Facing uncertainty - Pilot testing of a palliative prognostic index training with hospital aged care assessment teams

BACKGROUND

Prognostic avoidance can delay discussions about older hospital patients' life expectancy. This pilot study examined the effects of a prognostic training program on hospital clinicians' knowledge and confidence in identifying older patients at risk of dying.

METHODS

Fifty-seven clinicians from aged care assessment teams at two Australian hospitals were introduced to the Palliative Prognostic Index, a 5-item checklist indicating prognoses between 3 and 6 weeks. Mixed-methods training evaluation included pre-post-training surveys and semi-structured interviews, conducted three months post-training.

RESULTS

Clinicians used a combination of experience, knowledge, and intuition as strategies to generate prognoses. Allied health staff relied on intuition more often than medical and nursing staff. Prognostic tools were rarely used. Pre-post-training comparisons showed significant improvements in clinicians' knowledge and confidence in identifying signs of dying, particularly amongst allied health. Follow-up interviews highlighted advantages and challenges of using prognostic tools. Recommendations are made for addressing these.

Nurse-led supportive Coordinated Transitional Care (CTraC) program improves care for veterans with serious illness

BACKGROUND

The Coordinated Transitional Care (CTraC) program is a telephone-based, nurse-driven program shown to decrease readmissions. The aim of this project was to implement and evaluate an adapted version of CTraC, Supportive CTraC, to improve the quality of transitional and end-of-life care for veterans with serious illness.

METHODS

We used the Replicating Effective Programs framework to guide adaptation and implementation. An RN nurse case manager (NCM) with experience in geriatrics and palliative care worked closely with inpatient and outpatient care teams to coordinate care. Eligible patients had a life-limiting diagnosis with substantial functional impairment and were not enrolled in hospice. The NCM identified veterans at VA Boston Healthcare System during an acute admission and delivered a protocolized intervention to define care needs and preferences, align care with patient values, optimize discharge plans, and provide ongoing, intensive phone-based case management. To evaluate efficacy, we matched each Supportive CTraC enrollee 1:1 to a contemporary comparison subject by age, risk of death or hospitalization, and discharge diagnosis. We used Kaplan-Meier plots and Cox-Proportional Hazards models to evaluate outcomes. Outcomes included palliative and hospice care use, acute care use, Massachusetts Medical Orders for Life Sustaining Treatment documentation, and survival.

RESULTS

The NCM enrolled 104 veterans with high protocol fidelity. Over 1.5 years of follow-up, Supportive CTraC enrollees were 61% more likely to enroll in hospice than the comparison group (n = 57 vs. 39; HR = 1.61; 95% CI = 1.07-2.43). While overall acute care use was similar between groups, Supportive CTraC patients had fewer ICU admissions (n = 36 vs. 53; p = 0.005), were more likely to die in hospice (53 vs. 34; p = 0.008), and twice as likely to die at home with hospice (32.0 vs. 15.5; p = 0.02). There was no difference in survival between groups.

CONCLUSIONS

A nurse-driven transitional care program for veterans with serious illness is feasible and effective at improving end-of-life outcomes.

STS-1 and STS-2, Multi-Enzyme Proteins Equipped to Mediate Protein-Protein Interactions

STS-1 and STS-2 form a small family of proteins that are involved in the regulation of signal transduction by protein-tyrosine kinases. Both proteins are composed of a UBA domain, an esterase domain, an SH3 domain, and a PGM domain. They use their UBA and SH3 domains to modify or rearrange protein-protein interactions and their PGM domain to catalyze protein-tyrosine dephosphorylation. In this manuscript, we discuss the various proteins that have been found to interact with STS-1 or STS-2 and describe the experiments used to uncover their interactions.

The ostrich approach - Prognostic avoidance, strategies and barriers to assessing older hospital patients' risk of dying

BACKGROUND

Predicting older patients' life expectancy is an important yet challenging task. Hospital aged care assessment teams advise treating teams on older patients' type and place of care, directly affecting quality of care. Yet, little is known about their experiences with prognostication.

METHODS

Twenty semi-structured interviews were conducted with seven geriatricians/ registrars, ten nurses and three allied health staff from aged care assessment teams across two hospitals in Melbourne, Australia. Data were analysed thematically.

RESULTS

To generate prognoses, clinicians used analytical thinking, intuition, assessments from others, and pattern matching. Prognostic tools were an underutilised resource. Barriers to recognition of dying included: diffusion of responsibility regarding whose role it is to identify patients at end-of-life; lack of feedback about whether a prognosis was correct; system pressures to pursue active treatment and vacate beds; avoidance of end-of-life discussions; lack of confidence, knowledge and training in prognostication and pandemic-related challenges.

Non-beneficial resuscitation during in-hospital cardiac arrests in a metropolitan teaching hospital

PURPOSE

To describe the prevalence of non-beneficial resuscitation attempts in hospitalised patients and identify interventions that could be used to reduce these events.

METHODS

A retrospective analysis was conducted of all adult IHCAs receiving cardiopulmonary resuscitation (CPR) in a teaching hospital over nine years. Demographics and arrest characteristics were obtained from a prospectively collected database. Non-beneficial CPR was defined as CPR being administered to patients who had a current not for resuscitation (NFR) order in place or who had an NFR order enacted on a previous hospital admission. Further antecedent factors and resuscitation characteristics were collected for these patients.

RESULTS

There were 257 IHCAs, of which 115 (44.7%) occurred on general wards, with 19.8% of all patients surviving to discharge home. There were 39 (15.2%) instances of non-beneficial CPR of which 28/39 (72%) occurred in unmonitored patients on the ward comprising nearly a quarter (28/115) of all arrests in this patient group. A specialist had reviewed 30/39 (76.9%) of these patients, and 33.3% (13/39) had a medical emergency team (MET) review prior to their arrest.

CONCLUSIONS

Over one in seven resuscitation attempts were non-beneficial. MET reviews and specialist ward rounds provide opportunities to improve the documentation and visibility of NFR status. This article is protected by copyright. All rights reserved.

COVID-19 Pandemic: End of Life Experience in Australian Residential Aged Care Facilities

Background

The COVID‐19 pandemic has significantly impacted those in residential aged care facilities (RACF). This research was undertaken to explore and better understand the effects of the pandemic on the experience of next‐of‐kin and carers who encountered the death of a loved one who resided within a RACF during the pandemic.

Aims

To explore end‐of‐life experiences for residents who die in RACF and their next‐of‐kin/carers during the COVID‐19 pandemic, to identify areas of concern and areas for improvement.

Methods

Prospective single‐centre mixed methods research was undertaken involving telephone interview with next‐of‐kin or carers of residents who died within 30 days of being referred to Austin Health Residential InReach Service during the ‘second wave’ of COVID‐19 in Melbourne, Australia, in 2020. Qualitative and quantitative data were collected. Qualitative description and aspects of grounded theory were used for analysing qualitative data. Thematic analysis of the interview transcripts used open and axial coding to identify initial themes and then to group these under major themes.

Results

Forty‐one telephone interviews were analysed. Major themes identified included: COVID‐19 pandemic, communication and technology, death and dying experience, bereavement and grief, and social supports and external systems.

Conclusions

Findings identify the many COVID‐19 pandemic‐related challenges faced by participants and their dying loved one in RACF. Access to palliative care and bereavement support is crucial for dying residents and for grieving that has been made more difficult by the pandemic.

Support for and willingness to be involved in voluntary assisted dying: A multisite, cross-sectional survey study of clinicians in Victoria, Australia

CONTEXT

In the Australian state of Victoria, specialist doctors are central to the operation of Voluntary Assisted Dying (VAD). However, a broad range of clinicians may be involved in the care of patients requesting or using VAD.

OBJECTIVES

To conduct a multisite, cross-sectional survey of clinicians in seven Victorian hospitals, to describe levels of support for and willingness to be involved in VAD and consider factors associated with clinician support for the VAD legislation and physicians' willingness to provide VAD in practice.

METHODS

All clinicians were invited to complete an online survey measuring demographic characteristics, awareness of and support for the VAD legislation, willingness to participate in VAD related activities, and reasons for willingness or unwillingness to participate in VAD.

RESULTS

Of 5690 who opened the survey, 5159 (90.1%) were included in the final sample and 73% (n=3768) supported the VAD legislation. The strongest predictor of support for the VAD legislation was clinical role. Forty percent (n=238) of medical specialists indicated they would be willing to participate in either the VAD consulting or coordinating role. Doctors did not differ in willingness between high impact (44%) and low impact specialty (41%), however, doctors specializing in palliative care or geriatric medicine were significantly less willing to participate (27%).

CONCLUSION

Approximately 73% of surveyed staff supported Victoria's VAD legislation. However, only a minority of medical specialists reported willingness to participate in VAD, suggesting potential access issues for patients requesting VAD in accordance with the legal requirements in Victoria. This article is protected by copyright. All rights reserved.

Front-Line innovation: Rapid implementation of a nurse-driven protocol for care of outpatients with COVID-19

Aims and objectives

Our objective was to rapidly adapt and scale a registered nurse‐driven Coordinated Transitional Care (C‐TraC) programme to provide intensive home monitoring and optimise care for outpatient Veterans with COVID‐19 in a large urban Unites States healthcare system.

Background

Our diffuse primary care network had no existing model of care by which to provide coordinated result tracking and monitoring of outpatients with COVID‐19.

Design

Quality improvement implementation project.

Methods

We used the Replicating Effective Programs model to guide implementation, iterative Plan‐Do‐Study‐Act cycles and SQUIRE reporting guidelines. Two transitional care registered nurses, and a geriatrician medical director developed a protocol that included detailed initial assessment, overnight delivery of monitoring equipment and phone‐based follow‐up tailored to risk level and symptom severity. We tripled programme capacity in time for the surge of cases by training Primary Care registered nurses.

Results

Between 23 March and 15 May 2020, 120 Veterans with COVID‐19 were enrolled for outpatient monitoring; over one‐third were aged 65 years or older, and 70% had medical conditions associated with poor COVID‐19 outcomes. All Veterans received an initial call within a few hours of the laboratory reporting positive results. The mean length of follow‐up was 8.1 days, with an average of 4.2 nurse and 1.3 physician or advanced practice clinician contacts per patient. The majority (85%) were managed entirely in the outpatient setting. After the surge, the model was disseminated to individual primary care teams through educational sessions.

Conclusion

A model based on experienced registered nurses can provide comprehensive, effective and sustainable outpatient monitoring to high‐risk populations with COVID‐19.

Basal ganglia echogenicity in preterm infants: A case series

BACKGROUND

Damage to the basal ganglia and thalamus (BGT) can be caused by multiple perinatal factors and may be associated with movement disorders, cognitive delay and visual difficulties. Changes in BGT structure, seen as echogenicity on ultrasound, are difficult to objectively quantify. The aetiology, clinical relevance and developmental outcomes of BGT echogenicity are poorly understood. We aimed to gain a better understanding of the natural history of BGT echogenicity in a preterm population.

METHODS

Retrospective review of clinical course, neuroimaging and development in infants born <32weeks gestation over 5 years with evidence of BGT echogenicity.

RESULTS

BGT echogenicity was reported in 18/650 infants (2.7%). Echogenicity appeared at a median of 8 days (2-45 days) and resolved on pre-discharge ultrasound in 50%. Thirteen infants had a term corrected MRI brain with abnormal BGT signal seen in 3 infants (23%). All 3 infants had persisting echogenicity on discharge ultrasound. No infant with echogenicity resolution on ultrasound had changes on term MRI. 14 infants had developmental progress available at 1 year corrected. Abnormal development was reported in four children of whom one had BGT changes on term MRI. Two children with persistent BGT changes but an otherwise normal MRI had reported normal neurodevelopment.

CONCLUSION

BGT echogenicity is relatively common on routine ultrasound and resolves in the majority of infants by term corrected. This review suggests that at term corrected, normal cranial ultrasound may obviate the need for MRI where no other concerns exist. BGT echogenicity did not appear to independently influence neurodevelopment.

Care to the end: a retrospective observational study of aged care facility residents transferred to hospital in the last day of life

BACKGROUND

While transfer of aged care facility (ACF) residents to an acute hospital is sometimes necessary, for those at end of life this can cause fragmented care and disruption.

AIM

To explore the characteristics of ACF residents transferred to hospital in the last 24 h of life and factors that might influence this decision, including access to medical review, advance care planning (ACP) and pre-emptive symptom management prescribing, an area not previously researched.

METHODS

A retrospective observational audit of ACF residents transferred to a metropolitan hospital between 2012 and 2017 who died within 24 h of transfer.

RESULTS

A total of 149 patients met the criteria. The median age was 87 years, and 63 (42%) were male. Eighty-three (56%) were transferred 'out-of-hours', the majority (71%) having no medical review in the 24 h prior, and 43 (29%) died within 4 h of arrival. The most common reasons for transfer were dyspnoea (46%) and altered conscious state (32%), and the most common cause of death was pneumonia (37%). Some form of ACP documentation was available in 48%. Of the 86 (58%) patients who required injectable opioid for symptom management in hospital, only 7 (8%) had this pre-emptively prescribed on their ACF medication chart.

CONCLUSIONS

Appropriate decision-making around hospital transfers and end-of-life care for ACF residents may be influenced by access to professionals able to diagnose dying and access to appropriate symptom management medications. ACP is important, but often requires the aforementioned to be enacted. Further research is needed to better inform how we can identify and meet the end-of-life care needs of this cohort.

Detection of first gammaherpesvirus sequences in Central African bats

Herpesviruses have been identified in many species; however, relatively few bat herpesvirus are known, considering the enormous diversity of bats. We used consensus PCR to test bats from the Republic of the Congo and found DNA of two different novel bat herpesviruses. One was detected in a Pipistrellus nanulus, the other in a Triaenops persicus bat and both resemble gammaherpesviruses. On the amino acid level, the amplified sequences differ by 55% from each other, and by 27% and 25% from the next closest known viruses. The findings point towards the diversity of herpesviruses in Central African bats.

'This is uncharted water for all of us': challenges anticipated by hospital clinicians when voluntary assisted dying becomes legal in Victoria

ObjectiveThe aim of this study was to identify the challenges anticipated by clinical staff in two Melbourne health services in relation to the legalisation of voluntary assisted dying in Victoria, Australia. MethodsA qualitative approach was used to investigate perceived challenges for clinicians. Data were collected after the law had passed but before the start date for voluntary assisted dying in Victoria. This work is part of a larger mixed-methods anonymous online survey about Victorian clinicians’ views on voluntary assisted dying. Five open-ended questions were included in order to gather text data from a large number of clinicians in diverse roles. Participants included medical, nursing and allied health staff from two services, one a metropolitan tertiary referral health service (Service 1) and the other a major metropolitan health service (Service 2). The data were analysed thematically using qualitative description. ResultsIn all, 1086 staff provided responses to one or more qualitative questions: 774 from Service 1 and 312 from Service 2. Clinicians anticipated a range of challenges, which included burdens for staff, such as emotional toll, workload and increased conflict with colleagues, patients and families. Challenges regarding organisational culture, the logistics of delivering voluntary assisted dying under the specific Victorian law and how voluntary assisted dying would fit within the hospital’s overall work were also raised. ConclusionsThe legalisation of voluntary assisted dying is anticipated to create a range of challenges for all types of clinicians in the hospital setting. Clinicians identified challenges both at the individual and system levels. What is known about the topic?Voluntary assisted dying became legal in Victoria on 19 June 2019 under the Voluntary Assisted Dying Act 2017. However there has been little Victorian data to inform implementation. What does this paper add?Victorian hospital clinicians anticipate challenges at the individual and system levels, and across all clinical disciplines. These challenges include increased conflict, emotional burden and workload. Clinicians report concerns about organisational culture, the logistics of delivering voluntary assisted dying under the specific Victorian law and effects on hospitals’ overall work. What are the implications for practitioners?Careful attention to the breadth of staff affected, alongside appropriate resourcing, will be needed to support clinicians in the context of this legislative change.

'It all depends!': A qualitative study of preferences for place of care and place of death in terminally ill patients and their family caregivers

BACKGROUND

It is often suggested that terminally ill patients favour end-of-life care at home. Yet, it is unclear how these preferences are formed, if the process is similar for patients and family caregivers, and if there are discrepancies between preferences for place of care and place of death. Understanding these nuances is essential to support people in their decision-making and ultimately provide better care at the end-of-life.

AIM

To gain an in-depth understanding of how terminally ill patients and their family caregivers make decisions about preferred place of care and place of death.

DESIGN

Semi-structured interviews with patients and family caregivers, which were analysed thematically using qualitative description.

SETTING/PARTICIPANTS

A total of 17 participants (8 patients and 9 caregivers) recruited from an acute palliative care hospital ward, a sub-acute hospice unit, and a palliative homecare organisation in Melbourne, Australia.

RESULTS

The process of forming location preferences was shaped by uncertainty relating to the illness, the caregiver and the services. Patients and caregivers dealt with this uncertainty on a level of thoughts, emotions, and actions. At the end of this process, patients and caregivers expressed their choices as contextual, personal, relational, conditional and flexible preferences.

CONCLUSIONS

These findings suggest that in many cases end-of-life decision-making does not conclude with a clear and stable choice. Understanding the reasons for the malleability of preferences and the process of how they are formed has implications for both clinicians and researchers.

Goals of patient care system change with video-based education increases rates of advance cardiopulmonary resuscitation decision-making and discussions in hospitalised rehabilitation patients

BACKGROUND

Advance cardiopulmonary resuscitation (CPR) discussions and decision-making are not routine clinical practice in the hospital setting. Frail older patients may be at risk of non-beneficial CPR.

AIM

To assess the utility and safety of two interventions to increase CPR decision-making, documentation and communication for hospitalised older patients.

METHODS

A pre-post study tested two interventions: (i) standard ward-based education forums with CPR content; and (ii) a combined, two-pronged strategy with 'Goals of Patient Care' (GoPC) system change and a structured video-based workshop; against usual practice (i.e. no formal training). Participants were a random sample of patients in a hospital rehabilitation unit. The outcomes were the proportion of patients documented as: (i) not for resuscitation (NFR); and (ii) eligible for rapid response team (RRT) calls, and rates of documented discussions with the patient, family and carer.

RESULTS

When compared with usual practice, patients were more likely to be documented as NFR following the two-pronged intervention (adjusted odds ratio (aOR): 6.4, 95% confidence interval (CI): 3.0; 13.6). Documentation of discussions with patients was also more likely (aOR: 3.3, 95% CI:1.8; 6.2). Characteristics of patients documented NFR were similar between the phases, but were more likely for RRT calls following Phase 3 (P 0.03).

CONCLUSION

An increase in advance CPR decisions occurred following GoPC system change with education. This appears safe as NFR patients had the same level of frailty between phases but were more likely to be eligible for RRT review. Increased documentation of discussions suggests routine use of the GoPC form may improve communication with patients about their care.

Health and death literacy and cultural diversity: insights from hospital-employed interpreters

Objectives

001225The aim of this qualitative study is to better understand, through the experiences and insights of hospital interpreters, how people from culturally and linguistic diverse (CALD) communities might respond to advance care planning (ACP) and end-of-life discussions.

Methods

Hospital interpreters from five Melbourne metropolitan health services were recruited for in-depth semi-structured interviews that explored the question, ‘What can be learnt from hospital interpreters about cultural issues related to ACP and end-of-life decision-making?’ Thirty-nine interpreters, representing 22 language groups, were interviewed. Analysis of the transcribed interviews used qualitative description.

Results

Thematic analysis identified three major themes: (1) moral difference; (2) health and death literacy; and (3) diversity within culture.

Conclusion

A value-based approach to ACP is recommended as a way to capture the person’s individual values and beliefs. Health and death literacy have been identified as areas that may be over-estimated; areas that can be addressed and improved, if recognised. Health and death literacy is a particular area that needs to be assessed and addressed as a pre-requisite to ACP discussions.

Detection and assessment of copy number variation using PacBio long-read and Illumina sequencing in New Zealand dairy cattle

Single nucleotide polymorphisms have been the DNA variant of choice for genomic prediction, largely because of the ease of single nucleotide polymorphism genotype collection. In contrast, structural variants (SV), which include copy number variants (CNV), translocations, insertions, and inversions, have eluded easy detection and characterization, particularly in nonhuman species. However, evidence increasingly shows that SV not only contribute a substantial proportion of genetic variation but also have significant influence on phenotypes. Here we present the discovery of CNV in a prominent New Zealand dairy bull using long-read PacBio (Pacific Biosciences, Menlo Park, CA) sequencing technology and the Sniffles SV discovery tool (version 0.0.1; https://github.com/fritzsedlazeck/Sniffles). The CNV identified from long reads were compared with CNV discovered in the same bull from Illumina sequencing using CNVnator (read depth-based tool; Illumina Inc., San Diego, CA) as a means of validation. Subsequently, further validation was undertaken using whole-genome Illumina sequencing of 556 cattle representing the wider New Zealand dairy cattle population. Very limited overlap was observed in CNV discovered from the 2 sequencing platforms, in part because of the differences in size of CNV detected. Only a few CNV were therefore able to be validated using this approach. However, the ability to use CNVnator to genotype the 557 cattle for copy number across all regions identified as putative CNV allowed a genome-wide assessment of transmission level of copy number based on pedigree. The more highly transmissible a putative CNV region was observed to be, the more likely the distribution of copy number was multimodal across the 557 sequenced animals. Furthermore, visual assessment of highly transmissible CNV regions provided evidence supporting the presence of CNV across the sequenced animals. This transmission-based approach was able to confirm a subset of CNV that segregates in the New Zealand dairy cattle population. Genome-wide identification and validation of CNV is an important step toward their inclusion in genomic selection strategies.

Development of a video-based education and process change intervention to improve advance cardiopulmonary resuscitation decision-making

BACKGROUND

Advance cardiopulmonary resuscitation (CPR) decision-making and escalation of care discussions are variable in routine clinical practice. We aimed to explore physician barriers to advance CPR decision-making in an inpatient hospital setting and develop a pragmatic intervention to support clinicians to undertake and document routine advance care planning discussions.

METHODS

Two focus groups, which involved eight consultants and ten junior doctors, were conducted following a review of the current literature. A subsequent iterative consensus process developed two intervention elements: (i) an updated 'Goals of Patient Care' (GOPC) form and process; (ii) an education video and resources for teaching advance CPR decision-making and communication. A multidisciplinary group of health professionals and policy-makers with experience in systems development, education and research provided critical feedback.

RESULTS

Three key themes emerged from the focus groups and the literature, which identified a structure for the intervention: (i) knowing what to say; (ii) knowing how to say it; (iii) wanting to say it. The themes informed the development of a video to provide education about advance CPR decision-making framework, improving communication and contextualising relevant clinical issues. Critical feedback assisted in refining the video and further guided development and evolution of a medical GOPC approach to discussing and recording medical treatment and advance care plans.

CONCLUSION

Through an iterative process of consultation and review, video-based education and an expanded GOPC form and approach were developed to address physician and systemic barriers to advance CPR decision-making and documentation. Implementation and evaluation across hospital settings is required to examine utility and determine effect on quality of care.

The effect of antenatal magnesium sulfate on left ventricular afterload and myocardial function measured using deformation and rotational mechanics imaging

OBJECTIVE

Assess the effect of antenatal magnesium sulfate (MgSO4) on left ventricular function measured using deformation and rotational mechanics imaging.

STUDY DESIGN

Infants who received MgSO4 were matched for gestation, birth weight and mode of delivery with controls. Echocardiography was carried out on days 1 and 2 to measure left ventricle longitudinal strain (LV LS), twist, untwist rate, ejection fraction (EF), and systemic vascular resistance (SVR).

RESULTS

Thirty-eight infants with a median gestation and birth weight of 27.1 weeks and 923 g were included. On day 1, the MgSO4 group (n=19) had a lower SVR and higher LV LS, EF, twist and untwist rate than the Control group (n=19) (all P<0.05). There were no differences between the groups on day 2.

CONCLUSION

Antenatal MgSO4 administration is associated with a lower SVR and higher myocardial function on day 1 in preterm infants <29 weeks gestation.

The Goals of Patient Care project: implementing a proactive approach to patient-centred decision-making

BACKGROUND

Patients in the later stages of their lives risk being harmed by futile or unwanted interventions if realistic care goals and patient values are not recognised. Doctors have difficulty discussing and informing patients' healthcare goals.

AIMS

To review implementation of a Goals of Patient Care (GOPC) summary in medical inpatients and its applicability in emergency medical response (EMR) situations.

METHODS

Single-centre cross-sectional study of adult medical inpatients and adult inpatients requiring EMR at a Victorian general hospital.

MEASURES

presence and content of GOPC summary, secondary review of decision-making and discussion documentation, patient characteristics; EMR precipitants and outcomes.

RESULTS

GOPC were documented for 82 of 101 patients. One had an existing advance directive, and six had records of a patient-appointed substitute decision-maker. For patients with GOPC, 80 had life-prolonging treatment aims, with a varying degree of treatment limitation in 48. Discussion with patient or substitute decision-maker was evident in 43 cases. GOPC were documented prior to nine of 23 EMR. The EMR triggered a GOPC modification in three instances.

CONCLUSIONS

Introduction of a routine GOPC summary encourages consideration of goals of care for most medical inpatients. Few have pre-existing records of their wishes, and there are opportunities for improvement in this regard. Doctors may still have difficulty determining goals of care, and discussion of GOPC with patients and families may not be clearly documented. Most patients requiring EMR do not have prior GOPC review, and the role of the summary in these situations remains unclear.

Attitudes of Hospital Healthcare Workers towards Influenza Vaccination in a Tertiary Hospital Setting

The rate of uptake of seasonal influenza vaccination worldwide by healthcare workers (HCWs) has been suboptimal. Nationally, uptake among hospital HCWs was less than 20% prior to 2014. Indeed in our hospital following the 2010/2011 influenza season, a significant number of staff chose to have their vaccinations after the usual campaign period. The Occupational Health Department (OHD) undertook a questionnaire survey to determine the reason(s) for their late presentation. This was not anonymised, with a 21.7% participation rate (119 replied out of 548). We found 86(72.3%) HCWs believed influenza to be a serious illness, 84(70.6%) wanted to protect their family members and friends, and 64(53.8%) their patients from the infection. Nevertheless, 77(64.7%) were influenced by the recent media attention on the H1N1 influenza pandemic. We conclude external factors such as the arrival of the H1N1 pandemic continue to play an important role in influencing HCWs' attitudes towards receiving the vaccine.

Sharps injuries in a teaching hospital: changes over a decade

BACKGROUND

Sharps injuries create a high volume of occupational health (OH) workload in the health care setting. The deadline for implementation of the European Sharps Directive was 11 May 2013.

AIMS

To compare the epidemiology of sharps injuries reported in a large Irish teaching hospital in 2008-10 with those reported between 1998 and 2000.

METHODS

We compared data from electronic and paper OH records of sharps injuries reported between 1 January 2008 and 31 December 2010 with those from a previous study of sharps injuries reported between 1 January 1998 and 31 December 2000.

RESULTS

A total of 325 sharps injuries were reported in 2008-10, compared with 332 in 1998-2000 (P = 0.568). Hepatitis B immunity in sharps injury recipients in 2008-10 was 87% compared to 86% in 1998-2000 (P = 0.32). Glove use was reported in 80% of reported injuries in 2008-10 compared with 74% in 1998-2000 (P = 0.32). In 2008-10, 49% of injuries occurred during disposal or following improper disposal of sharps, compared with 42% in 1998-2000.

CONCLUSIONS

There was no significant change in the epidemiology of sharps injuries reported between 2008 and 2010 compared with 1998-2000. Further education in standard precautions, safe disposal of sharps, the use of safety-engineered devices and the benefits of hepatitis B immunization is needed.

Evaluation of spinosad for the oral treatment and control of flea infestations on cats in Europe

METHODS

An ectoparasiticide containing spinosad was evaluated as an oral formulation for cats. Two European laboratory studies and a European multicentre field efficacy and safety study assessed the use of a chewable tablet formulation of spinosad at a dose range of 50-75 mg/kg for treatment and control of flea infestations on cats.

RESULTS

The studies with experimentally infested cats consistently demonstrated persistent activity against Ctenocephalides felis with >98 per cent efficacy at four weeks post-treatment. In the field study with naturally infested client-owned cats from 18 clinics across Germany and Italy, two monthly doses of spinosad were administered; selamectin was the comparator product. Safety was evaluated in 226 cats, each receiving at least one dose of spinosad or selamectin; both products were well tolerated. 113 spinosad-treated cats and 71 selamectin-treated cats showed >97 per cent reductions in geometric mean flea counts within 14 days post-treatment and at 60 days post-treatment efficacy was >98 per cent in both groups. Analysis of success rates showed 96 per cent in spinosad-treated cats compared with 90.9 per cent in selamectin-treated cats at day 60. The spinosad tablets were successfully administered to over 98 percent of cats. These studies indicate that this formulation of spinosad is safe and efficacious for treatment and prevention of flea infestations in cats.

Yarning/Aboriginal storytelling: towards an understanding of an Indigenous perspective and its implications for research practice

There is increasing recognition of Indigenous perspectives from various parts of the world in relation to storytelling, research and its effects on practice. The recent emergence of storytelling or yarning as a research method in Australian Aboriginal and Torres Strait Island studies and other Indigenous peoples of the world is gaining momentum. Narratives, stories, storytelling and yarning are emerging methods in research and has wide ranging potential to shape conventional research discourse making research more meaningful and accessible for researchers. In this paper we argue for the importance of Indigenous research methods and Indigenous method(ology), within collaborative respectful partnerships with non-Indigenous researchers. It is imperative to take these challenging steps together towards better outcomes for Indigenous people and their communities. In the Australian context we as researchers cannot afford to allow the gap between Aboriginal and Torres Strait Islanders and mainstream Australia health outcomes to grow even wider. One such pathway is the inclusion of Aboriginal storytelling or yarning from an Aboriginal and Torres Strait perspective within Indigenous and non-Indigenous research paradigms. Utilising Aboriginal storytelling or yarning will provide deeper understanding; complementing a two-way research paradigm for collaborative research. Furthermore, it has significant social implications for research and clinical practice amongst Indigenous populations; thus complementing the biomedical medical paradigm.

Building Indigenous Australian research capacity

OBJECTIVES

To build individual Indigenous research capacity and strengthen the capability of health research programmes to be culturally and ethically inclusive of Indigenous Australians in public health research.

METHODS

In order to facilitate optimal participation and in recognition of the differing levels of research experience and knowledge held within this community of practice, an inclusive and culturally appropriate mixed methods approach with influences from action research and Indigenous research principles was undertaken.

RESULTS

Over the duration of the project, participants improved their research outcomes as measured by a range of factors including publications, completion of degrees and retention of project members.

CONCLUSIONS

Provision of an Indigenous led, culturally appropriate system of infrastructure and support centred on capacity building is effective in strengthen the inclusion of Indigenous Australians in research.

Clinical model for ethical cardiopulmonary resuscitation decision-making

BACKGROUND

Decisions to withhold cardiopulmonary resuscitation (CPR) for future cardiac arrest continue to be problematic, with a lack of consistency in how doctors approach this decision.

AIMS

To develop a clinical model that can be used in education to improve consistency in CPR decision-making.

METHODS

A qualitative study, using semistructured interviews with a total of 33 senior doctors, junior doctors and nurses from two Melbourne hospitals explored how decisions to withhold CPR are made. Interviews explored: issues arising; how doctors learn to make these decisions; how they deal with disagreement and their experiences of performing CPR. The transcripts were coded and analysed thematically.

RESULTS

Three major themes were identified: CPR as a life-and-death decision; good and bad dying; and trust. The research also defined the two elements to a CPR decision: (i) technical and (ii) ethical.

CONCLUSIONS

Applying ethical principles commonly used in medicine, a model for ethical CPR decision-making has been developed that identifies four patient groups, each with a different discussion aim. This approach simplifies the complexities of the CPR decision, providing a structured way to teach CPR decision-making to doctors and thereby achieve greater consistency in the decisions made.

The Houdini effect--an unusual case of blunt abdominal trauma resulting in perforative appendicitis

We present a unique case of perforative appendicitis that occurred in an adult following blunt abdominal trauma. This case represents the first such reported case from Ireland. It also represents a modern practical example of Laplace's theory of the effect of increased pressure on colonic wall tension leading to localized perforation, and serves to highlight not only the importance in preoperative imaging for blunt abdominal trauma, but also the importance of considering appendiceal perforation.

Evaluation of spinosad for the oral treatment and control of flea infestations on dogs in Europe

The novel ectoparasiticide spinosad is a naturally occurring mixture of spinosyns A and D formed during a fermentation process. The spinosyns are tetracyclic macrolides with a unique ring system. Their mode of action differs from that of other commercially available insecticides. Laboratory and field trials were conducted to evaluate the use of spinosad in a chewable tablet at a dose range of 45 to 70 mg/kg for the treatment and control of flea infestations on dogs in Europe. Laboratory studies with artificially infested dogs confirmed persistent activity against Ctenocephalides felis of higher than 99 per cent at three weeks post-treatment with values of 96.5 to 97.8 per cent at four weeks. Two multicentric field trials with naturally infected client-owned animals in five European countries used selamectin as comparator. Monthly doses were given during the summer when many homes were heavily infested. Households with spinosad-treated dogs showed cumulative benefits with flea burdens reduced by about 97 per cent at 14 and 30 days and by 99.6 per cent at 60 and 90 days. Corresponding figures for selamectin were significantly lower (P<0.05) at all time points: between 88.5 and 91 per cent at 14 and 30 days, then 97.8 and 98.2 per cent at 60 and 90 days. Thus, the performance of spinosad compared favourably with that of the established reference product.