significant change in administration errors post EMS (adjusted Odds Ratio [aOR] 1.09; 95% CI 0.89-1.32) and no change in rates of potentially serious administration errors (aOR 1.18; 95%CI 0.9-1.56), or those resulting in actual harm (aOR 0.92; 95%CI 0.34-2.46). Errors in administration of medications by some routes increased post EMS. In the first 70 days of EMS use medication administration error rates were largely unchanged.

The Economics of Medication Safety: A Cost-Benefits Analysis Framework for Evaluating an Electronic Medication System

Medication prescribing in paediatrics is complex and compounded by the need to provide age and weight related doses, and errors continue to be problematic. Electronic medication systems (EMS) can reduce errors through dosing calculators and computerised decision support. However, evidence on costs and benefits of these systems is limited, particularly in paediatric hospitals. This paper presents the development of a cost-benefit analysis (CBA) framework to assess the impact of an EMS implementation in a paediatric tertiary hospital. An innovative component of the framework is the incorporation of the impact of the effects of the EMS for both the health system as well as for patients and their wider family networks, allowing a net social benefit assessment. We describe the impact of non-clinical out-of-pocket costs of admission and use discrete choice experiments to measure both medication related harm and the importance of medication safety to families and members of the community.

Designing an Informatics Infrastructure for a National Aged Care Medication Roundtable

In the residential aged care sector medication management has been identified as a major area of concern contributing to poor outcomes and quality of life for residents. Monitoring medication management in residential aged care in Australia has been highly reliant on small, internal audits. The introduction of electronic medication administration systems provides new opportunities to establish improved methods for ongoing, timely and efficient monitoring of a range of medication indicators, made more meaningful by linking medication data with resident characteristics and outcomes. Benchmarking contemporary medication indicators provides a further opportunity for improvement and is most effective when indicator data are adjusted to take account of confounding factors, such as residents' characteristics and health conditions. Roundtables provide a structure for sharing and discussing indicator data in a trusted and supportive environment and encourage the identification of strategies which may be effective in improving medication management. This paper describes a new project to establish, implement and evaluate a National Aged Care Medication Roundtable.

Is there an association between out-of-pocket hospital costs, quality and care outcomes? A systematic review of contemporary evidence

BACKGROUND

Out of pocket (OOP) costs vary substantially by health condition, procedure, provider, and service location. Evidence of whether this variation is associated with indicators of healthcare quality and/or health outcomes is lacking.

METHODS

The current review aimed to explore whether higher OOP costs translate into better healthcare quality and outcomes for patients in inpatient settings. The review also aimed to identify the population and contextual-level determinants of inpatient out-of-pocket costs. A systematic electronic search of five databases: Scopus, Medline, Psych Info, CINAHL and Embase was conducted between January 2000 to October 2022. Study procedures and reporting complied with PRISMA guidelines. The protocol is available at PROSPERO (CRD42022320763).

FINDINGS

A total of nine studies were included in the final review. A variety of quality and health outcomes were examined in the included studies across a range of patient groups and specialities. The scant evidence available and substantial heterogeneity created challenges in establishing the nature of association between OOP costs and healthcare quality and outcomes. Nonetheless, the most consistent finding was no significant association between OOP cost and inpatient quality of care and outcomes.

INTERPRETATION

The review findings overall suggest no beneficial effect of higher OOP costs on inpatient quality of care and health outcomes. Further work is needed to elucidate the determinants of OOP hospital costs.

FUNDING

This study was funded by Medibank Better Health Foundation.

Short- and long-term effects of an electronic medication management system on paediatric prescribing errors

Electronic medication management (eMM) systems are designed to improve safety, but there is little evidence of their effectiveness in paediatrics. This study assesses the short-term (first 70 days of eMM use) and long-term (one-year) effectiveness of an eMM system to reduce prescribing errors, and their potential and actual harm. We use a stepped-wedge cluster randomised controlled trial (SWCRCT) at a paediatric referral hospital, with eight clusters randomised for eMM implementation. We assess long-term effects from an additional random sample of medication orders one-year post-eMM. In the SWCRCT, errors that are potential adverse drug events (ADEs) are assessed for actual harm. The study comprises 35,260 medication orders for 4821 patients. Results show no significant change in overall prescribing error rates in the first 70 days of eMM use (incident rate ratio [IRR] 1.05 [95%CI 0.92-1.21], but a 62% increase (IRR 1.62 [95%CI 1.28-2.04]) in potential ADEs suggesting immediate risks to safety. One-year post-eMM, errors decline by 36% (IRR 0.64 [95%CI 0.56-0.72]) and high-risk medication errors decrease by 33% (IRR 0.67 [95%CI 0.51-0.88]) compared to pre-eMM. In all periods, dose error rates are more than double that of other error types. Few errors are associated with actual harm, but 71% [95%CI 50-86%] of patients with harm experienced a dose error. In the short-term, eMM implementation shows no improvement in error rates, and an increase in some errors. A year after eMM error rates significantly decline suggesting long-term benefits. eMM optimisation should focus on reducing dose errors due to their high frequency and capacity to cause harm.

Compression Therapy Is Cost-Saving in the Prevention of Lower Limb Recurrent Cellulitis in Patients with Chronic Edema

Background: Cellulitis is a common and often recurrent infection that causes substantial financial burden and morbidity. Compression therapy reduces the risk of recurrent cellulitis episodes for adults with chronic edema; however, little is known about the cost-effectiveness of the intervention. Methods and Results: A cost analysis was undertaken during a randomized controlled trial (RCT) involving 84 participants with lower limb chronic edema and a history of recurrent cellulitis. The intervention group received compression therapy and education, while the control group received education only. A clinical audit and survey were used to measure health service and patient resource use for (1) the most recent episode of cellulitis, and (2) compression therapy over 18 months. Australian reference costs were used to calculate cellulitis and compression therapy costs, and the mean expenditure in both the RCT groups. Of the 84 RCT participants, 43 were surveyed and audited on the cost of cellulitis, and 40 on the cost of compression therapy. The mean cost of a hospitalized and nonhospitalized episode of cellulitis was $9071 and $506 from a health service perspective, and $4496 and $1320 from a patient perspective. The mean cost of compression therapy per participant over 18 months was $1905 and $421 from health service and patient perspectives, respectively. During the RCT, the mean annual cost per participant was $4972 in the experimental group and $26,382 in the control group, giving a cost-saving of $21,483 (95% confidence interval, 3136-48,176) per participant. Conclusion: For patients with lower limb chronic edema and recurrent cellulitis, compression therapy is both efficacious and cost-saving. Trial Registration: ACTRN12617000412336.

Decisions and Dilemmas: The Context of Prioritization Dilemmas and Influences on Staff Members' Prioritization Decisions in Residential Aged Care

Staff members in residential aged care facilities (RACFs) make prioritization decisions to determine which aspects of care are most important and thus should be attended to first. Prioritization can potentially result in substandard care if lower priority tasks are delayed or left undone, known as "missed care." This study investigated the contexts in which prioritization dilemmas arise in RACFs and the influences on prioritization decision-making. Thirty-two staff members participated in a think-aloud task during a prioritization activity, a demographic questionnaire, a post-sorting interview, and a semi-structured interview. Data were analyzed using inductive content analysis. Prioritization dilemmas occurred in response to high workloads, inadequate staffing, unexpected events, and conflicting demands. Seven influences on prioritization decision-making were identified. In some instances, these influences were seen to be in conflict, making prioritization decision-making challenging. Efforts to prevent missed care should consider the influences on staff members' decision-making and aim to reduce prioritization dilemmas.

Unfinished Care in Residential Aged Care Facilities: An Integrative Review

BACKGROUND AND OBJECTIVES

When workload demands are greater than available time and resources, staff members must prioritize care by degree of importance and urgency. Care tasks assigned a lower priority may be missed, rationed, or delayed; collectively referred to as "unfinished care." Residential aged care facilities (RACFs) are susceptible to unfinished care due to consumers' complex needs, workforce composition, and constraints placed on resource availability. The objectives of this integrative review were to investigate the current state of knowledge of unfinished care in RACFs and to identify knowledge gaps.

RESEARCH DESIGN AND METHODS

We conducted a search of academic databases and included English-language, peer-reviewed, empirical journal articles that discussed unfinished care in RACFs. Data were synthesized using mind mapping techniques and frequency counts, resulting in two categorization frameworks.

RESULTS

We identified 17 core studies and 27 informing studies (n = 44). Across core studies, 32 types of unfinished care were organized under five categories: personal care, mobility, person-centeredness, medical and health care, and general care processes. We classified 50 factors associated with unfinished care under seven categories: staff member characteristics, staff member well-being, resident characteristics, interactions, resources, the work environment, and delivery of care activities.

DISCUSSION AND IMPLICATIONS

This review signifies that unfinished care in RACFs is a diverse concept in terms of types of unfinished care, associated factors, and terminology. Our findings suggest that policymakers and providers could reduce unfinished care by focusing on modifiable factors such as staffing levels. Four key knowledge gaps were identified to direct future research.

Home-based, tailored intervention for reducing falls after stroke (FAST): Protocol for a randomized trial

RATIONALE

People with stroke experience falls at more than twice the rate of the general older population resulting in high fall-related injuries. However, there are currently no effective interventions that prevent falls after stroke.

AIMS

To determine the effect and cost-benefit of an innovative, home-based, tailored intervention to reduce falls after stroke.

SAMPLE SIZE ESTIMATE

A total of 370 participants will be recruited in order to be able to detect a clinically important between-group difference of a 30% lower rate of falls with 80% power at a two-tailed significance level of 0.05.

METHODS AND DESIGN

Falls after stroke trial (FAST) is a multistate, Phase III randomized trial with concealed allocation, blinded assessment, and intention-to-treat analysis. Ambulatory stroke survivors within five years of stroke who have been discharged from formal rehabilitation to the community and who have no significant language impairment will be randomly allocated to receive habit-forming exercise, home safety, and community mobility training or usual care.

STUDY OUTCOMES

The primary outcome is the rate of falls over the previous 12 months. Secondary outcomes are the risk of falling (proportion of fallers), community participation, self-efficacy, balance, mobility, physical activity, depression, and health-related quality of life. Health care utilization will be collected retrospectively at baseline and prospectively to 6 and 12 months.

DISCUSSION

The results of FAST are anticipated to directly influence intervention for stroke survivors in the community.Trial Registration: ANZCTR 12619001114134.

Aged care residents' prioritization of care: A mixed-methods study

Background

Eliciting residents’ priorities for their care is fundamental to delivering person‐centred care in residential aged care facilities (RACFs). Prioritization involves ordering different aspects of care in relation to one another by level of importance. By understanding residents’ priorities, care can be tailored to residents’ needs while considering practical limitations of RACFs.

Objectives

To investigate aged care residents’ prioritization of care.

Design

A mixed‐methods study comprising Q methodology and qualitative methods.

Setting and participants

Thirty‐eight residents living in one of five Australian RACFs.

Method

Participants completed a card–sorting activity using Q methodology in which they ordered 34 aspects of care on a pre‐defined grid by level of importance. Data were analysed using inverted factor analysis to identify factors representing shared viewpoints. Participants also completed a think‐aloud task, demographic questionnaire, post‐sorting interview and semi‐structured interview. Inductive content analysis of qualitative data was conducted to interpret shared viewpoints and to identify influences on prioritization decision making.

Results

Four viewpoints on care prioritization were identified through Q methodology: Maintaining a sense of spirituality and self in residential care; information sharing and family involvement; self‐reliance; and timely access to staff member support. Across the participant sample, residents prioritized being treated with respect, the management of medical conditions, and their independence. Inductive content analysis revealed four influences on prioritization decisions: level of dependency; dynamic needs; indifference; and availability of staff.

Conclusions

Recommendations for providing care that align with residents’ priorities include establishing open communication channels with residents, supporting residents’ independence and enforcing safer staffing ratios.

Implementing large-system, value-based healthcare initiatives: a realist study protocol for seven natural experiments

INTRODUCTION

Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond 'what works' towards more nuanced understanding of 'what tends to work for whom under which circumstances'. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts.

METHODS AND ANALYSIS

This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context-mechanism-outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.

Compression Therapy to Prevent Recurrent Cellulitis of the Leg

BACKGROUND

Chronic edema of the leg is a risk factor for cellulitis. Daily use of compression garments on the leg has been recommended to prevent the recurrence of cellulitis, but there is limited evidence from trials regarding its effectiveness.

METHODS

In this single-center, randomized, nonblinded trial, we assigned participants with chronic edema of the leg and recurrent cellulitis, in a 1:1 ratio, to receive leg compression therapy plus education on cellulitis prevention (compression group) or education alone (control group). Follow-up occurred every 6 months for up to 3 years or until 45 episodes of cellulitis had occurred in the trial. The primary outcome was the recurrence of cellulitis. Participants in the control group who had an episode of cellulitis crossed over to the compression group. Secondary outcomes included cellulitis-related hospital admission and quality-of-life assessments.

RESULTS

A total of 183 patients were screened, and 84 were enrolled; 41 participants were assigned to the compression group, and 43 to the control group. At the time of a planned interim analysis, when 23 episodes of cellulitis had occurred, 6 participants (15%) in the compression group and 17 (40%) in the control group had had an episode of cellulitis (hazard ratio, 0.23; 95% confidence interval [CI], 0.09 to 0.59; P = 0.002; relative risk [post hoc analysis], 0.37; 95% CI, 0.16 to 0.84; P = 0.02), and the trial was stopped for efficacy. A total of 3 participants (7%) in the compression group and 6 (14%) in the control group were hospitalized for cellulitis (hazard ratio, 0.38; 95% CI, 0.09 to 1.59). Most quality-of-life outcomes did not differ between the two groups. No adverse events occurred during the trial.

CONCLUSIONS

In this small, single-center, nonblinded trial involving patients with chronic edema of the leg and cellulitis, compression therapy resulted in a lower incidence of recurrence of cellulitis than conservative treatment. (Funded by Calvary Public Hospital Bruce; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000412336.).

Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients

BACKGROUND

Double-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades. While the practice is widespread, evidence of its effectiveness in reducing errors or harm is scarce.

OBJECTIVES

To measure the association between double-checking, and the occurrence and potential severity of medication administration errors (MAEs); check duration; and factors associated with double-checking adherence.

METHODS

Direct observational study of 298 nurses, administering 5140 medication doses to 1523 patients, across nine wards, in a paediatric hospital. Independent observers recorded details of administrations and double-checking (independent; primed-one nurse shares information which may influence the checking nurse; incomplete; or none) in real time during weekdays and weekends between 07:00 and 22:00. Observational medication data were compared with patients' medical records by a reviewer (blinded to checking-status), to identify MAEs. MAEs were rated for potential severity. Observations included administrations where double-checking was mandated, or optional. Multivariable regression examined the association between double-checking, MAEs and potential severity; and factors associated with policy adherence.

RESULTS

For 3563 administrations double-checking was mandated. Of these, 36 (1·0%) received independent double-checks, 3296 (92·5%) primed and 231 (6·5%) no/incomplete double-checks. For 1577 administrations double-checking was not mandatory, but in 26·3% (n=416) nurses chose to double-check. Where double-checking was mandated there was no significant association between double-checking and MAEs (OR 0·89 (0·65-1·21); p=0·44), or potential MAE severity (OR 0·86 (0·65-1·15); p=0·31). Where double-checking was not mandated, but performed, MAEs were less likely to occur (OR 0·71 (0·54-0·95); p=0·02) and had lower potential severity (OR 0·75 (0·57-0·99); p=0·04). Each double-check took an average of 6·4 min (107 hours/1000 administrations).

CONCLUSIONS

Compliance with mandated double-checking was very high, but rarely independent. Primed double-checking was highly prevalent but compared with single-checking conferred no benefit in terms of reduced errors or severity. Our findings raise questions about if, when and how double-checking policies deliver safety benefits and warrant the considerable resource investments required in modern clinical settings.

Family members' prioritisation of care in residential aged care facilities: A case for individualised care

OBJECTIVES

To investigate family members' prioritisation of care in residential aged care facilities (RACFs).

INTRODUCTION AND BACKGROUND

Family members are often involved in the care of their older relatives even after these relatives transit to a RACF. Understanding family members' priorities regarding care (i.e., what is most important to them) can provide valuable insights into how to better meet residents' needs.

DESIGN

A multisite mixed-methods study comprising qualitative methods and Q methodology. The qualitative component of the study was guided by the COREQ checklist.

METHODS

Participants comprised 27 family members of residents living in one of five participating Australian RACFs. Participants rank-ordered 34 cards, each representing an aspect of care, on a predefined grid from "Least important" (-4) to "Most important" (+4). Participants also engaged in a think-aloud task, demographic questionnaire, post-sorting interview and semi-structured interview. Q data were analysed using inverted factor techniques to identify factors that each represent a portion of shared meaning. Factors were interpreted as viewpoints using data from the think-aloud task and interviews. These data were further analysed using inductive content analysis to reveal influences on prioritisation decision-making.

RESULTS

Three distinct viewpoints were identified through Q methodology: prioritisation of residents' physical needs, maintaining residents' independence, and human connection. Inductive content analysis revealed four influences on prioritisation decision-making: residents' capabilities and support requirements, unmet needs, family bridging the gaps, and family knowledge of residents.

CONCLUSIONS

The study indicated that to meet residents' needs and family members' priorities, individualised approaches to care are warranted. It also demonstrated the vital role family members play in residents' care when needs are not fully met.

RELEVANCE TO CLINICAL PRACTICE

Strategies to improve individualised care in clinical practice include flexibility of routines, supporting family members' involvement in care, workforce training focused on family-staff communication, and safer staffing ratios.

Staff members' prioritisation of care in residential aged care facilities: a Q methodology study

BACKGROUND

When healthcare professionals' workloads are greater than available resources, care activities can be missed, omitted or delayed, potentially leading to adverse patient outcomes. Prioritisation, a precursor to missed care, involves decision-making about the order of care task completion based on perceived importance or urgency. Research on prioritisation and missed care has predominantly focused on acute care settings, which differ from residential aged care facilities in terms of funding, structure, staffing levels, skill mix, and approaches to care. The objective of this study was to investigate how care staff prioritise the care provided to residents living in residential aged care.

METHODS

Thirty-one staff members from five Australian residential aged care facilities engaged in a Q sorting activity by ranking 34 cards representing different care activities on a pre-defined grid from 'Least important' (- 4) to 'Most important' (+ 4). Concurrently, they participated in a think-aloud task, verbalising their decision-making processes. Following sorting, participants completed post-sorting interviews, a demographics questionnaire and semi-structured interviews. Q sort data were analysed using centroid factor analysis and varimax rotation in PQMethod. Factor arrays and data from the think-aloud task, field notes and interviews facilitated interpretation of the resulting factors.

RESULTS

A four-factor solution, representing 22 participants and 62% of study variance, satisfied the selection criteria. The four distinct viewpoints represented by the solution were: 1. Prioritisation of clinical care, 2. Prioritisation of activities of daily living, 3. Humanistic approach to the prioritisation of care, and 4. Holistic approach to the prioritisation of care. Participants' prioritisation decisions were largely influenced by their occupations and perceived role responsibilities. Across the four viewpoints, residents having choices about their care ranked as a lower priority.

CONCLUSIONS

This study has implications for missed care, as it demonstrates how care tasks deemed outside the scope of staff members' defined roles are often considered a lower priority. Our research also shows that, despite policy regulations mandating person-centred care and the respect of residents' preferences, staff members in residential aged care facilities tend to prioritise more task-oriented aspects of care over person-centredness.

Standardising the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC)

Classifying harm associated with a medication error can be time consuming and labour intensive and limited studies undertake this step. There is no standardised process, and few studies that report harm assessment provide adequate methods to allow for study replication. Studies typically mention that a clinical review panel classified patient harm and provide a reference to a classification tool. Moreover, in many studies it is unclear whether potential or actual harm was classified as studies refer only to ‘error severity’. The tools used to categorise the severity of patient harm vary widely across studies and few have been assessed for inter-rater reliability and criterion validity. In this paper, we describe the systematic process we undertook to synthesise the defining elements and strengths, while mitigating the limitations, of existing harm classification tools to derive the Harm Associated with Medication Error Classification (HAMEC). This new tool provides a harm classification for use across clinical and research settings. The provision of an explicit process for its application and guiding category descriptors are designed to reduce the risk of misclassification and produce results that are comparable across studies. As the World Health Organisation embarks on its international safety challenge of reducing medication-related harm by 50%, accompanying methodological advances are required to measure progress.

CMS-01 Genetic testing for familial amyotrophic lateral sclerosis (ALS): insights and challenges

Background: Pathogenic variants in ALS genes are known to be present in up to 70% of familial and 10% of apparently sporadic ALS cases, and can be associated with risks for ALS only, or risks for other neurodegenerative diseases (eg. frontotemporal dementia). While there are no changes to medical management for patients confirmed as pathogenic variant carriers, genetic testing may be important for future drug trials. Confirmation of a pathogenic variant also provides relatives with the opportunity to consider predictive and/or reproductive genetic testing. Genetic counselling is an important aspect of testing decision-making as it enables individuals to make informed decisions about genetic testing while minimising adverse psychological, ethical and legal outcomes. Few studies have explored how individuals decide whether to pursue testing, nor the needs and experiences of familial ALS families.Objective: To identify factors that influence patient and family member decision-making about genetic testing for ALS genes, assess the impact of familial disease on the patient and their family, and identify information and support needs.Methods: In-depth, semi-structured interviews with individuals from Australian ALS families with known pathogenic gene variants explored experiences of familial ALS, and factors that influenced genetic testing decision-making. Interviews were analysed using an inductive approach.Results: Thirty-four individuals from 24 families were interviewed and included patients (n = 4), spouses (n = 4), and asymptomatic at-risk relatives (n = 26). Life stage, experience of disease, costs, research opportunities, and attitudes to familial ALS and/or reproductive options influenced decision-making. Some patients and relatives experienced difficulty gaining accurate information from their health professionals about the costs and implications of genetic counselling or testing, resulting in a reluctance to proceed.Discussion and conclusion: This study provides new insight into the Australian experience of genetic testing and counselling for familial ALS. It highlights the need to work together with other health professionals to ensure the complexities of genetic testing decision-making, and referral pathways are better understood.

Impact of Compression Therapy on Cellulitis (ICTOC) in adults with chronic oedema: a randomised controlled trial protocol

INTRODUCTION

Cellulitis represents a significant burden to patients' quality of life (QOL) and cost to the healthcare system, especially due to its recurrent nature. Chronic oedema is a strong risk factor for both an initial episode of cellulitis and cellulitis recurrence. Expert consensus advises compression therapy to prevent cellulitis recurrence in individuals with chronic oedema, however, there is little supporting evidence. This research aims to determine if the management of chronic oedema using compression therapy effectively delays the recurrence of lower limb cellulitis.

METHODS AND ANALYSIS

A randomised controlled trial with cross-over will be used to assess the impact of compression therapy on clinical outcomes (time to next episode of cellulitis, rate of cellulitis-related hospital presentations, QOL and leg volume). Using concealed allocation, 162 participants will be randomised into the intervention (compression) or control (no compression) group. Randomisation will be stratified by prophylactic antibiotic use. Participants will be followed up at 6 monthly intervals for up to 3 years or until 45 episodes of cellulitis occur across the cohort. Following an episode of recurrent cellulitis, control group participants will cross-over to the intervention group. Survival analysis will be undertaken to assess the primary outcome measure of time to cellulitis recurrence. The hypotheses are that compression therapy to control lower limb chronic oedema will delay recurrent lower limb cellulitis, reduce the rate of associated hospitalisations, minimise affected limb volume and improve the QOL of this population.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the ethics committees of all relevant institutions. Results will be disseminated through relevant peer-reviewed journal articles and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12617000412336; Pre-results. The ICTOC trial is currently in progress. Participant recruitment started in May 2017 and is expected to continue until December 2019.

Is Reclassification of the Oral Contraceptive Pill from Prescription to Pharmacist-Only Cost Effective? Application of an Economic Evaluation Approach to Regulatory Decisions

BACKGROUND AND OBJECTIVE

Unplanned pregnancies can lead to poorer maternal and child health outcomes. The Australian Therapeutic Goods Administration committee rejected reclassifying a range of oral contraceptive pills (OCPs) from prescription to pharmacist-only medicines in 2015, mainly based on safety concerns. Improving access to OCPs may encourage some women to use contraceptives or switch from other contraceptive methods. However, some adverse events may increase and some women may stop using condoms, increasing their risk of sexually transmitted infections. This study aimed to estimate the cost effectiveness of reclassifying OCPs from prescription to pharmacist-only.

PERSPECTIVE

Healthcare system.

SETTING

Australian primary care.

METHODS

A Markov model was used to synthesise data from a variety of sources. The model included all Australian women aged 15-49 years (N = 5,644,701). The time horizon was 35 years. Contraceptive use before reclassification was estimated using data from the Household, Income and Labour Dynamics in Australia (HILDA) survey, while survey data informed use after reclassification. Health outcomes included pregnancies, pregnancy outcomes (live birth, miscarriage, stillbirth, ectopic pregnancy and abortion), sexually transmitted infections, adverse events (venous thromboembolism, depression, myocardial infarction and stroke), ovarian cancer cases and quality-adjusted life-years. Costs included those related to general practitioner and specialist consultations, contraceptives and other medicines, pharmacist time, hospitalisations and adverse events. All costs were reported in 2016 Australian Dollars. A 5% discount rate was applied to health outcomes and costs.

RESULTS

Reclassifying OCPs resulted in 85.70 million quality-adjusted life-years experienced and costs of $46,910.14 million over 35 years, vs. 85.68 million quality-adjusted life-years experienced and costs of $50,274.95 million with OCPs remaining prescription-only. Thus, reclassifying OCPs was more effective and cost saving. However, a sensitivity analysis found that more research on the probability of pregnancy in women not using contraception and not trying to conceive is needed.

CONCLUSION

Reclassifying OCPs is likely to be considered cost effective by Australian decision makers.

Understanding the priorities of residents, family members and care staff in residential aged care using Q methodology: a study protocol

INTRODUCTION

Residential aged care facilities (RACFs) are under increasing pressure to provide high-quality, round the clock care to consumers. However, they are often understaffed and without adequate skill mix and resources. As a result, staff must prioritise care by level of importance, potentially leading to care that is missed, delayed or omitted. To date, the literature on prioritisation and missed care has been dominated by studies involving nursing staff, thereby failing to take into account the complex networks of diverse stakeholders that RACFs comprise. This study aims to investigate the priorities of residents, family members and care staff in order to make comparisons between how care is prioritised in RACFs by the different stakeholder groups.

METHODS AND ANALYSIS

This study comprises a Q sorting activity using Q methodology, a think-aloud task, a demographics questionnaire and semi-structured interview questions. The study will be conducted in five RACFs across NSW and QLD, Australia. Using purposive sampling, the project will recruit up to 33 participants from each of the three participant groups. Data from the Q sorting activity will be analysed using the analytic software PQMethod to identify common factors (shared viewpoints). Data from the think-aloud task and semi-structured interviews questions will be thematically analysed using the Framework Method and NVivo qualitative data analysis software.

ETHICS AND DISSEMINATION

The study has been approved by St Vincent's Health and Aged Care Human Research and Ethics Committee and Macquarie University Human Research Ethics Committee. It is expected that findings from the study will be disseminated: in peer-reviewed journals; as an executive report to participating facilities and a summary sheet to participants; as a thesis to fulfill the requirements of a Doctor of Philosophy; and presented at conferences and seminars.

Cost-Effectiveness of Reclassifying Triptans in Australia: Application of an Economic Evaluation Approach to Regulatory Decisions

BACKGROUND

Migraine is a common, chronic, disabling headache disorder. Triptans, used as an acute treatment for migraine, are available via prescription in Australia. An Australian Therapeutic Goods Administration (TGA) committee rejected reclassifying sumatriptan and zolmitriptan from prescription medicine to pharmacist-only between 2005 and 2009, largely on the basis of concerns about patient risk. Nevertheless, pharmacist-only triptans may reduce migraine duration and free up healthcare resources.

OBJECTIVES

To estimate the cost-effectiveness of reclassifying triptans from prescription-only to pharmacist-only in Australia.

METHODS

The study design included decision-analytic modeling combining data from various sources. Behavior before and after reclassification was estimated using medical practitioner and patient surveys and also administrative data. Health outcomes included migraine frequency and duration as well as adverse events (AEs) discussed by the TGA committee. Efficacy and AEs were estimated using randomized controlled trials and observational studies.

RESULTS

Reclassifying triptans will reduce migraine duration but increase AEs. This will result in 337 quality-adjusted life-years gained at an increased cost of A$5.9 million over 10 years for all Australian adults older than 15 years (19.6 million). The incremental cost-effectiveness ratio was estimated to be A$17 412/quality-adjusted life-year gained.

CONCLUSIONS

The incremental cost-effectiveness ratio is likely to be considered cost-effective by Australian decision makers. Serotonin syndrome, a key concern of the TGA committee, had little impact on the results. Further research is needed regarding pharmacist-only triptan use by migraineurs currently using over-the-counter medicines and by nonmigraineurs, the efficacy of triptans, and the risk of cardiovascular and cerebrovascular AEs and chronic headaches with triptans.

Determinants of health and wellbeing in refractory epilepsy and surgery: The Patient Reported, ImpleMentation sciEnce (PRIME) model

This paper offers a new way of understanding the course of a chronic, neurological condition through a comprehensive model of patient-reported determinants of health and wellbeing: The Patient Reported ImpleMentation sciEnce (PRIME) model is the first model of its kind to be based on patient-driven insights for the design and implementation of initiatives that could improve tertiary, primary, and community healthcare services for patients with refractory epilepsy, and has broad implications for other disorders; PRIME focuses on: patient-reported determinants of health and wellbeing, pathways through care, gaps in treatment and other system delays, patient need and expectation, and barriers and facilitators to high-quality care provision; PRIME highlights that in the context of refractory epilepsy, patients value appropriate, clear, and speedy referrals from primary care practitioners and community neurologists to specialist healthcare professionals based in tertiary epilepsy centers. Many patients also want to share in decisions around treatment and care, and gain a greater understanding of their debilitating disease, so as to find ways to self-manage their illness more effectively and plan for the future. Here, PRIME is presented using refractory epilepsy as the exemplar case, while the model remains flexible, suitable for adaptation to other settings, patient populations, and conditions; PRIME comprises six critical levels: 1) The Individual Patient Model; 2) The Patient Relationships Model; 3) The Patient Care Pathways Model; 4) The Patient Transitions Model; 5) The Pre- and Postintervention Model; and 6) The Comprehensive Patient Model. Each level is dealt with in detail, while Levels 5 and 6 are presented in terms of where the gaps lie in our current knowledge, in particular in relation to patients' journeys through healthcare, system intersections, and individuals adaptive behavior following resective surgery, as well as others' views of the disease, such as family members.

Promoting faster pathways to surgery: a clinical audit of patients with refractory epilepsy

Background

Individuals with epilepsy who cannot be adequately controlled with anti-epileptic drugs, refractory epilepsy, may be suitable for surgical treatment following detailed assessment. This is a complex process and there are concerns over delays in referring refractory epilepsy patients for surgery and subsequent treatment. The aim of this study was to explore the different patient pathways, referral and surgical timeframes, and surgical and medical treatment options for refractory epilepsy patients referred to two Tertiary Epilepsy Clinics in New South Wales, Australia.

Methods

Clinical records were reviewed for 50 patients attending the two clinics, in two large teaching hospitals (25 in Clinic 1; 25 in Clinic 2. A purpose-designed audit tool collected detailed aspects of outpatient consultations and treatment. Patients with refractory epilepsy with their first appointment in 2014 were reviewed for up to six visits until the end of 2016. Data collection included: patient demographics, type of epilepsy, drug management, and assessment for surgery. Outcomes included: decisions regarding surgical and/or medical management, and seizure status following surgery. Patient-reported outcome measures to assess anxiety and depression were collected in Clinic 1 only.

Results

Patient mean age was 38.3 years (SD 13.4), the mean years since diagnosis was 17.3 years (SD 9.8), and 88.0% of patients had a main diagnosis of focal epilepsy. Patients were taking an average of 2.3 (SD 0.9) anti-epileptic drugs at the first clinic visit. A total of 17 (34.0%) patients were referred to the surgical team and 11 (22.0%) underwent a neuro-surgical procedure. The average waiting time between visit 1 to surgical referral was 38.8 weeks (SD 25.1), and between visit 1 and the first post-operative visit was 55.8 weeks (SD 25.0).

Conclusion

The findings confirm international data showing significant waiting times between diagnosis of epilepsy and referral to specialist clinics for surgical assessment and highlight different approaches in each clinic in terms of visit numbers and recorded activities. A standardised pathway and data collection, including patient-reported outcome measures, would provide better evidence for whether promoting earlier referral and assessment for surgery improves the lives of this disease group.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1255-0) contains supplementary material, which is available to authorized users.

Measuring the financial and productivity burden of paediatric hospitalisation on the wider family network

AIM

To estimate the non-medical out-of-pocket costs for families with a child in hospital.

METHODS

This study was a survey of 225 parents of paediatric inpatients on nine wards of an Australian public paediatric teaching hospital on two separate days. Our primary outcomes were the costs associated with: (i) time taken off work to care for the child in hospital; (ii) time off work or contributed by family and friends to care for other dependents; and (iii) travel, meals, accommodation and incidental expenses during the child's stay. Demographic data included postcode (to assess distance, socio-economic status and remoteness), child's age, ward and whether this was their child's first admission.

RESULTS

Mean patient age was 6.5 years (standard deviation 5.2). On an average per patient day basis, parents took 1.12 days off work and spent 0.61 (standard deviation 0.53) nights away from home, with 83.8% of nights away at the child's bedside. Parents spent Australian dollars (AUD)89 per day on travel and AUD36 on meals and accommodation. Total costs (including productivity costs) were AUD589 per patient day. Higher costs per patient day were correlated with living in a more remote area (0.48) and a greater travel distance to the hospital (0.41). A higher number of days off work was correlated (0.69) with number of school days missed.

CONCLUSION

These results demonstrate the considerable time and financial resources expended by families caring for a child in hospital and are important inputs in evaluating health-care interventions that affect risk of hospitalisation and length of stay in paediatric care.

Controlled pre-post, mixed-methods study to determine the effectiveness of a national delirium clinical care standard to improve the diagnosis and care of patients with delirium in Australian hospitals: a protocol

INTRODUCTION

Delirium, an acute confusional state, affects up to 29% of acute inpatients aged 65 years and over. The Australian Delirium Clinical Care Standard (the Standard) contains evidence-based, multicomponent interventions, to identify and reduce delirium. This study aims to: (1) conduct a controlled, before-and-after study to assess the clinical effectiveness of the Standard to improve diagnosis and treatment of delirium; (2) conduct a cost-effectiveness study of implementing the Standard and (3) evaluate the implementation process.

METHODS AND ANALYSIS

The study will use a controlled, preimplementation and postimplementation mixed-methods study design, including: medical record reviews, activity-based costing analysis and interviews with staff, patients and their family members. The study population will comprise patients 65 years and over, admitted to surgical, medical and intensive care wards in four intervention hospitals and one control hospital. The primary clinical outcome will be the incidence of delirium. Secondary outcomes include: length of stay, severity and duration of delirium, inhospital mortality rates, readmission rates and use of psychotropic drugs. Cost-effectiveness will be evaluated through activity-based costing analysis and outcome data, and the implementation process appraised through the qualitative results.

ETHICS AND DISSEMINATION

Ethics approval has been received for two hospitals. Additional hospitals have been identified and ethics applications will be submitted once the tools in the pilot study have been tested.The results will be submitted for publication in peer-reviewed journals and presented to national and international conferences. Results seminars will provide a quality feedback mechanism for staff and health policy bodies.

Better evidence for earlier assessment and surgical intervention for refractory epilepsy (The BEST study): a mixed methods study protocol

INTRODUCTION

One-third of patients with refractory epilepsy may be candidates for resective surgery, which can lead to positive clinical outcomes if efficiently managed. In Australia, there is currently between a 6-month and 2-year delay for patients who are candidates for respective epilepsy surgery from the point of referral for surgical assessment to the eventual surgical intervention. This is a major challenge for implementation of effective treatment for individuals who could potentially benefit from surgery. This study examines implications of delays following the point of eligibility for surgery, in the assessment and treatment of patients, and the factors causing treatment delays.

METHODS AND ANALYSIS

Mixed methods design: Observations of qualitative consultations, patient and healthcare professional interviews, and health-related quality of life assessments for a group of 10 patients and six healthcare professionals (group 1); quantitative retrospective medical records' reviews examining longitudinal outcomes for 50 patients assessed for, or undergoing, resective surgery between 2014 and 2016 (group 2); retrospective epidemiological study of all individuals hospitalised with a diagnosis of epilepsy in New South Wales (NSW) in the last 5 years (2012-2016; approximately 11 000 hospitalisations per year, total 55 000), examining health services' use and treatment for individuals with epilepsy, including refractory surgery outcomes (group 3).

ETHICS AND DISSEMINATION

Ethical approval has been granted by the North Sydney Local Health District Human Research Ethics Committee (HREC/17/HAWKE/22) and the NSW Population & Health Services Research Ethics Committee (HREC/16/CIPHS/1). Results will be disseminated through publications, reports and conference presentations to patients and families, health professionals and researchers.

How does accreditation influence staff perceptions of quality in residential aged care?

Purpose

Quality of care in the residential aged sector has changed over the past decade. The purpose of this paper is to examine these changes from the perspectives of staff to identify factors influencing quality of residential aged care, and the role and influence of an aged care accreditation programme.

Design/methodology/approach

Focus groups were held with 66 aged care staff from 11 Australian aged care facilities. Data from semi-structured interviews were analysed to capture categories representing participant views.

Findings

Participants reported two factors stimulating change: developments in the aged care regulatory and policy framework, and rising consumer expectations. Four corresponding effects on service quality were identified: increasing complexity of resident care, renewed built environments of aged care facilities, growing focus on resident-centred care and the influence of accreditation on resident quality of life. The accreditation programme was viewed as maintaining minimum standards of quality throughout regulatory and social change, yet was considered to lack capacity of itself to explicitly promote or improve resident quality of life.

Research limitations/implications

For an increasingly complex aged care population, regulatory and societal change has led to a shift in service provision from institutional care models to one that is becoming more responsive to consumer expectations. The capacity of long-established and relatively static accreditation standards to better accommodate changing consumer needs comes into question.

Originality/value

This is the first study to examine the relationship between accreditation and residential aged care service quality from the perspectives of staff, and offers a nuanced view of “quality” in this setting.

Examining challenges to reliability of health service accreditation during a period of healthcare reform in Australia

PURPOSE

Health systems are changing at variable rates. Periods of significant change can create new challenges or amplify existing barriers to accreditation program credibility and reliability. The purpose of this paper is to examine, during the transition to a new Australian accreditation scheme and standards, challenges to health service accreditation survey reliability, the salience of the issues and strategies to manage threats to survey reliability.

DESIGN/METHODOLOGY/APPROACH

Across 2013-2014, a two-phase, multi-method study was conducted, involving five research activities (two questionnaire surveys and three group discussions). This paper reports data from the transcribed group discussions involving 100 participants, which was subject to content and thematic analysis. Participants were accreditation survey coordinators employed by the Australian Council on Healthcare Standards.

FINDINGS

Six significant issues influencing survey reliability were reported: accreditation program governance and philosophy; accrediting agency management of the accreditation process, including the program's framework; survey coordinators; survey team dynamics; individual surveyors; and healthcare organizations' approach to accreditation. A change in governance arrangements promoted reliability with an independent authority and a new set of standards, endorsed by Federal and State governments. However, potential reliability threats were introduced by having multiple accrediting agencies approved to survey against the new national standards. Challenges that existed prior to the reformed system remain.

ORIGINALITY/VALUE

Capturing lessons and challenges from healthcare reforms is necessary if improvements are to be realized. The study provides practical and theoretical strategies to promote reliability in accreditation programs.

Assessing Data Integration and Quality for the Evaluation of Point-of-Care Testing Across Rural and Remote Emergency Departments in Australia

In Australia, New South Wales Health Pathology's implementation of managed Point-of-Care Testing (PoCT) services across rural and remote emergency departments (EDs) has the potential to significantly improve access to results for certain types of pathology laboratory tests and help to deliver timely patient care. The aim of this study was to assess the quality of the datasets, including the integration of PoCT results into clinical systems, as a precursor to the application of an evaluation framework for monitoring the delivery of PoCT services and their impact on patient care. Three datasets, including laboratory, ED presentations and hospital admissions data were extracted from the relevant clinical information systems. Each dataset was assessed on six dimensions: completeness, uniqueness, timeliness, validity, accuracy, and consistency. Data incompleteness was the largest problem. Assessing the PoCT data integration and data quality is a precondition for the evaluation of PoCT and for monitoring and improving service delivery.

Point-of-Care Testing Across Rural and Remote Emergency Departments in Australia: Staff Perceptions of Operational Impact

New South Wales (NSW) Health Pathology is implementing one of the world's largest managed PoCT services across rural and remote Emergency Departments (EDs) in New South Wales, Australia to improve patient access to care. The aim of this qualitative study was to gain a context-rich understanding of the operational impact of the NSW rollout of PoCT across rural and remote ED settings as experienced by frontline clinical staff. Clinical professionals (n=14) participated in interviews and focus groups in August 2015 at four rural and remote NSW EDs. Participants perceived that PoCT provided greater access to pathology thus facilitating more efficient and effective patient care via faster test turnaround and time to treatment and more effective decisions about the need to transfer patients to appropriate sites when required. These factors have a potentially important role in saving lives. Staff also identified innovative and disruptive challenges to clinical work patterns associated with PoCT implementation, particularly in relation to work flows, resource allocation and the governance arrangements.

Stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce medication errors, adverse drug events and average length of stay at two paediatric hospitals: a study protocol

INTRODUCTION

Medication errors are the most frequent cause of preventable harm in hospitals. Medication management in paediatric patients is particularly complex and consequently potential for harms are greater than in adults. Electronic medication management (eMM) systems are heralded as a highly effective intervention to reduce adverse drug events (ADEs), yet internationally evidence of their effectiveness in paediatric populations is limited. This study will assess the effectiveness of an eMM system to reduce medication errors, ADEs and length of stay (LOS). The study will also investigate system impact on clinical work processes.

METHODS AND ANALYSIS

A stepped-wedge cluster randomised controlled trial (SWCRCT) will measure changes pre-eMM and post-eMM system implementation in prescribing and medication administration error (MAE) rates, potential and actual ADEs, and average LOS. In stage 1, 8 wards within the first paediatric hospital will be randomised to receive the eMM system 1 week apart. In stage 2, the second paediatric hospital will randomise implementation of a modified eMM and outcomes will be assessed. Prescribing errors will be identified through record reviews, and MAEs through direct observation of nurses and record reviews. Actual and potential severity will be assigned. Outcomes will be assessed at the patient-level using mixed models, taking into account correlation of admissions within wards and multiple admissions for the same patient, with adjustment for potential confounders. Interviews and direct observation of clinicians will investigate the effects of the system on workflow. Data from site 1 will be used to develop improvements in the eMM and implemented at site 2, where the SWCRCT design will be repeated (stage 2).

ETHICS AND DISSEMINATION

The research has been approved by the Human Research Ethics Committee of the Sydney Children's Hospitals Network and Macquarie University. Results will be reported through academic journals and seminar and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ANZCTR) 370325.

The impact of national accreditation reform on survey reliability: a 2-year investigation of survey coordinators' perspectives

RATIONALE, AIMS AND OBJECTIVE

Accrediting health care organizations against standards is a recognized safety and quality intervention. The credibility of an accreditation programme relies on surveying reliability. We investigated accreditation survey coordinators' perceptions of reliability issues and their continued relevancy, during a period of national accreditation reform.

METHOD

In 2013 and 2014, questionnaire surveys were developed using survey coordinators' feedback of their experiences and concerns regarding the accreditation process. Each year, a purpose-designed questionnaire survey was administered during the accrediting agency survey coordinator training days.

RESULTS

Participants reported that survey reliability was informed by five categories of issues: the management of the accreditation process, including standards and health care organizational issues; surveyor workforce management; survey coordinator role; survey team; and individual surveyors. A new accreditation system and programme did not alter the factors reported to shape survey reliability. However, across the reform period, there was a noted change within each category of the specific issues that were of concern. Furthermore, consensus between coordinators that existed in 2013 appears to have diminished in 2014. Across all categories, in 2014 there was greater diversity of opinion than in 2013.

CONCLUSIONS

The known challenges to the reliability of an accreditation programme retained their potency and relevancy during a period of reform. The diversity of opinion identified across the coordinator workforce could potentially place the credibility and reliability of the new scheme at risk. The study highlights that reliability of an accreditation scheme is an ongoing achievement, not a one-off attainment.

Counting the costs of accreditation in acute care: an activity-based costing approach

OBJECTIVES

To assess the costs of hospital accreditation in Australia.

DESIGN

Mixed methods design incorporating: stakeholder analysis; survey design and implementation; activity-based costs analysis; and expert panel review.

SETTING

Acute care hospitals accredited by the Australian Council for Health Care Standards.

PARTICIPANTS

Six acute public hospitals across four States.

RESULTS

Accreditation costs varied from 0.03% to 0.60% of total hospital operating costs per year, averaged across the 4-year accreditation cycle. Relatively higher costs were associated with the surveys years and with smaller facilities. At a national level these costs translate to $A36.83 million, equivalent to 0.1% of acute public hospital recurrent expenditure in the 2012 fiscal year.

CONCLUSIONS

This is the first time accreditation costs have been independently evaluated across a wide range of hospitals and highlights the additional cost burden for smaller facilities. A better understanding of the costs allows policymakers to assess alternative accreditation and other quality improvement strategies, and understand their impact across a range of facilities. This methodology can be adapted to assess international accreditation programmes.

Development and application of an indicator assessment tool for measuring health services accreditation programs

Background

Hospital accreditation programs are internationally widespread and consume increasingly scarce health resources. However, we lack tools to consistently identify suitable indicators to assess and monitor accreditation outcomes. We describe the development and validation of such a tool.

Results

Using Australian accreditation standards as our reference point we: reviewed the research evidence for potential indicators; looked for links with existing external indicators; and assessed relevant state and federal policies. We allocated provisional scores, on a five point Likert scale, to the five accountability criteria in the tool: research; accuracy; proximity; no adverse effects; and specificity. An expert panel validated the use of the purpose designed indicator assessment tool. The panel identified hand hygiene compliance rates as a suitable process indicator, and hospital acquired Staphylococcus aureus infection (SAB) rates as an outcome indicator, with the hypothesis that improved hand hygiene compliance rates and lower SAB rates would correlate with accreditation performance.

Conclusions

This new tool can be used to identify, analyse, and compare accreditation indicators. Using infection control indicators such as hand hygiene compliance and SAB rates to measure accreditation effectiveness has merit, and their efficacy can be determined by comparing accreditation scores with indicator outcomes. To verify the tool as a robust instrument, testing is needed in other health service domains, both in Australia and internationally. This tool provides health policy makers with an important means for assessing the accreditation programs which form a critical part of the national patient safety and quality framework.

A hybrid health service accreditation program model incorporating mandated standards and continuous improvement: interview study of multiple stakeholders in Australian health care

The study aim was to investigate the understandings and concerns of stakeholders regarding the evolution of health service accreditation programs in Australia. Stakeholder representatives from programs in the primary, acute and aged care sectors participated in semi-structured interviews. Across 2011-12 there were 47 group and individual interviews involving 258 participants. Interviews lasted, on average, 1 h, and were digitally recorded and transcribed. Transcriptions were analysed using textual referencing software. Four significant issues were considered to have directed the evolution of accreditation programs: altering underlying program philosophies; shifting of program content focus and details; different surveying expectations and experiences and the influence of external contextual factors upon accreditation programs. Three accreditation program models were noted by participants: regulatory compliance; continuous quality improvement and a hybrid model, incorporating elements of these two. Respondents noted the compatibility or incommensurability of the first two models. Participation in a program was reportedly experienced as ranging on a survey continuum from "malicious compliance" to "performance audits" to "quality improvement journeys". Wider contextual factors, in particular, political and community expectations, and associated media reporting, were considered significant influences on the operation and evolution of programs. A hybrid accreditation model was noted to have evolved. The hybrid model promotes minimum standards and continuous quality improvement, through examining the structure and processes of organisations and the outcomes of care. The hybrid model appears to be directing organisational and professional attention to enhance their safety cultures. Copyright © 2015 John Wiley & Sons, Ltd.

Analysing 'big picture' policy reform mechanisms: the Australian health service safety and quality accreditation scheme

BACKGROUND

Agencies promoting national health-care accreditation reform to improve the quality of care and safety of patients are largely working without specific blueprints that can increase the likelihood of success.

OBJECTIVE

This study investigated the development and implementation of the Australian Health Service Safety and Quality Accreditation Scheme and National Safety and Quality Health Service Standards (the Scheme), their expected benefits, and challenges and facilitators to implementation.

METHODS

A multimethod study was conducted using document analysis, observation and interviews. Data sources were eight government reports, 25 h of observation and 34 interviews with 197 diverse stakeholders.

RESULTS

Development of the Scheme was achieved through extensive consultation conducted over a prolonged period, that is, from 2000 onwards. Participants, prior to implementation, believed the Scheme would produce benefits at multiple levels of the health system. The Scheme offered a national framework to promote patient-centred care, allowing organizations to engage and coordinate professionals' quality improvement activities. Significant challenges are apparent, including developing and maintaining stakeholder understanding of the Scheme's requirements. Risks must also be addressed. The standardized application of, and reliable assessment against, the standards must be achieved to maintain credibility with the Scheme. Government employment of effective stakeholder engagement strategies, such as structured consultation processes, was viewed as necessary for successful, sustainable implementation.

CONCLUSION

The Australian experience demonstrates that national accreditation reform can engender widespread stakeholder support, but implementation challenges must be overcome. In particular, the fundamental role of continued stakeholder engagement increases the likelihood that such reforms are taken up and spread across health systems.

Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals

OBJECTIVES

The study aims are twofold. First, to investigate the suitability of hand hygiene as an indicator of accreditation outcomes and, second, to test the hypothesis that hospitals with better accreditation outcomes achieve higher hand hygiene compliance rates.

DESIGN

A retrospective, longitudinal, multisite comparative survey.

SETTING

Acute public hospitals in New South Wales, Australia.

PARTICIPANTS

96 acute hospitals with accreditation survey results from two surveys during 2009-2012 and submitted data for more than four hand hygiene audits between 2010 and 2013.

OUTCOMES

Our primary outcome comprised observational hand hygiene compliance data from eight audits during 2010-2013. The explanatory variables in our multilevel regression model included: accreditation outcomes and scores for the infection control standard; timing of the surveys; and hospital size and activity.

RESULTS

Average hand hygiene compliance rates increased from 67.7% to 80.3% during the study period (2010-2013), with 46.7% of hospitals achieving target compliance rates of 70% in audit 1, versus 92.3% in audit 8. Average hand hygiene rates at small hospitals were 7.8 percentage points (pp) higher than those at the largest hospitals (p<0.05). The association between hand hygiene rates, accreditation outcomes and infection control scores is less clear.

CONCLUSIONS

Our results indicate that accreditation outcomes and hand hygiene audit data are measuring different parts of the quality and safety spectrum. Understanding what is being measured when selecting indicators to assess the impact of accreditation is critical as focusing on accreditation results would discount successful hand hygiene implementation by smaller hospitals. Conversely, relying on hand hygiene results would discount the infection control related research and leadership investment by larger hospitals. Our hypothesis appears to be confounded by an accreditation programme that makes it more difficult for smaller hospitals to achieve high infection control scores.

Stakeholder perspectives on implementing accreditation programs: a qualitative study of enabling factors

BACKGROUND

Accreditation programs are complex, system-wide quality and safety interventions. Despite their international popularity, evidence of their effectiveness is weak and contradictory. This may be due to variable implementation in different contexts. However, there is limited research that informs implementation strategies. We aimed to advance knowledge in this area by identifying factors that enable effective implementation of accreditation programs across different healthcare settings.

METHODS

We conducted 39 focus groups and eight interviews between 2011 and 2012, involving 258 diverse healthcare stakeholders from every Australian State and Territory. Interviews were semi-structured and focused on the aims, implementation and consequences of three prominent accreditation programs in the aged, primary and acute care sectors. Data were thematically analysed to distil and categorise facilitators of effective implementation.

RESULTS

Four factors were identified as critical enablers of effective implementation: the accreditation program is collaborative, valid and uses relevant standards; accreditation is favourably received by health professionals; healthcare organisations are capable of embracing accreditation; and accreditation is appropriately aligned with other regulatory initiatives and supported by relevant incentives.

CONCLUSIONS

Strategic implementation of accreditation programs should target the four factors emerging from this study, which may increase the likelihood of accreditation being implemented successfully.

Health services accreditation: what is the evidence that the benefits justify the costs?

PURPOSE

To identify and analyse research on the use of economic evaluation in health services accreditation.

DATA SOURCES

Seven online health and economic databases, and key accreditation agency and health department websites were searched between June and December 2011.

STUDY SELECTION

The selection criteria were English language and published empirical research studies on the topic of economic evaluation of health service accreditation. No formal economic evaluation of health services accreditation has been carried out to date. Empirical data on costs and benefits were analysed in 6 and 15 studies, respectively. Data extraction Meta-analysis was unsuitable due to output variability. Attributes relating to

STUDY DESIGN

scalability and independence of outcome data were collected. For the benefit studies, we also assessed the strength of claim that accreditation improved patient safety and quality, and sources of potential bias.

RESULTS OF DATA SYNTHESIS

The incremental costs ranged from 0.2 to 1.7% of total costs averaged over the accreditation cycle. The benefit studies were inconclusive in terms of showing clear evidence that accreditation improves patient safety and quality of care.

CONCLUSION

The lack of formal economic appraisal makes it difficult to evaluate accreditation in comparison to other methods to improve patient safety and quality of care. The lack of a clear relationship between accreditation and the outcomes measured in the benefit studies makes it difficult to design and conduct such appraisals without a more robust and explicit understanding of the costs and benefits involved.

Economic evaluation of Australian acute care accreditation (ACCREDIT-CBA (Acute)): study protocol for a mixed-method research project

INTRODUCTION

The Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork-Cost-Benefit Analysis (ACCREDIT-CBA (Acute)) study is designed to determine and make explicit the costs and benefits of Australian acute care accreditation and to determine the effectiveness of acute care accreditation in improving patient safety and quality of care. The cost-benefit analysis framework will be provided in the form of an interactive model for industry partners, health regulators and policy makers, accreditation agencies and acute care service providers.

METHODS AND DESIGN

The study will use a mixed-method approach to identify, quantify and monetise the costs and benefits of accreditation. Surveys, expert panels, focus groups, interviews and primary and secondary data analysis will be used in cross-sectional and case study designs.

ETHICS AND DISSEMINATION

The University of New South Wales Human Research Ethics Committee has approved this project (approval number HREC 10274). The results of the study will be reported via peer-reviewed publications, conferences and seminar resentations and will form part of a doctoral thesis.