Experiences and impacts of out-of-pocket healthcare expenditure on remote Aboriginal families

INTRODUCTION

Aboriginal Australians face significant health disparities, with hospitalisation rates 2.3 times greater, and longer hospital length of stay, than non-Indigenous Australians. This additional burden impacts families further through out-of-pocket healthcare expenditure (OOPHE), which includes additional healthcare expenses not covered by universal taxpayer insurance. Aboriginal patients traveling from remote locations are likely to be impacted further by OOPHE. The objective of this study was to examine the impacts and burden of OOPHE for rurally based Aboriginal individuals.

METHODS

Participants were recruited through South Australian community networks to participate in this study. Decolonising methods of yarning and deep listening were used to centralise local narratives and language of OOPHE. Qualitative analysis software was used to thematically code transcripts and organise data.

RESULTS

A total of seven yarning sessions were conducted with 10 participants. Seven themes were identified: travel, barriers to health care, personal and social loss, restricted autonomy, financial strain, support initiatives and protective factors. Sleeping rough, selling assets and not attending appointments were used to mitigate or avoid OOPHE. Government initiatives, such as the patient assistance transport scheme, did little to decrease OOPHE burden on participants. Family connections, Indigenous knowledges and engagement with cultural practices were protective against OOPHE burden.

CONCLUSION

Aboriginal families are significantly burdened by OOPHE when needing to travel for health care. Radical change of government initiative and policies through to health professional awareness is needed to ensure equitable healthcare access that does not create additional financial hardship in communities already experiencing economic disadvantage.

Emotional reactions to concepts of racism and white privilege in non-Aboriginal professionals working in remote Aboriginal communities

INTRODUCTION

This research, conducted by a non-Aboriginal, White researcher, examines how health professionals working in remote Aboriginal communities engage with antiracism as instructed by national standards, whether strong emotions are elicited while reflecting on these concepts, and how these reactions impact on antiracist professional practice.

METHODS

Eleven non-Indigenous allied health professionals were interviewed in a semi-structured format. Interviews were transcribed, thematically analysed and compared to existing literature.

RESULTS AND DISCUSSION

Every participant identified overwhelming emotions that they linked to reflecting on racism, White privilege and colonisation. Professionals reported grappling with denial, anger, guilt, shame, fear, anxiety and perfectionism, loss of belonging, disgust and care. They reported that these emotions caused overwhelm, exhaustion, tensions with colleagues and managers, and disengagement from antiracism efforts, and contributed to staff turmoil and turnover.

CONCLUSION

Previously, these emotional reactions and their impact on antiracism have only been described in the context of universities and by antiracist activists. This research identifies for the first time that these reactions also occur in health services in Aboriginal communities. Wider research is needed to better understand how these reactions impact on health service delivery to Aboriginal communities, and to evaluate ways of supporting staff to constructively navigate these reactions and develop antiracist, decolonised professional practice.

A qualitative exploration of the experiences of Aboriginal and Torres Strait Islander people using a real-time video-based telehealth service for diabetes-related foot disease

INTRODUCTION

Diabetes-related foot disease (DFD) is one of the most prevalent causes of global hospitalisation and morbidity, and it accounts for up to 75% of lower-extremity amputations globally. The 5-year mortality rate following any amputation ranges from 53% to 100%. Early identification of wounds and multidisciplinary management can reduce amputation rates by 39-56%. Rural and remote communities and Indigenous populations are disproportionately affected by DFD. This is reflected in amputation rates, which are much higher for Indigenous than for non-Indigenous Australians and for those in very remote areas than for those in major cities or inner regional areas. The large geographical spread of the population in Australia is a substantial barrier for those providing or accessing health services, particularly multidisciplinary and specialist services, which undoubtedly contributes to poorer DFD outcomes in rural and remote communities.

METHODS

A real-time, video-based telehealth service for DFD management was established at the Royal Adelaide Hospital Vascular Services clinic to improve access to specialist services for rural and remote Aboriginal and Torres Strait Islander communities. An exploratory qualitative study that utilised one-on-one, semi-structured interviews was conducted with 11 participants who identified as Aboriginal and who had participated in the telehealth foot service. Interviews were transcribed, de-identified and analysed using thematic analysis, using an inductive approach.

RESULTS

Four interrelated themes emerged. 'Practical benefits of staying home' describes the reduced burden of travel and advantages of having local healthcare providers and support people at consultations. 'Access to specialists and facilities' highlights how some participants felt that there was a lack of appropriate facilities in their area and appreciated the improved access telehealth provided. 'Feeling reassured that a specialist has seen their feet' reflects the positive impact on wellbeing that participants experienced when their feet were seen by specialist health staff. 'Facilitates communication' describes how participants felt included in consultations and how seeing a person on screen assisted conversation.

CONCLUSION

The advantages of real-time, video-based telehealth go beyond reduced travel burden and improved access to specialist care. This model of care may facilitate relationship-building, patient wellbeing, and feelings of trust and safety for Aboriginal and Torres Strait Islander DFD patients.

Nasal high flow therapy in remote hospitals: guideline development using a modified Delphi technique

INTRODUCTION

In remote Australian hospitals there are no onsite paediatric intensive care units (PICUs), increasing the reliance on aeromedical retrieval to access tertiary care. Nasal high flow (NHF) therapy is an oxygen therapy used in tertiary hospitals to treat paediatric patients with respiratory conditions. In rural and remote Queensland, Australia, the use of NHF therapy is inconsistent and there are no guidelines on how this therapy should be implemented in practice. Therefore, three remote hospitals within the Torres Strait and Cape York commenced a project to improve consistent and equitable access to NHF therapy. Implementing NHF therapy in remote hospitals may improve health and social outcomes for children with acute respiratory distress. A clinical guideline for the use of NHF therapy in the three participating remote hospitals was published on 28 October 2021. This study aimed to develop a clinical guideline for the use of NHF therapy in three remote hospitals.

METHODS

A modified Delphi technique was used to develop the guideline. Remote medicine and nursing clinicians at the three study sites, retrieval experts, a receiving tertiary-based paediatrician, PICU specialists and NHF therapy experts made up the expert panel of participants. These experts participated in an iterative round table discussion to develop remote-specific guidelines for the use of NHF therapy. Prior to the meeting, panellists were provided with an executive summary of the current literature on NHF therapy implementation with key questions for consideration. Participants were able to add relevant issues ad hoc. A final guideline representing the panellists' recommendations was submitted to the Torres and Cape Health Service for ratification.

RESULTS

Remote-specific decisions on the following topics were produced: environment of care, nasogastric tube usage, timings of chest X-ray, automatic approvals to arrange courier services for pathology, medication use, staff training; staff ratios, observations regimes, both tertiary and local medical consultation frequency and the experience level of the medical officer required to attend to these consultations, location of the on-call medical officer, documentation, escalation of care considerations and disposition of the patient in relation to retrievals.

DISCUSSION

Decisions were made to mitigate two highly representative remote factors: delays in the workplace practices, such as time to arrange treatment locally and delays in retrievals; and burden of the lack of access to services, such as lack of access to trained staff, staffing levels on-shift, adequate oxygen and equipment/consumable supplies.

CONCLUSION

The aim was to develop a clinical guideline that was contextualised to the remote hospital. This outcome was achieved by using a modified Delphi technique, with a panel of experts providing the decision-making for the guideline. Consistency and safety were addressed by reducing delays in workplace practices; examples were time to arrange treatment locally and mitigate delays in an unknown time to retrievals, access to trained staff, staffing levels, and communication between remote and tertiary teams.

Health and social care needs of people living with dementia: a qualitative study of dementia support in the Victorian region of Gippsland, Australia

INTRODUCTION

There is a lack of information about the experiences of people living with dementia and their carers, especially in rural and regional areas. Understanding these experiences helps to identify gaps and unmet needs within the health system and improve quality of care and outcomes for people living with dementia. The aim of this study was to improve our knowledge of dementia support needs. This included access to health and social care services and supports for people living with dementia and those who provide informal or formal support to someone living with dementia.

METHODS

Interviews were conducted with 26 participants from the Gippsland region of Victoria, Australia with knowledge of dementia care. Purposive sampling engaged people with lived experience, carers/family members and health professionals delivering dementia care and social services. Discussions centred around participants' experiences of support services, the diagnosis process and what they thought was needed to improve the services and supports offered. Thematic analysis of the data was undertaken using the framework method.

RESULTS

The interview data indicated that the needs of many people living with dementia and their carers were not currently being met. The themes were limited access to services and supports, including primary and specialist care, often impacted by lack of knowledge of care options, difficulty navigating the system and funding models as a barrier, leading to delays in getting a diagnosis and accessing specialist services; lack of holistic care to enable people living with dementia to 'live well'; and stigma impacted by a lack of knowledge of dementia among professionals and in the community. Relationship-centred care was described as a way to improve the lives of people living with dementia.

CONCLUSION

Key areas for improvement include increasing community awareness of dementia and available local services, more support to obtain an early dementia diagnosis, increased help to navigate the system, especially immediately after diagnosis, and easier access to appropriate home support services when they are needed. Other recommendations include person-centred care across settings - supported by funding models, more education and communication skills training for health professionals and care staff - and greater support for and increased recognition of carers.

Implementation of telehealth primary health care services in a rural Aboriginal Community-Controlled Health Organisation during the COVID-19 pandemic: a mixed-methods study

INTRODUCTION

Globally, primary care organisations responded rapidly to COVID-19 physical distancing requirements through the adoption of telehealth to maintain the delivery of health care to communities. In Australia, temporary Medicare Benefits Schedule (MBS) telehealth items were introduced in March 2020 to enable the provision of telehealth services in the primary care setting. These changes included funding for two modes of telehealth delivery: videoconferencing and telephone consultations. As primary care organisations, Aboriginal Community Controlled Health Organisations (ACCHOs) rapidly adopted telehealth consultations to maintain the delivery of primary care services to Aboriginal and Torres Strait Islander clients. The aim of the present study was to evaluate the implementation (specifically the uptake, acceptability and requirements for delivery) of telehealth primary healthcare services for Aboriginal and/or Torres Strait Islander peoples by a rural ACCHO during COVID-19.

METHODS

A single-site convergent-parallel mixed-methods study was undertaken in the context of an ongoing research partnership established between a rural ACCHO and a university department of rural health. De-identified health service data from March 2020 to March 2021 was extracted, including MBS telehealth consultations and client demographics (eg age, gender and postcode). Variables were analysed using descriptive statistics to examine the uptake of telehealth by Aboriginal and Torres Strait Islander clients. A geographical analysis of postcode data was also undertaken. Semi-structured interviews were undertaken concurrently with a purposive sample of health service personnel (including health professionals) involved in the implementation or delivery of telehealth, and Aboriginal and/or Torres Strait Islander clients who had accessed telehealth, to explore the acceptability of telehealth and requirements for delivery. Thematic analysis using an inductive approach was undertaken. The analyses of quantitative and qualitative findings were merged to identify key concepts pertaining to the uptake, acceptability and requirements for telehealth delivery.

RESULTS

During the first year of implementation, 435 telehealth primary healthcare consultations were delivered to Aboriginal and/or Torres Strait Islander clients. Seven health personnel and six Aboriginal and/or Torres Strait Islander clients participated in interviews. Merged findings from an analysis of quantitative and qualitative data were grouped under three concepts: uptake of telehealth consultations by Aboriginal and Torres Strait Islander clients, maintaining the delivery of ACCHO services during COVID-19, and implications for sustaining telehealth in an ACCHO. Findings identified that telehealth maintained the delivery of ACCHO services to Aboriginal and/or Torres Strait Islander clients across the lifespan during COVID-19, despite a preference for face-to-face consultations. A greater uptake of telephone consultations compared to videoconferencing was identified. Barriers to the utilisation of videoconferencing were largely technology related, highlighting the need for additional support for clients.

CONCLUSION

Telehealth was a useful addition to face-to-face consultations when used in the appropriate context such as the administration of long-term medication prescriptions by a GP. Engaging the ACCHO sector in the policy discourse around telehealth is imperative for identifying requirements for ongoing implementation.

Building the capacity of rural allied health generalists through online postgraduate education: a qualitative evaluation

INTRODUCTION

Workforce development is a key strategy for building the capacity and capability of a workforce. Accordingly, rural and remote practising allied health professionals require relevant and accessible continuing professional development to enhance their knowledge and skills and improve consumer health outcomes. This study explored the impact of an online postgraduate allied health rural generalist education program, from the perspective of allied health professionals participating in the program and their supervisors and managers.

METHODS

A qualitative, exploratory descriptive study design was employed using semistructured interviews. This study formed the qualitative component of a larger convergent mixed-methods evaluation study aimed at evaluating the reach, quality and impact of an online rural generalist education program for allied health professionals in Australia. Allied health professionals from seven professions enrolled in an online postgraduate rural generalist education program, the rural generalist program (RGP). Their designated work-based supervisors and their managers who were responsible for the operational management of the study sites were invited to participate in the study. All participants were employed in rural and remote health services in 10 sites across four Australian states. Study participants' experience and perceptions of the impact of the RGP on themselves, the healthcare service and the broader community were explored using semistructured interviews. Data were thematically analysed site by site, then across sites using Braun and Clarke's (2012) systematic six-phase approach. Provisional codes were generated and iteratively compared, contrasted and collapsed into secondary, more advanced codes until final themes and subthemes were developed.

RESULTS

Semistructured interviews were conducted with 23 allied health professionals enrolled in the RGP and their 27 work-based supervisors and managers across the 10 study sites. Three final themes were identified that describe the impact of the RGP: building capability as rural generalist allied health professionals; recruiting and building a rural workforce; enhancing healthcare services and consumer outcomes.

CONCLUSION

Allied health professionals working in rural and remote locations valued the RGP because it provided accessible postgraduate education that aligned with their professional and clinical needs. Integrated into a supportive, well-structured development pathway, the experience potentiated learning and facilitated safe clinical practice that met the needs of consumers and organisations. The findings demonstrate that effective work-integrated learning strategies can enhance the development of essential capabilities for rural practice and support early-career allied health professionals' transition to rural and remote practice. These experiences can engage allied health professionals in a way that engenders a desire to remain working in rural and remote contexts.

Aeromedical retrievals as a measure of potentially preventable hospitalisations and cost comparison with provision of GP-led primary health care in a remote Aboriginal community

INTRODUCTION

Kowanyama is a very remote Aboriginal community on the Cape York Peninsula of Far North Queensland, Australia. It is among the five most disadvantaged communities in Australia, with a very high burden of disease. It has access to 2.5 days each week of fly-in, fly-out, GP-led primary health care for a population of 1200. All patients requiring higher level care undergo aeromedical retrieval to a bigger centre. A retrospective clinical audit of charts was undertaken assessing aeromedical retrievals from Kowanyama for the year 2019 to assess whether GP access might correlate with retrievals or hospital admissions for potentially preventable conditions and whether it could be cost-effective and improve outcomes to provide the benchmarked staffing of GPs.

METHODS

Using a tool made by the authors for this audit, the management and reason for evacuation were assessed against Queensland Health's Primary Clinical Care Manual guidelines, whether the presence of a rural generalist GP would have prevented the need for retrieval, and assessed against accepted Australian (and Canadian) criteria for potentially preventable hospital admissions. Each retrieval was then assessed as 'preventable' or 'not preventable'. The cost of providing benchmark levels of GPs in community was compared with the cost of potentially preventable retrievals.

RESULTS

In 2019, there were 89 retrievals of 73 patients. Thirty-nine percent (35) of all retrievals occurred when a doctor was on site. Of preventable retrievals, 33% (18) occurred with a doctor on site and 67% (36) occurred with no doctor on site. All retrievals with a doctor on site resulted in an admission. All immediate discharges (10% (9)) or deaths (1% (1)) were for retrievals without a doctor on site. Sixty-one percent (54) of all retrievals were potentially preventable, with the two most common conditions being pneumonia - non vaccine preventable (18% (9)) and bacterial/unspecified (14% (7)). Thirty-two percent (20) of patients accounted for 52% (46) of retrievals and of these 63% (29) were potentially preventable (compared to 61% overall). For preventable condition retrievals, the mean number of visits to the clinic compared to non-preventable condition retrievals was higher for registered nurse or Aboriginal Health Worker visits (1.24 v 0.93) and lower for doctor visits (0.22 v 0.37). The conservatively calculated costs of retrievals matched the maximum cost of providing benchmark numbers (2.6 full-time equivalents) of rural generalist doctors in a rotating model for the audited community.

CONCLUSION

Greater access to GP-led primary health care may lead to fewer retrievals/hospital admissions for potentially preventable conditions. It is likely that some preventable condition retrievals might be avoided if full coverage with benchmarked numbers of rural generalist GPs in a GP-led primary health team was provided in remote communities. This may be cost-effective and improve patient outcomes, and should be further explored.

The safety of anaesthesia delivered by rural generalist anaesthetists: a scoping review of the literature

INTRODUCTION

Rural generalist anaesthetists (RGAs) are central to the delivery of health care in much of rural and remote Australia. This article details a systematic review of the literature specifically asking the question, 'What is the current evidence of the 'safety' of anaesthesia delivered by RGAs?'

METHODS

Six databases were searched using terms including 'safety', 'rural', 'anaesthetics', 'general practitioners', and associated search terms. Relevant articles were assessed for rigour, and information was summarised using qualitative grid analysis that included information on the study setting, participants, methods, limitations and key result areas. The primary author developed key themes from the data, which were refined in discussion with other authors.

RESULTS

The safety of RGAs was described using five concepts: appropriate training and leadership, rates of complications, volume or scope of practice, access to equipment, and case selection.

CONCLUSION

RGAs are pivotal in the delivery of health care in rural and remote communities. The sparse literature available on RGA safety is broadly grouped into five areas. There is a need to characterise and describe the role of RGAs, review and revise training and education, recognise RGA scope of practice and understand how RGAs lead the management of safety and risk in their practice.

Do dose administration aids support medication adherence for Aboriginal and Torres Strait Islander peoples? An exploration of patients' perspectives, experiences and use on the North Coast of New South Wales

INTRODUCTION

Management of medication regimens and improvement of medication-taking behaviours may require various levels of support, education, engagement and barrier reduction from health services and or pharmacists. The use of dose administration aids (DAAs) may improve medication management for some people, and therefore may facilitate positive health benefits. This Australian study was informed by a literature review that found there was a dearth of data about Aboriginal and Torres Strait Islander peoples' use of DAAs. This study therefore aimed to understand the experiences of Aboriginal and Torres Strait Islander people living on the North Coast of New South Wales with DAAs and if the provision of DAAs supported medication-taking behaviours.

METHODS

A mixed-methods approach that included data collected from a questionnaire and a series of focus groups was used in this study. Analysis was completed at three stages throughout the study.

RESULTS

A total of 30 Aboriginal participants participated in the study. Participants lived in the area ranging from Tweed Heads to Port Macquarie. Twenty-six participants completed the questionnaire and 20 participated in the focus groups; 16 completed both. Participants felt they were managing their medications well. The study noted that, despite this assessment, 45% of focus group participants (9/20) missed taking medications regularly for various reasons. The medication regimens of participants were varied and potentially complex; for example, some participants were taking up to 23 individual doses of oral medications and insulin injections daily as a part of these regimens. Participants described their use of DAAs and how they supported their medication-taking both functionally and financially. Most participants reported that DAAs helped them manage their medications. The weekly or fortnightly provision of DAAs provided regular opportunities for pharmacists to interact with patients and/or their caregivers, supporting improved therapeutic relationships and possibly better health outcomes.

CONCLUSION

DAAs were an important tool for improving medication management for most study participants. DAAs provided affordable and appropriate in-home support for patients to follow prescribed medication regimens. For the participants from this small study who used DAAs and viewed them as an important tool for managing medications, removal of financial subsidies that assist the provision of DAAs to Aboriginal and Torres Strait Islander peoples would have a negative effect on their ability to access them. This in turn may affect their medication-taking behaviours, potentially negatively affecting their long-term health outcomes. Further study regarding the Aboriginal and Torres Strait Islander patient experience of the use of DAAs over a longer period tracking medication adherence, and for a larger cohort of Aboriginal and Torres Strait Islander people, would be beneficial to understanding experience of use of DAAs on a wider scale.

Reflections on an evaluation of the 'Remote Health Experience' - an interprofessional learning, cultural immersion program

INTRODUCTION

Cultural immersion can be an effective method of health professional student cultural learning, and part of interprofessional learning. This evaluation aimed to report the views of staff and Aboriginal and Torres Strait Islander contributors about a cultural immersion program, as well as the student perspective.

METHODS

Semi-structured interviews with staff (11 non-Aboriginal, 3 Aboriginal) and Aboriginal contributors (n=3) were conducted after the 2020 immersion program. Data were collected from 138 student participants following the 2018 (n=45), 2019 (n=33) and 2020 (n=60) remote health experience immersion weekends in Katherine, in the Northern Territory of Australia. Seven staff of the 2020 weekend provided written feedback about their experiences. Qualitative data were analysed thematically, and quantitative results scored from ratings on a five-point scale were presented as means, standard deviations and percentage of respondents agreeing or strongly agreeing with evaluative statements.

RESULTS

Results are presented under the four themes that were identified: (1) understanding remote practice, (2) Aboriginal culture, (3) working together and learning from each other, and (4) ongoing opportunities. Feedback from students and staff was overwhelmingly positive, with learning occurring in each of the intended areas. Relationship building and embedding Aboriginal and Torres Strait Islander culture and knowledge throughout the weekend were seen as invaluable components.

CONCLUSION

The Katherine Remote Health Experience is a valuable, immersive introduction to remote health practice for students from multiple disciplines. As a standalone event it has developed positive relationships, improved knowledge, and encouraged students to consider practising outside of metropolitan areas. There is scope to further develop pathways into remote practice for interested students.

'COVID on Country': an innovative model safely supporting high-risk patients in Central Australia

In January 2022, as the COVID pandemic reached remote communities in Central Australia, The Northern Territory Health Central Australian Regional Health Service and the Royal Flying Doctor Service (RFDS) executed 'COVID on Country', a program designed to triage cases and to implement treatment and clinical review of individuals in their community without the need to be relocated to larger centres for safe provision of care. The program assessed patient factors and community/capacity factors to triage and enact pathways. Remote living people who qualified for the program or who declined aeromedical retrieval, were provided with comprehensive clinical support, including administration of intravenous sotrovimab by daily scheduled visits to all affected communities by a doctor transported on an RFDS plane. Evaluation of the program demonstrated that it was a safe and effective way to provide complex care in a culturally safe manner.

Seeking to improve access to COVID-19 therapeutics in the remote Torres and Cape communities of Far North Queensland during the first COVID-19 omicron outbreak

INTRODUCTION

The first outbreak of the omicron variant of COVID-19 in the Torres and Cape region of Far North Queensland in Australia was declared in late December 2021. A COVID-19 Care at Home program was created to support the health and non-health needs of people with COVID-19 and their families throughout the mandatory isolation periods and included centralising the coordination and delivery of COVID-19 therapeutics. The therapeutics available included one intravenous monoclonal antibody (sotrovimab) and two oral antiviral therapies: nirmatrelvir and ritonavir (Paxlovid®) and molnupiravir (Lagevrio®). This article describes the uptake and delivery of this therapeutics program.

METHODS

COVID-19 cases were documented in a notification database, screened to determine eligibility for COVID-19 therapies and prioritised based on case age, vaccination status, immunosuppression status and existing comorbidities, in line with Queensland clinical guidelines. Eligible cases were individually contacted by phone to discuss treatment options, and administration of therapies were coordinated in partnership with local primary healthcare centres and hospitals.

RESULTS

A total of 4744 cases were notified during the outbreak period, of which 217 (4.6%) were deemed eligible for treatment after medical review. Treatment was offered to 148/217 cases (68.2%), with 90/148 cases (60.8%) declining treatment and 53/148 cases (35.8%) receiving therapeutic treatment for COVID-19. Among these 53 cases, 29 received sotrovimab (54.7%), 20 received Paxlovid (37.7%) and four received Lagevrio (7.5%). First Nations people accounted for 48/53 cases (90.6%) who received treatment, and COVID-19 therapeutics were delivered to cases in 16 remote First Nations communities during the outbreak period.

CONCLUSION

The COVID-19 Care at Home program demonstrated a novel, public health led approach to delivering time-critical medications to individuals across a large, remote and logistically complex region. The application of similar models to outbreaks and chronic conditions of public health importance offers potential to address many health access inequities experienced by remote Australian First Nations communities.

Evaluation of an occupational therapy led Paediatric Burns Telehealth Review Clinic: exploring the experience of family/carers and clinicians

INTRODUCTION

Children with deep-partial or full-thickness burns often require complicated post-surgical care and rehabilitation, including specialist occupational therapy (OT) intervention, to achieve optimal outcomes. Those from rural and remote areas rarely have access to these services and must travel to a tertiary referral hospital to access follow-up, placing them at higher risk of complications and poorer outcomes. The OT-Led Paediatric Burn Telehealth Review (OTPB) Clinic, based at Townsville University Hospital in northern Queensland, Australia, was set up to address this inequity. The aim of this study was to investigate the experience of both family members and clinicians in using the OTPB Clinic.

METHODS

A qualitative approach, guided by interpretive phenomenology, was used. Eight family members and six clinicians participated in semi-structured interviews conducted by phone or telehealth. Thematic analysis was used to identify key themes.

RESULTS

Four major themes were derived through thematic analysis: continuity of care, family-centred care, technology and building of rural capacity.

CONCLUSION

Family and clinicians confirm benefits of a telehealth service for delivering care to rural and remote children after burn injury. The results show this expanded-scope, OT-led telehealth model provides quality patient-centred and expert clinical advice within local communities and builds the skill and capacity of local clinicians. Areas for service enhancement were uncovered. This telehealth model can be translated to other clinical subspecialties across Australia.

Tailoring immunisation programs in Lismore, New South Wales - we want our children to be healthy and grow well, and immunisation really helps

INTRODUCTION

In 2018 in the Australian town of Lismore, New South Wales, 175 children were overdue for scheduled vaccinations, 11% of them being Aboriginal and/or Torres Strait Islander (2018). This study aimed to gain a deeper understanding of the reasons for low coverage.

METHODS

Aboriginal and non-Aboriginal parents, carers and health service providers were invited to take part in semi-structured interviews and focus groups. Open-ended questions were asked about immunisation barriers and enablers, and what strategies may be effective in improving coverage in Lismore.

RESULTS

A total of 35 participants took part. Six themes were developed: childhood immunisation in Lismore is limited by access barriers to health services, some families may need additional support to access vaccination services, health services need to ensure that Aboriginal families feel safe and comfortable when accessing their service, parents and carers value reminders and recalls to keep their children's vaccinations up to date, parents' and carers' views influence their decisions to immunise their children, and reliable information about immunisation needs to be available in ways that are meaningful and appropriate for parents and carers.

CONCLUSION

Access barriers and vaccine hesitancy have been contributing to children falling behind in their scheduled vaccinations in Lismore. More flexible health services, culturally safe and appropriate care and more practical support can help overcome structural barriers to health services. Tailored health messages for both Aboriginal and non-Aboriginal parents and carers can assist parents in making wise immunisation choices. More consistent analysis and reporting of routinely available data can identify pockets of low coverage. Publicly funded health services and Aboriginal Community Controlled Health Services are well placed to provide flexible vaccination services for those families who may struggle with access barriers.

Trauma care in the tropics: addressing gaps in treating injury in rural and remote Australia

In Australia, over half a million people are admitted to hospital every year as a result of injury, and where you live matters. Rural populations have disproportionately higher injury hospitalisation rates (1.5-2.5-fold), higher rates of preventable secondary complications, higher mortality rates (up to fivefold), and higher costs (threefold) than patients injured in major cities. These disparities scale up rapidly with increased remoteness, and shift the service needle from 'scoop and run' to 'continuum of care'. Poorer outcomes, however, are not solely due to longer retrieval distances or delays; they arise from inefficiencies in one or more potentially modifiable factors in the chain of survival. After discussing the burden of injury in Australia, we present a brief history of retrieval services in Queensland and discuss how remoteness requires a different kind of service delivery with many moving parts from point of injury to definitive care. We next address the ongoing challenges for the Australian Trauma Registry, and how centralisation of data from the metropolitan cities masks the inequities in rural and remote trauma. There is an urgent need for accurate data from all service providers around Australia to inform state and federal governments, and we highlight the paucity of trauma data analysis in North Queensland. Last, we identify some major gaps in treating rural and remote polytrauma and en-route patient stabilisation, and discuss the relevance of combat casualty care research and practices. We conclude that a greater emphasis should be placed on collecting more robust trauma patient records, as only accurate data will drive change.

Comment: Sedation as part of secondary prophylaxis to prevent recurrent rheumatic fever in Aboriginal and Torres Strait Islander peoples: time for a reset?

Australia's national clinical practice guidelines recommend intramuscular (IM) penicillin every 28 days for persons diagnosed with an initial episode of acute rheumatic fever (ARF). This antibiotic coverage is initiated to reduce recurrent ARF episodes by preventing repeat infections with the causative bacterium, group A Streptococcus. Because disease has already occurred, this regimen is known as secondary prophylaxis (SP), done in order to prevent more episodes of ARF (known as recurrences). In 2020, eight authors shared with readers of Rural and Remote Health their experience of introducing off-label an oral, centrally acting, alpha agonist sedative to the prescribed SP regimen of IM penicillin for each of three Aboriginal children previously diagnosed with ARF. The living environments of the three children increased their risk for repeat group A Streptococcus infections and subsequent recurrences of ARF. We find the clinical case report perpetuates a troubling academic tone about this singular priority for SP. Injecting a child with IM penicillin appears to supersede all other objectives. Off-label sedation in remote settings is legitimised in order to succeed in this imperative. Those articles that peer-reviewed medical journals choose to publish privilege directions for priorities, policy and practice. In this commentary, we present alternative perspectives and initiatives for consideration.

Bakmaranhawuy - the broken connection. Perspectives on asking and answering questions with Yolŋu patients in healthcare contexts

INTRODUCTION

Questioning is a key method in general information-seeking behaviour and teaching used by the dominant culture in Australia. Within an Australian health context the fundamental diagnostic tool used by medical staff is the biomedical interview or history taking, which is based on a battery of direct questions. Similarly, many health professionals rely on patient questions to prompt the sharing of information, or to make them aware of gaps in communication. This is problematic for many First Nations peoples, including Yolηu (First Nations people of North-East Arnhem Land), who are culturally less inclined to use direct questioning as it is deemed impolite within their cultural context.

METHODS

Semi-structured conversational interviews using culturally congruent communication processes were conducted with participants in their preferred language. Interviews were translated, transcribed and analysed inductively using NVivo v12.

RESULTS

A total of 30 participants were interviewed (10 health staff and 20 Yolηu with recent experience in engaging with health services). All participating health staff believed that questioning was essential for determining how to best treat patients but many felt that questions created problems for some Yolηu patients. They also felt that Yolηu patients ask fewer questions related to their health issues than patients of other cultures. Yolηu participants conveyed overwhelmingly negative experiences with the health system and at the tertiary hospital in particular. Yolηu participants described feelings of frustration, fear and trauma when talking of their experiences, and these feelings were often direct outcomes of poor communication with staff. Regarding the use of questions in health care specifically, Yolηu participants identified four key and interrelated conditions within which questioning was deemed an acceptable communication mechanism. Dhämanapan (connection) was identified as an essential condition for effective communication between health staff and patients. This connection was established and maintained through a shared understanding of matha (language), dukmaram (Yolηu understandings of healing) and djuηuny (Yolηu norms of polite communication). Strategies for overcoming barriers to effective communication related to the concept of dhuwurr (skill) in health communication, which could increase the acceptability of health staff asking questions of Yolηu and the confidence of Yolηu patients in asking questions of health staff.

CONCLUSION

The findings from this study indicate a fundamental disconnect between the current health system and the needs of the Yolηu patients it seeks to serve. In order for this to change, Yolηu patients and health staff need to develop dhuwurr in health communication, which incorporates the four key conditions for effective communication identified in this study. To achieve this, ongoing and mandatory intercultural communication training for health staff is needed, just as mandatory training is required for hygiene and resuscitation training. Intercultural communication training must be comprehensive - reflecting the complexity involved in developing this dhuwurr - and sustained, for example with ongoing support from cultural communication mentors.

Parent perceptions of minimally invasive dental treatment of Australian Aboriginal pre-school children in rural and remote communities

INTRODUCTION

Aboriginal* children in rural and remote communities in Australia have a higher burden of dental decay and poorer access to dental services than their non-Aboriginal counterparts. In the Kimberley region of Western Australia (WA), Aboriginal children experience six times the rate of untreated dental decay of non-Aboriginal children. Access to dental care is challenged by the availability and appropriate delivery of services in remote locations. This study elicited the experiences and perceptions of parents and carers who participated in a project that tested the minimally invasive atraumatic restorative treatment and the Hall technique approaches (ART-HT) to manage early childhood dental caries among Australian Aboriginal preschool children.

METHODS

The core study design was a stepped-wedge, cluster-community-randomised controlled trial. Consenting communities in the Kimberley region of WA were randomised into early and delayed intervention groups. Children were clinically examined at study commencement; the early intervention group was offered dental treatment using the ART-HT approach, and the delayed group was advised to seek dental care from their usual service provider. At the 12-month follow-up, children in both groups were re-examined and offered care using the minimally invasive model of care, and parents and carers were invited to take part in focus group or one-to-one interviews. Semistructured interviews, guided by the yarning approach, were conducted with consenting parents and carers in community locations of convenience to participants. The same open-ended questions were asked of all participants, and the interviews were audio-recorded with permission and transcribed by an independent agency. Thematic analysis was undertaken, the transcripts were coded by NVivo software, and emergent themes were identified and developed.

RESULTS

One-to-one interviews were conducted with 29 parents and carers (10 from five test communities; 19 from eight control communities). Interview participants consisted of 3 males and 26 females. Following thematic analysis, three main themes (and subthemes) were identified: (1) access to care (barriers, service availability, impact on family due to lack of access); (2) experience of care (cultural safety, child-centred care, comprehensiveness of care); (3) community engagement (service information, engagement, oral health education). Structural and system factors as well as geography were identified as barriers by parents and carers in accessing timely and affordable dental care in culturally safe environments; parents and carers also identified the impacts from lack of access to care. They valued comprehensive care delivered within community, underpinned by child- and family-centred care. Of equal importance was the holistic approach adopted through the building of community engagement and trusting relationships.

CONCLUSION

A high level of satisfaction was reported by parents and carers with their experience of dental care for their children with the minimally invasive approach. Satisfaction was expressed around ease of accessing services delivered in a child- and family-centred manner, and that were well supported by appropriate engagement between service providers, communities and families. The findings from this study suggest a minimally invasive dental care model can be considered effective and culturally acceptable and should be considered in delivering oral health services for young children in rural and remote locations. * The term Aboriginal is inclusive of Aboriginal and Torres Strait Islander peoples.

COVID-19 Australia: Epidemiology Report 52 Reporting period ending 10 October 2021

This is the fifty-second epidemiological report for coronavirus disease 2019 (COVID-19), reported in Australia as at 23:59 Australian Eastern Daylight Time [AEDT] 10 October 2021. It includes data on COVID-19 cases diagnosed in Australia and the international situation.

Competencies for entry-level rural and remote physiotherapy practice: a Delphi approach

INTRODUCTION

Rural physiotherapy is a challenging area of practice that requires clinicians to respond to the unique factors that contribute to rurality. This study aimed to outline an introductory set of competencies that contribute to effective physiotherapy practice in rural Australia.

METHODS

A three-round Delphi study was undertaken using a panel of expert physiotherapists. The panel was asked to provide open-ended responses to the following question: 'What unique knowledge, skills, abilities, attributes or other characteristics do physiotherapists need to possess, or learn in order to provide effective physiotherapy specifically in a rural or remote setting?' These responses were then thematically analysed to create competencies. The competencies were evaluated in the subsequent rounds by the Delphi panel. Consensus was set at 80%. Rural and remote experts were determined through criteria including duration of practice, established expert frameworks, and self- or peer nomination. The publicly accessible Australian Physiotherapy Association database was used to access the contact details of 222 physiotherapists working in rural and remote locations across all Australian states and territories. Seventeen expert physiotherapists met inclusion criteria and consented to participation.

RESULTS

Seventeen expert physiotherapists completed round one with a 100% response rate. Analysis of the expert panel responses yielded an initial 24 competencies. The second round had a response rate of 94.1%, and the third round 93.8%. A final set of 19 competencies was established. The knowledge, skills and attributes featured in the competencies relate to responsivity to rural locality, adapting to individual community needs and problem solving in response to challenges to practising in rural and remote locations.

CONCLUSION

This study has introduced a set of competencies that may contribute towards effective physiotherapy practice in the rural setting. The competencies provide a common language for physiotherapists and their employers, and may be used to guide training or mentorship in this setting.

Not just simple cellulitis: a case report of polymicrobial Aeromonas infection from rural Queensland

CONTEXT

The Gram-negative organism Aeromonas is found in freshwater and marine environments and can cause a range of disease in humans, most commonly gastrointestinal illness and soft tissue infections. The severity of soft tissue infections can vary, ranging from cellulitis to rapidly spreading soft tissue infection. Prompt recognition of this pathogen is needed as empirical antibiotics for cellulitis generally do not provide sufficient cover for Aeromonas. Additionally, while cellulitis is generally managed medically, early surgical intervention may be required when Aeromonas is the causative pathogen.

ISSUES

A Caucasian male aged 39 years injured his right foot falling in a creek bed in the Darling Downs region of rural Queensland, sustaining a laceration in the webbing between his first and second toes. He was seen in two rural hospitals following this event, with oral antibiotics prescribed following his second presentation to cover for a localised soft tissue infection. Circumstances meant he did not take these, and he finally presented to a third hospital after noting erythema tracking up his leg and discharge emanating from the wound on his foot. He was admitted and commenced on empirical antibiotics, however severity of the infection necessitated surgical team involvement and multiple debridements. Due to the extent of tissue removal, a skin graft was required. Intraoperative specimens revealed polymicrobial Aeromonas as the causative pathogen.

LESSONS LEARNED

This case report documents a polymicrobial soft tissue infection in a systemically well young male requiring prompt surgical intervention, even without systemic symptoms of illness. Lack of early recognition of risk factors for infection may have delayed appropriate antibiotic therapy. It highlights the importance of early recognition and appropriate antibiotic cover to prevent spreading infection in individuals in whom Aeromonas may be the suspected pathogen. Empirical antibiotics for cellulitis generally do not include the agents to which Aeromonas is susceptible, hence guidelines recommend a regime of trimethoprim-sulfamethoxazole or ciprofloxacin in addition to either dicloxacillin or flucloxacillin. Initiation of appropriate antibiotics earlier in this case may have prevented the need for surgical intervention. This case also demonstrates that early surgical referral and intervention may be warranted in suspected Aeromonas infections.

COVID-19 Australia: Epidemiology Report 51 Reporting period ending 26 September 2021

This is the fifty-first epidemiological report for coronavirus disease 2019 (COVID-19), reported in Australia as at 23:59 Australian Eastern Standard Time [AEST] 26 September 2021. It includes data on COVID-19 cases diagnosed in Australia.

Role of Aboriginal Health Practitioners in administering and increasing COVID-19 vaccination rates in a Victorian Aboriginal Community Controlled Health Organisation

The COVID-19 pandemic has devastated communities throughout the world and has required rapid paradigm changes in the manner in which health care is administered. Previous health models and practices have been modified and changed at a rapid pace. This commentary provides the experiences of a regional Victorian Aboriginal Community Controlled Organisation in a COVID-19 vaccination program led and managed by Aboriginal Health Practitioners.

Rationale and protocol for the Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study: a large-scale longitudinal investigation of graduate practice destinations

INTRODUCTION

Inequitable distribution of health workforce limits access to healthcare services and contributes to adverse health outcomes. WHO recommends tracking health professionals from their points of entry into university and over their careers for the purpose of workforce development and planning. Previous research has focused on medical students and graduates' choice of practice location. Few studies have targeted nursing and allied health graduates' practice intentions and destinations. The Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study is investigating factors affecting Australian nursing and allied health students and graduates' choice of graduate practice location over the course of their studies and up to 10 years after graduation by linking multiple data sources, including routinely collected university administrative and professional placement data, surveys of students and graduates, and professional registration data.

METHODS

By using a prospective cohort study design, each year a new cohort of about 2000 students at each participating university (Deakin University, Monash University and the University of Newcastle) is tracked throughout their courses and for 10 years after graduation. Disciplines include medical radiation practice, nursing and midwifery, occupational therapy, optometry, paramedicine, pharmacy, physiotherapy, podiatry and psychology. University enrolment data are collected at admission and professional placement data are collected annually. Students' practice destination intentions are collected via questions added into the national Student Experience Survey (SES). Data pertaining to graduates' practice destination, intentions and factors influencing choice of practice location are collected in the first and third years after graduation via questions added to the Australian Graduate Outcomes Survey (GOS). Additionally, participants may volunteer to receive a NAHGOT survey in the second and fourth-to-tenth years after graduation. Principal place of practice data are accessed via the Australian Health Practitioner Regulation Agency (Ahpra) annually. Linked data are aggregated and analysed to test hypotheses comparing associations between multiple variables and graduate practice location.

RESULTS

This study seeks to add to the limited empirical evidence about factors that lead to rural practice in the nursing and allied health professions. This prospective large-scale, comprehensive study tracks participants from eight different health professions across three universities through their pre-registration education and into their postgraduate careers, an approach not previously reported in Australia. To achieve this, the NAHGOT study links data drawn from university enrolment and professional placement data, the SES, the GOS, online NAHGOT graduate surveys, and Ahpra data. The prospective cohort study design enables the use of both comparative analysis and hypothesis testing. The flexible and inclusive study design is intended to enable other universities, as well as those allied health professions not regulated by Ahpra, to join the study over time.

CONCLUSION

The study demonstrates how the systematic, institutional tracking and research approach advocated by the WHO can be applied to the nursing and allied health workforce in Australia. It is expected that this large-scale, longitudinal, multifactorial, multicentre study will help inform future nursing and allied health university admission, graduate pathways and health workforce planning. Furthermore, the project could be expanded to explore health workforce attrition and thereby influence health workforce planning overall.

A cautionary tale of hyperbilirubinaemia in subhepatic appendicitis

Subhepatic appendicitis is rare in children and often presents with atypical symptoms and signs, resulting in delayed diagnosis with attendant complications. The presence of hyperbilirubinemia could be a marker of complicated appendicitis and may assist rural physicians to seek specialist assistance early.

Remote area nurses' perceptions of the enablers and barriers for delivering end-of-life care in remote Australia to Aboriginal people who choose to pass away on their traditional lands

INTRODUCTION

This research was undertaken to gain insight into what remote area nurses perceived were enablers and barriers to being involved in delivering care to an Aboriginal person with a terminal diagnosis passing away on their traditional lands. It is hoped that this gives remote area nurses, Aboriginal Australians and service providers a glimpse into what is happening in the remote areas of Australia. Remote area nurses often work in isolated and in extreme geographical locations. This also means that a significant proportion work alongside and with Aboriginal Australians. In addition, remote area nurses are often left to support people in the communities they work in under extreme and often under-resourced conditions.

METHODS

A literature review was undertaken on this subject and a four-section questionnaire was then developed based on the literature. This included demographic questions and two sections using an ordinal Likert scale. The Likert scale questions asked remote area nurses about the skills they felt they used to deal with particular situations and the capacity of the health service to deal with the situations. The fourth section comprised open-ended questions. Thematic analysis was undertaken on the open-ended questions. Categories and themes were developed, and the results discussed. The four-part questionnaire was designed to be anonymous, and it formed part of the questionnaire distributed to students enrolled with the School of Indigenous and Remote Health Alice Springs, Flinders University by email, and to not-for-profit membership organisation CRANAplus for distribution through their networks.

RESULTS

Remote area nurses felt that the barriers to supporting an Aboriginal Australian with a terminal diagnosis passing away on their traditional lands were a lack of support around the delivery of culturally appropriate end-of-life care, lack of a stable workforce, insufficient cultural knowledge and understanding, and a lack of guidance and support from family. They felt the enablers were effective communication with the family and Aboriginal elders providing advice to staff and direction on how they can support the family, willingness of staff to participate in care, and input from Aboriginal health practitioners.

CONCLUSION

Remote area nurses perceived they lacked support and knowledge from several different areas, both from within their communities and outside of their communities. Despite the barriers, it was evident that remote area nurses can be very resourceful at enabling the processes of supporting Aboriginal people with a terminal diagnosis passing away on their traditional lands.

COVID-19 Australia: Epidemiology Report 27: Fortnightly reporting period ending 11 October 2020

Nationally, there was a continuing downward trend in notifications of COVID-19. The daily average number of cases for this reporting period was 14 compared to an average of 23 cases per day in the previous fortnight. There were 192 cases of COVID-19 and 23 deaths this fortnight, bringing the cumulative case count to 27,344 and 898 deaths. While the majority of cases in this reporting period were from Victoria (60%; 116/192), there continues to be a decrease in cases in this state resulting from public health interventions. During this fortnight, 66% (127/192) of all cases were reported as locally acquired, with the majority reported from Victoria (108/127). The highest proportion of overseas-acquired cases was reported in New South Wales (75%; 38/51), followed by Western Australia (22%; 11/51). Although testing rates declined, they remain high overall at 9.2 tests per week per 1,000 persons. There was variability in the testing rate by jurisdiction, with testing rates depending on the epidemic context. The overall positivity rate for the reporting period was 0.05%, with Victoria reporting a positivity rate of 0.08% for this reporting period. In all other jurisdictions the positivity rate was ≤ 0.06%.

Developing a mobile data collection tool to manage a dispersed mental health workforce

CONTEXT

The Rural Adversity Mental Health Program (RAMHP) connects people who need mental health assistance in rural and remote New South Wales (NSW), Australia with appropriate services and resources. In 2016, RAMHP underwent a comprehensive reorientation to meet new state and federal priorities. A full assessment of program data collection methods for management, monitoring and evaluation was undertaken. Reliable data were needed to ensure program fidelity and to assess program performance.

ISSUES

The review indicated that existing data collection methods provided limited and unreliable information, were inconvenient for RAMHP coordinators to use and unsuited to their itinerant role. A mobile collection tool (app) was developed to address RAMHP activity data needs. A design and implementation process was followed to optimise data collection and to ensure the successful use of the app by coordinators.

LESSONS LEARNED

The early planning investment was worthwhile, the app was successfully adopted by the coordinators and a much improved data collection capability was achieved. Moreover, data capture increased, while errors decreased. Data are more reliable, specific, timely and informative and are used for strategic and operational planning and to demonstrate program performance.

Evaluation for learning and improvement at the right time: an example from the field

Evaluation expertise to assist with identifying improvements, sourcing relevant literature and facilitating learning from project implementation is not routinely available or accessible to not-for-profit organisations. The right information, at the right time and in an appropriate format, is not routinely available to program managers. Program management team members who were implementing The Fred Hollows Foundation's Indigenous Australia Program's Trachoma Elimination Program required information about what was working well and what required improvement. This article describes a way of working where the program management team and an external evaluation consultancy collaboratively designed and implemented an utilisation-focused evaluation, informed by a developmental evaluation approach. Additionally, principles of knowledge translation were embedded in this process, thereby supporting the evaluation to translate knowledge into practice. The lessons learned were that combining external information and practice-based knowledge with local knowledge and experience is invaluable; it is useful to incorporate evaluative information from inception and for the duration of a program; a collaborative working relationship can result in higher quality information being produced and it is important to communicate findings to different audiences in different formats.

Social and community networks influence dietary attitudes in regional New South Wales, Australia

INTRODUCTION

Rural populations in Australia have a higher prevalence of obesity, cardiovascular disease, type II diabetes and some cancers. The purpose of the present study was to determine associations between socioeconomic characteristics (socioeconomic position, income, wealth, debt, occupation, social network diversity), dietary attitudes, and fruit and vegetable intake for people living rurally in Australia.

METHOD

A community based cross-sectional survey between February and July 2018 of 326 adults (median age 57 years, range 20-90 years, 64.4% female) who attended rural shows in four rural towns in south-eastern New South Wales, supplemented with data from patients attending general practices in two additional towns. Participants completed a questionnaire that recorded self-reported daily consumption of fruit and vegetables, a dietary attitude score, and items measuring social and economic circumstances.

RESULTS

Using multivariable regression analysis, the odds of meeting Australian fruit intake guidelines was 13% higher for each unit increase in dietary attitude score (odds ratio (OR)=1.13, 95% confidence interval (CI)=1.03-1.23). The odds of meeting vegetable intake guidelines were 19% higher for each unit increase in score (OR=1.19, 95%CI=1.09-1.31). Social and economic factors were not independently associated with fruit or vegetable intake. Dietary attitude score, in turn, increased on average by 0.07 points (95%CI=0.01-0.12) for each additional occupation type among the participants' social networks. For women who socialised regularly in small towns the score was 1.97 points higher (95%CI=0.93-3.00). Men in outer regional areas were more likely to meet vegetable intake guidelines than men in inner regional areas, whereas women in outer regional areas were more likely to meet fruit intake guidelines than women in inner regional areas.

CONCLUSIONS

Greater fruit and vegetable intake was predicted by healthier dietary attitudes which in turn were related to social and community connections, rather than economic factors.

Adherence to antithrombotic therapy guidelines and atrial fibrillation in a rural hospital: a clinical audit

INTRODUCTION

Atrial fibrillation (AF) is a major risk factor for ischaemic stroke and a common presentation in general practice. Scoring systems to guide antithrombotic treatment have been available since 1996, with the CHA2DS2-VASC in current use; however, little is known about adherence to guidelines in rural general practice. The purpose of this study was to determine whether patients in a rural population and with documented history of AF are prescribed antithrombotic treatment according to recognised guidelines.

METHODS

A retrospective cohort study of inpatients was performed at a rural country hospital in South Australia. All patients with an ICD-10 CM code at the time of discharge were selected from June 2008 to July 2013. This included both newly diagnosed AF as well cases with existing history of AF.

RESULTS

Among the 59 patients studied, 77% of patients received appropriate anticoagulation according to CHADS2 score and 83% according to CHA2DS2-VASC score.

CONCLUSIONS

This study confirms that the guidelines are routinely followed in clinical practice in this rural population.

Advocating for end-of-life choice at home: a survey of rural Australian nurses

INTRODUCTION

Rural healthcare resource limitations can affect the choices people make and their quality of life during its end stages. In rural regions of Australia, district nurses (DNs) working in generalist community roles provide access to care by visiting people in their homes. They may be well positioned to improve the quality of the end-of-life experience by advocating for choice and person-centred end-of-life goals; however, knowledge about care in this context is limited. Initial findings from an exploratory qualitative study describing how rural DNs are able to successfully advocate for the end-of-life choices and goals of people living at home need to be confirmed and further developed to inform clinical practice. This survey aimed to test and complement the findings from a narrative exploration of how DNs advocate successfully for the end-of-life goals of rural Australians.

METHOD

A sequential mixed methods study based on a pragmatic design was used to explore how DNs advocate successfully for the end-of-life goals of rural Australians. In the first phase of the study two stages of reflection on experience by rural DNs from the state of Victoria (N=7) provided written and in-depth narrative understandings of how advocacy is enabled and actioned in the practice context. The data were analysed with interpretive description, resulting in findings that could be used to inform a survey for the second phase. The survey, reported here, was designed as an online questionnaire to be distributed by email across inner and outer regional Australia. It was trialled by rural health professionals (N=13) and modified according to the advice received. The participation criteria for the survey specified registered nurses working in generalist community nursing roles with experience in providing successful end-of-life advocacy for people at home. Scales were used to test and complement the phase 1 findings and analysed using Cronbach's alpha and descriptive statistics, with a 95% confidence interval calculated. Open-ended questions added to complement the understanding of how successful advocacy is enabled and actioned in this context were analysed with descriptive interpretation.

RESULTS

A self-selecting sample of nurses (N=91) responded to the survey between March and July 2015. The response came from most Australian states and territories, and confirmed the findings that willing nursing involvement in end-of-life experiences, specialised rural relational knowledge, and feeling supported, together enable nurses to advocate successfully for person-centred goals. Actions based on advocacy that were highly rated for success include holistic assessment, effective end-of-life communication and the organisation of empowering and supportive care, confirming the phase 1 findings. High levels of emotional intelligence, understandings of 'going beyond duty', the types of support used and the need for advocacy for resources were reported.

CONCLUSION

The results provide both confirmatory and new knowledge that can be used with confidence to inform practice with a model for rural end-of-life nursing advocacy in the home setting.