Journal articles on the topic 'Medical audit Victoria'

Aims: Renal mass biopsy (RMB) is advocated to improve management of small renal masses, however there is concern about its clinical utility. This study aimed to elicit opinions about the role of RMB in small renal mass management from surgeons managing renal cell carcinomas (RCC), and examine the frequency of pre-treatment biopsy in those with RCC. Methods: All surgeons in two Australian states (Queensland: n = 59 and Victoria: n = 108) who performed nephrectomies for RCC in 2012/2013 were sent questionnaires to ascertain views about RMB. Response rates were 54% for Queensland surgeons and 38% for Victorian surgeons. We used medical records data from RCC patients to determine RMB frequency. Results: Most Queensland (81%) and Victorian (59%) surgeons indicated they rarely requested RMB; however 34% of Victorians reported often requesting RMB, compared with no Queensland surgeons. This was consistent with medical records data: 17.6% of Victorian patients with T1a tumours received RMB versus 6.7% of Queensland patients ( p < 0.001). Surgeons’ principal concerns regarding RMB related to sampling reliability (90%) and/or histopathological interpretation (76%). Conclusions: Most surgeons report infrequent use of RMB for small renal masses, however we observed practice variation. The principal reasons for infrequent use were concerns about sampling reliability and histopathological interpretation, which may be valid in regions with less access to interventional radiologists and uropathologists. Further evidence is required to define patient groups for whom biopsy results will alter management. Level of evidence: Not applicable for this multicentre audit.

This pilot study sought to describe the diagnostic pathways for patients with lung cancer and explore the feasibility of a medical record audit for this purpose. An audit of 25 medical records of patients with a confirmed diagnosis of lung cancer was conducted, at a single outer metropolitan hospital in Victoria. Patients were presented to secondary care from general practice (n = 17, 68%), the emergency department (n = 3, 12%) or specialist rooms (n = 1, 4%). Those who journeyed through general practice experienced the longest median intervals to diagnosis (20 days, interquartile range 7–47). The majority of patients (n = 15, 60%) were referred by a specialist to a multidisciplinary team after a diagnosis had been confirmed but before treatment commenced. These patients waited a median of 20 days from their first specialist appointment to a multidisciplinary team appointment. This research illustrated that a variety of pathways to diagnosis exist. Critically, it requires patient data and additional auditing of primary, public and private health sector records to determine generalisability of findings and the effectiveness of a medical record audit as a data collection tool.

Clinical Registries are established to provide a clinically credible means for monitoring and benchmarking healthcare processes and outcomes, to identify areas for improvement, and drive strategies for improving patient care. Clinical Registries are used to assess changes in clinical practice, appropriateness of care and health outcomes over time. The American Heart Association Policy Statement in April 2011 called for expanding the application for existing and future Clinical Registries, with well-designed Clinical Registry programs. Concurrently, in Australia, and similarly within the United States and United Kingdom, there has been an increased focus on performance measurement for quality and patient safety. Within Victoria, the Victorian Clinical Governance Policy Framework outlines clinical effectiveness as one of the four domains of Clinical Governance As Clinical Registries evaluate effectiveness and safety of patient care by measuring patient outcomes compared with peers, the use of Clinical Registries data to improve a health service’s quality of care seems intuitive. A mixed methods approach was utilised, involving (1) semi-structured interviews and (2) documentation audit in this study conducted at Austin Health, a major tertiary teaching hospital in North-Eastern metropolitan Melbourne, affiliated with the University of Melbourne and various research institutes within Austin LifeSciences. Although many studies have highlighted the benefits of data collected via individual Clinical Registries, [5,6] the level of voluntary medical staff participation in Clinical Registries at a health service level is yet to be established. The aim of this study was to document the level of medical staff involvement for Clinical Registries within a major tertiary teaching hospital, and the level of reporting into Quality Committees within the organisation. This study demonstrates that along with a very high level of medical staff participation in Clinical Registries, there is a lack of systematic reporting of Registries data into quality committees beyond unit level, and utilisation of such data to reflect upon practice and drive quality improvement. Abbreviations: CREPS – Centre for Excellence in Patient Safety; CSU – Clinical Services Unit; HOU – Heads of Unit; VASM – Victorian Audit of Surgical Mortality.

There is an increasing number of specialties performing office-based procedures, with many different providers practising in this field. Office Based Anaesthesia Solutions is a private enterprise designed to be a high-quality general anaesthesia and sedation service delivering care across 18 dental practices in Victoria. We undertook a criterion-based audit of our practice standards and outcomes. Following ethics approval, we retrospectively reviewed consecutive patients managed by our service between March 2014 and July 2017. We collected demographic data, information about anaesthesia technique, and surgical features. We assessed our findings against the Australian and New Zealand College of Anaesthetists (ANZCA) day surgery policy documents. During the specified period, we provided anaesthesia or sedation for 1,323 patients. Their ages ranged from two to 93 years (mean [standard deviation] 33.3 [18.6] years). Ninety-three percent of patients were American Society of Anesthesiologists (ASA) physical status classification 1 or 2. Patient demographics were in line with ANZCA day surgical policy documents. Total intravenous anaesthesia was used in 1,054 of the 1,096 documented general anaesthesia cases. There were three unplanned hospital transfers (annual incidence 0.07%). As this was the first Australian criteria-based audit of office-based anaesthesia (OBA) for dental procedures, we cannot compare our findings directly to previous studies. However, we feel that our patient demographics fell within acceptable ANZCA day procedure standards and our adverse event rate was both very low and similar to other published international adverse event rates. Our audit indicates that with careful screening processes, patient selection and medical governance, OBA is a viable model of care for patients undergoing dental procedures.

Background: Ectopic pregnancy remains the most common cause of early pregnancy mortality, with management options differing according to clinical presentation and investigations. This audit aims to investigate the indications for medical and surgical management of ectopic pregnancy at a tertiary hospital network, in order to assess variances in practice and adherence to local hospital protocols. Methods: A retrospective audit of the management of women with a diagnosis of ectopic pregnancy was performed over 12 months from July 2018 to June 2019, at three hospitals in the largest healthcare network in Victoria, Australia. Information collected included patient demographics, risk factors for ectopic pregnancy, pathology and radiology results, documented indication for surgery, and any complications of treatment. A subgroup analysis of data was done to investigate changes and deficiency in management of ectopic pregnancy compared to local hospital protocol. Results: Over a 12-month period, 138 women were diagnosed with an ectopic pregnancy, of which 99 (72%) received surgical management and 39 (28%) received medical management. Four women within the medical group were excluded from analysis, one due to loss of follow-up and three patients who were diagnosed with nontubal ectopic pregnancies. About 94% (33/35) of women who received methotrexate were within hospital guidelines for medical management and 91% (32/35) were successfully managed without surgery. All women who received surgical management underwent a salpingectomy and 97% (96/99) had clear indications documented for surgery within local protocol. Conclusion: Overall, the majority of women with ectopic pregnancy were treated according to local guidelines. Expectant management and the option of salpingostomy as a surgical alternative could be considered in the local guidelines. The dissemination of this clinical audit data is aimed at continuing clinical governance and improvements in outcomes.

IntroductionA voluntary State Government-led programme in Victoria, Australia ‘Defibrillators for Sporting Clubs and Facilities Program’ ran from 2015 to 2019, broadly aimed at increasing access to automated external defibrillators (AEDs), together with a greater number of community members trained for management of medical emergencies. This study aimed to understand whether participating sport clubs/facilities had successfully integrated an AED and medical planning with other club/facility safety practices, 12 months after delivery of the programme.MethodsThis was a qualitative case study of 14 sport clubs/facilities in Victoria, Australia in 2017, underpinned by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. We conducted observational audits of facilities (to locate AED placement, signage and other relevant location-specific factors) and semi-structured, face-to-face interviews with representatives of the clubs/facilities. Interview questions were designed to determine if and how the related, mandated emergency management programme was adapted for the long term (embedding), whether this aligned to ongoing organisational mission (active engagement), and whether or not it was still ongoing 6 months postinitial implementation (sustainability). Data were evaluated using qualitative descriptive methodology. For reporting, descriptive summaries of the audit were combined with interview data to contextualise and visualise the sport club/facility setting and key results.ResultsKey issues identified were accessibility and visibility of the AED, with inadequate signage and challenges identifying an efficient location for access and storage. Most interviewees reported the AED and training were received with no further actions taken towards safety planning or integration with club/facility practice. Several challenges regarding remaining up to date with training and ensuring required routine checks of the AED take place were also raised.ConclusionsThis study identified several challenges for community sport clubs/facilities in the implementation of an AED and medical planning programme, including where to store the AED, how to make its presence known to the community and how to integrate changes alongside other club/facility practices.

Objective The aim of the present study was to audit the current use of medical records to determine completeness and concordance with other sources of medical information. Methods Medical records for 40 patients from each of five Melbourne major metropolitan hospitals were randomly selected (n=200). A quantitative audit was performed for detailed patient information and medical record keeping, as well as data collection, storage and utilisation. Using each hospital’s current online clinical database, scanned files and paperwork available for each patient audited, the reviewers sourced as much relevant information as possible within a 30-min time allocation from both the record and the discharge summary. Results Of all medical records audited, 82% contained medical and surgical history, allergy information and patient demographics. All audited discharge summaries lacked at least one of the following: demographics, medication allergies, medical and surgical history, medications and adverse drug event information. Only 49% of records audited showed evidence the discharge summary was sent outside the institution. Conclusions The quality of medical data captured and information management is variable across hospitals. It is recommended that medical history documentation guidelines and standardised discharge summaries be implemented in Australian healthcare services. What is known about this topic? Australia has a complex health system, the government has approved funding to develop a universal online electronic medical record system and is currently trialling this in an opt-out style in the Napean Blue Mountains (NSW) and in Northern Queensland. The system was originally named the personally controlled electronic health record but has since been changed to MyHealth Record (2016). In Victoria, there exists a wide range of electronic health records used to varying degrees, with some hospitals still relying on paper-based records and many using scanned medical records. This causes inefficiencies in the recall of patient information and can potentially lead to incidences of adverse drug events. What does this paper add? This paper supports the concept of a shared medical record system using 200 audited patient records across five Victorian metropolitan hospitals, comparing the current information systems in place for healthcare practitioners to retrieve data. This research identifies the degree of concordance between these sources of information and in doing so, areas for improvement. What are the implications for practitioners? Implications of this research are the improvements in the quality, storage and accessibility of medical data in Australian healthcare systems. This is a relevant issue in the current Australian environment where no guidelines exist across the board in medical history documentation or in the distribution of discharge summaries to other healthcare providers (general practitioners, etc).

The number of older, frail patients undergoing surgery is increasing, prompting consideration of the benefits of intensive treatment. Despite collaborative decision-making processes such as advance care planning being supported by recent Australian legislation, their role in perioperative care is yet to be defined. Furthermore, there has been little evaluation of the quality of end-of-life care in the surgical population. We investigated documentation of the premorbid functional status, severity of illness, intensity of treatment, operative management and quality of end-of-life care in patients who died in a surgical unit, with a retrospective study of surgical mortality which was performed across three hospitals over a 23-month period in Victoria, Australia. Among 99 deceased patients in the study cohort, 68 had a surgical operation. Preoperative functional risk assessment by medical staff was infrequently documented in the medical notes (5%) compared with activities of daily living (69%) documented by nursing staff. Documented preoperative discussions regarding the risk of death were rarely and inconsistently done, but when done were extensive. Documented end-of-life care discussions were identified in 71%, but were frequently brief, inconsistent, and in 60% did not occur until 48 hours from death. In 35.4% of instances, documented discussions involved junior staff (registrars or residents), and 43.4% involved intensive care unit staff. Palliative or terminal care referrals also occurred late (1–2 days prior to death). Not-for-resuscitation orders were frequently changed when approaching the end of life. Overall, 57% of deceased patients had a documented opportunity for farewell with family. We conclude that discussions and documentation of end-of-life care practices could be improved and recommend that all surgical units undertake similar audits to ensure that end-of-life care discussions occur for high-risk and palliative care surgical patients and are documented appropriately.

Objectives: To investigate a method to identify and understand patterns of adverse events by utilising secondary data analysis; to identify the types of complications associated with elective surgery; to identify any specific ?adverse eventprone? elective procedures; and to consider the implications of these patterns for hospital patient safety programs. Setting: Public hospitals in Victoria. Design: Secondary analysis of data on acute hospital admissions for elective surgery in the period 1 July 2000 to 30 June 2001, for nonobstetric patients older than 15 years (n = 177 533). Main outcome measures: Estimated rates of adverse events for the most commonly performed elective surgery procedures; frequency of the most commonly recorded adverse event types. Results: Of all admissions, 15.5% had at least one complication of care. The most frequent firstrecorded single complication code, in 9.6% of cases with a complication, was ?Haemorrhage and haematoma complicating a procedure?. The most common adverse event categories were cardiac and circulatory complications (23%), symptomatic complications (18%), and surgical and drug-related complications (17%). The procedure blocks most frequently associated with an adverse event were coronary artery bypass surgery (67%), colectomy (52%), hip and knee arthroplasty (42% and 36%, respectively), and hysterectomy (20%). The types of complications associated with the four most adverse eventprone procedures were cardiac arrhythmias, surgical adverse events (haemorrhage or laceration), intestinal obstruction, anaemia, and symptomatic complications. Conclusion: Routinely collected data are valuable in obtaining information on complication types associated with elective surgery. International Classification of Diseases codes and surgical procedure ?blocks? allow very sophisticated investigation of types of complications and differences in complication rates for different surgical approaches. The usefulness of such data relies on good documentation in the medical record, thorough coding and periodic data audit. The limitations of the method described here include the lack of follow-up after discharge, variable coding standards between institutions and over time (potentially distorting information on rates), lack of information on the causative factors for some adverse events, and a limited capacity to support investigation of particular cases. Hospitals should consider monitoring complication rates for individual elective procedures or blocks of similar procedures, and comparing adverse event rates over time and with peer hospitals as an integral part of their patient safety programs.

23 Background: The diagnosis and treatment of cancer often causes financial stress, partly by impacting on the ability to continue in paid employment. Our aim was to identify changes in work status 12 months after a diagnosis of breast cancer. Methods: An audit of the medical records of women who presented to the Western Health (Victoria, Australia) nurse led breast cancer Survivorship Clinic (SC) between October 2015 and October 2016 was performed to identify employment status at diagnosis and at their review at SC 12 months later. Results: 111 records were reviewed. The mean age was 55 (range 28-82yrs). 84 of these women (76%) were 65 years of younger at the time of diagnosis. 46 of the 84 women ≤65 years were in paid employment at diagnosis (55%), and 38 (83%) were still working in some capacity at review in the SC. Of the 38 still working, 28 were working in the same capacity, 8 were working reduced hours, and 2 were working increased hours. Women who had axillary dissections were most likely to have changed work status. Financial stress was reported by 8/19 of women who stopped working or had changed work hours, including 9 no longer in paid employment and 10 with changed hours. 2/28 women working in the same capacity reported financial stress. 65% of those who reported financial stress (11/17) had chemotherapy as part of their treatment. Conclusions: A breast cancer diagnosis has the ability to influence a woman's work status one year after diagnosis. Health professionals should appreciate the potential work concerns and financial stresses continuing to affect their patients.

BACKGROUND: There are few reports of the use of the lidocaine 5% patch (L5%P) for neuropathic pain (NP) in the cancer patient. Within a comprehensive cancer centre, L5%P has been prescribed by the Pain and Palliative Care Service (Peter McCallum Cancer Centre, East Melbourne, Victoria, Australia) for selected patients with NP since 2001.OBJECTIVE: To retrospectively audit the use of L5%P within a comprehensive cancer centre.METHODS: All L5%P prescriptions up to January 2009 were listed and patient medical records were searched to determine neuropathic pain syndromes treated, the presence of allodynia, previous analgesic medications, treatment duration and outcome.RESULTS: L5%P was prescribed for 97 patients, most frequently for persistent postsurgical NP (n=26), postherpetic neuralgia (n=24) and cancer-related NP (n=18). Six patients had no history of cancer and two patients never applied L5%P. Reviewers classed L5%P analgesic efficacy as ‘potent’ in 38% of patients with postherpetic neuralgia, 35% of patients with postsurgical pain, 27% of patients with NP after other treatments for cancer and 12% of patients with NP attributed to cancer alone. Allodynia featured in at least 60% of patients. Where allodynia was present, the efficacy of L5%P was assessed as ‘potent’ in 38% and ‘partial’ in 24%, but ‘ineffective’ in 26%, and ‘causing worse pain’ in 3.4% of patients. Treatment duration extended longer than one month in 52 patients, longer than two months in 29 patients and longer than one year in 13 patients. Therapy was ceased due to skin irritation in seven patients. The outcomes in relation to other reports are discussed.CONCLUSION: The present data support trials of L5%P for cancer patients with NP syndromes associated with allodynia.

Objective The aim of the present study was to compare lung cancer diagnostic and treatment intervals with agreed target measures across three large public health services in Victoria and assess any differences in interval times by treatment type and health service. Methods A retrospective medical record audit of 78 patients admitted with a new diagnosis of lung cancer was conducted. Interval times from referral to diagnosis, diagnosis to first treatment and referral to first treatment were recorded in three treatment types: surgery, chemotherapy and radiotherapy. Results There was a significant difference in the mean number of days from referral to diagnosis by treatment type. Patients who underwent surgery waited significantly longer (mean (± s.d.) 41.6 ± 38.4 days) to obtain a diagnosis than those who received radiotherapy (15.1 ± 18.6 days). Only 47% of surgical patients obtained a diagnosis within the recommended 28 days. Moreover, only 45% and 44% of patients, respectively, met the diagnosis-to-treatment target of 14 days and referral-to-treatment target of 42 days. Conclusion The present study highlights the effect of treatment type on lung cancer referral interval times. It demonstrates the benefits of using evidenced-based interval target times to benchmark and compare performance outcomes in lung cancer. What is known about the topic? Lung cancer is the leading cause of cancer mortality in Australia and has the lowest 5-year survival rate of all cancer types. Delays in the diagnosis of lung cancer can change the prognosis from potentially curable to incurable, particularly in faster-growing tumours. What does this paper add? This study reveals treatment type was a greater factor in explaining variations in diagnosis and treatment than health service. Surgical patients were consistently lower in meeting the recommended interval targets across referral to diagnosis, diagnosis to treatment and referral to treatment. What are the implications for practitioners? This study demonstrates the value of using evidenced-based interval target times to benchmark and compare performance outcomes in lung cancer. Such measures may further improve prognostic outcomes in lung cancer by reducing unwanted delays.

ObjectivesTo evaluate the capacity of general practice (GP) electronic medical record (EMR) data to assess risk factor detection, disease diagnostic testing, diagnosis, monitoring and pharmacotherapy for the interrelated chronic vascular diseases—chronic kidney disease (CKD), type 2 diabetes (T2D) and cardiovascular disease.DesignCross-sectional analysis of data extracted on a single date for each practice between 12 April 2017 and 18 April 2017 incorporating data from any time on or before data extraction, using baseline data from the Chronic Disease early detection and Improved Management in PrimAry Care ProjecT. Deidentified data were extracted from GP EMRs using the Pen Computer Systems Clinical Audit Tool and descriptive statistics used to describe the study population.SettingEight GPs in Victoria, Australia.ParticipantsPatients were ≥18 years and attended GP ≥3 times within 24 months. 37 946 patients were included.ResultsRisk factor and disease testing/monitoring/treatment were assessed as per Australian guidelines (or US guidelines if none available), with guidelines simplified due to limitations in data availability where required. Risk factor assessment in those requiring it: 30% of patients had body mass index and 46% blood pressure within guideline recommended timeframes. Diagnostic testing in at-risk population: 17% had diagnostic testing as per recommendations for CKD and 37% for T2D. Possible undiagnosed disease: Pathology tests indicating possible disease with no diagnosis already coded were present in 6.7% for CKD, 1.6% for T2D and 0.33% familial hypercholesterolaemia. Overall prevalence: Coded diagnoses were recorded in 3.8% for CKD, 6.6% for T2D, 4.2% for ischaemic heart disease, 1% for heart failure, 1.7% for ischaemic stroke, 0.46% for peripheral vascular disease, 0.06% for familial hypercholesterolaemia and 2% for atrial fibrillation. Pharmaceutical prescriptions: the proportion of patients prescribed guideline-recommended medications ranged from 44% (beta blockers for patients with ischaemic heart disease) to 78% (antiplatelets or anticoagulants for patients with ischaemic stroke).ConclusionsUsing GP EMR data, this study identified recorded diagnoses of chronic vascular diseases generally similar to, or higher than, reported national prevalence. It suggested low levels of extractable documented risk factor assessments, diagnostic testing in those at risk and prescription of guideline-recommended pharmacotherapy for some conditions. These baseline data highlight the utility of GP EMR data for potential use in epidemiological studies and by individual practices to guide targeted quality improvement. It also highlighted some of the challenges of using GP EMR data.

The management of tubal pregnancy has changed since the first descriptions of it by the Victorian surgeon and founder of the Medical Defence Union, John Lawson Tait, but it still presents his successors with a major challenge. Dr Surray and Mrs Sharan report from Furness General Hospital on their audit of this dangerous condition, the incidence of which is rising with the increased prevalence of Chlamydia infection.

Background: Distress is the 6th vital sign in cancer yet it is only assessed in an ad hoc way in most cancer services. The Distress Thermometer (DT) and the associated Problem Checklist (PC) are the most widely available tools although few studies report on how they are used to effectively triage services. Aim: To explore the link between distress assessment, problem identification, referral to specific supportive care services by staff, and service uptake by cancer patients and survivors among a sample of people attending a major cancer hospital in Victoria Australia. Methods: A secondary analysis of quality assurance audit data were undertaken using data collected from patient medical records between January 2013 and June 2014. Data extracted were; age, sex, post code, language spoken, disease and treatment information, distress as measured by the DT and problems as identified by the PC. For the current study the focus was on the number of referrals offered and the number accepted or declined. The type of services referred to was also examined. Results: Data were collected for 877 patients although missing data resulted in a final sample size of 853. Only data associated with the first DT of each patient are presented. 729 patients (86%) participated in distress screening. The distress threshold of 4 was reported by 50% of participants, highlighting the prevalence of distress requiring support. This 50% reported an average of 9 problems on the PC, many of which came from the physical domain, with 91% reporting at least 1 physical problem. Other problems reported were emotional (74% of the sample); practical (24%), family (14%) and spiritual (2%). Referral data, which was available for 614 people, indicated that over 60% (372) were offered at least one referral. Referral offer was significantly predicted by DT score, and number of problems reported. Acceptance was significantly related to total number of problems, treatment type, and type of referral; referral for physical treatment was most likely to be accepted (87%) whereas referral for emotional support was least likely (53%). Conclusion: Routine distress screening and problem identification are critical to triaging to supportive care services. In a tertiary care setting, not all people will be screened or will want to be screened; not all people will be referred to services; and not all people will accept referral. Nonetheless, problems are extensive with most survivors reporting experiencing several problems. Despite a focus on the physical, these problems extend to other domains, including the emotional, and it is important that services are available to support these needs.

Abstract Introduction Falls in hospital cause significant morbidity and mortality for older patients, with 10-25% inpatient falls resulting in lacerations or fractures [Rubenstein, Age Ageing, 2006 Sep; 35Suppl 2:ii37–41]. In addition to patient individual falls risk factors, such as delirium, visual impairment and poor mobility, environmental factors should also be addressed to reduce inpatient falls risk. Methods An audit of the individual patient's environment or bed space was performed using the Queensland Health Individual Environment Checklist [The Victorian Quality Council Safety and Quality in Health]. Older people aged 65 years and older admitted to the medical wards in Raja Isteri Pengiran Anak Saleha (RIPAS) hospital, Brunei were included. Patients who were bed-bound or immobile were excluded from the audit. Results There were 30 patients included in this audit. 13 (43%) were male and 17 (57%) female. Median age was 74 years (Range 65 to 83 years). Several issues were identified from this audit: Although bedside tables and lockers were wheeled with a braking system, they were not secure enough to support a patient if they leaned against them. While 28 (93%) had functioning call bells, none of the patients were shown how to operate them. 22 (73%) did not have easy access to call-bells or night-lights. 14 (47%) did not have bedside lockers or tables within easy reach. 17 (57%) did not have mobility aids within reach or received education regarding safety with mobility aid use. Conclusion This audit highlighted several aspects of the individual patient environment in hospital that should be improved to reduce falls risk. For the medical wards, we recommend ensuring hospital furniture are sturdy enough in case patients lean on them and frequently checking ease of access to call-bells, night lights, walking aids and locker belongings.

Background Tuberculosis preventive treatment (TPT) is strongly recommended for children following infection with Mycobacterium tuberculosis because of their high risk of progression to active tuberculosis, including severe disseminated disease. We describe the implementation of TPT for children and adolescents with evidence of tuberculosis infection (TBI) at Victoria’s largest children’s hospital and examine factors affecting treatment completion. Methods We conducted a retrospective clinical audit of all children and adolescents aged <18 years diagnosed with latent TBI at the Royal Children’s Hospital, Melbourne, between 2010 and 2016 inclusive. The primary outcome was treatment completion, defined as completing TPT to within one month of a target duration for the specified regimen (for instance, at least five months of a six-month isoniazid course), confirmed by the treating clinician. Factors associated with treatment adherence were evaluated by univariate and multivariate analysis. Results Of 402 participants with TBI, 296 (74%) met the criteria for treatment “complete”. The most common TPT regimen was six months of daily isoniazid (377, 94%). On multivariate logistic regression analysis, treatment completion was more likely among children and adolescents who had refugee health screening performed (OR 2.31, 95%CI 1.34–4.00) or who were also treated for other medical conditions (OR 1.67 95%CI 1.0–2.85), and less likely among those who experienced side-effects (OR 0.32, 95%CI 0.11–0.94). However, TPT was generally well tolerated with side-effects reported in 15 participants (3.7%). Conclusion Identification of factors associated with TPT completion and deficiencies in the existing care pathway have informed service provision changes to further improve outcomes for Victorian children and adolescents with TBI.

AbstractBackgroundDiagnostic error is a major preventable cause of harm to patients. There is currently limited data in the literature on the rates of misdiagnosis of doctors working in an ophthalmic emergency department (ED). Misdiagnosis was defined as a presumed diagnosis being proven incorrect upon further investigation or review.MethodsIn this retrospective audit, data was collected and analysed from 1 week of presentations at the Royal Victorian Eye and Ear Hospital (RVEEH) ED.ResultsThere were 534 ophthalmic presentations during the study period. The misdiagnosis rates of referrers were: general practitioners (30%), optometrists (25.5%), external hospital EDs (18.8%), external hospital ophthalmology departments (25%) and private ophthalmologists (0%). Misdiagnosis rates of RVEEH doctors were: emergency registrars (7.1%), RVEEH residents (16.7%), first-year registrars (5.1%), second-year registrars (7.1%), third-year registrars (7.7%), fourth-year registrars (0%), senior registrars (6.9%), fellows (0%) and consultants (8.3%).ConclusionsThe misdiagnosis rates in our study were comparable to general medical diagnostic error rates of 10–15%. This study acts as a novel pilot; in the future, a larger-scale multi-centre audit of ophthalmic presentations to general emergency departments should be undertaken to further investigate diagnostic error.

Objective To audit written medical discharge summary procedure and practice against Standard Six (clinical handover) of the Australian National Safety and Quality Health Service Standards at a major regional Victorian health service. Methods Department heads were invited to complete a questionnaire about departmental discharge summary practices. Results Twenty-seven (82%) department heads completed the questionnaire. Seven (26%) departments had a documented discharge summary procedure. Fourteen (52%) departments monitored discharge summary completion and 13 (48%) departments monitored the timeliness of completion. Seven (26%) departments informed the patient of the content of the discharge summary and six (22%) departments provided the patient with a copy. Seven (26%) departments provided training for staff members on how to complete discharge summaries. Completing discharge summaries was usually delegated to the medical intern. Conclusions The introduction of the National Service Standards prompted an organisation-wide audit of discharge summary practices against the external criterion. There was substantial variation in the organisation’s practices. The Standards and the current audit results highlight an opportunity for the organisation to enhance and standardise discharge summary practices and improve communication with general practice. What is known about the topic? The Australian National Safety and Quality Health Service Standards (Standard 6) require health service organisations to implement documented systems that support structured and effective clinical handover. Discharge summaries are an important and often the only form of communication during a patient’s transition from hospital to the community. Incomplete, inaccurate and unavailable discharge summaries are common and expose patients to greater health risks. Junior staff members find completing discharge summaries difficult and fail to receive appropriate education or support. There is little published evidence regarding the discharge summary practices of inpatient health services. What does this paper add? The paper demonstrates that there is substantial variation in practice regarding discharge summaries in a large regional health service. Departments have different processes and vary in the degree of attention and quality assurance provided to discharge summaries. Variable organisation procedures make completing discharge summaries more difficult for junior doctors, who regularly move between departments. Variable practice is likely to increase the risk of absent, untimely, incomplete or incorrect communication between acute and community services, thereby reducing the quality of patient care. It is likely that similar findings would be found in other hospitals. What are the implications for practitioners? To be accredited under the National Safety and Quality Health Service Standards, health organisations must ensure that adequate processes are in place for safe and effective clinical handover. Organisations should reduce the practice variability by standardising processes, monitoring compliance with processes, and training and supporting junior doctors.

BackgroundEmergency departments (EDs) are usually the first point of contact, and often the only medical service available, for patients with mild traumatic brain injury (mTBI) in rural and regional areas. Clinical practice guidelines (CPGs) have been created to ensure best practice management of mTBI in EDs. Adherence to mTBI CPGs has rarely been evaluated in rural and regional areas.AimThe aim of this paper was to assess a regional health service’s adherence to their mTBI CPG.MethodsThis was a 12-month retrospective audit of 1280 ED records of patients ≥16 years presenting with mTBI to a regional Australian ED. Case selection used the Victorian Admitted Episodes Dataset codes for suspected head injury: principal diagnosis codes (S00-T98), concussive injury recorded in diagnosis codes (S06.00-S06.05) and unintentional external cause code (V00-X59). The data were collected to determine 4-hour observation rates, CT scan rates, safe discharge and appropriate referral documentation.ResultsFewer people received a CT scan than qualified (n=245, 65.3%), only 45% had 4-hour observations recorded, safe discharge was documented in 74.1% of cases and 33% received educational resources.Discussion/conclusionSeveral key elements for the management of mTBI were under-recorded, particularly 4-hour observations, safe discharge and education. Acquired brain injury clinic referrals were received in overwhelmingly fewer cases than had a CT scan (n=19, 6.3%). Overall, this study suggests that the regional health service does not currently fully adhere to the CPG and that the referral services are potentially underutilised.

IntroductionAs cancer treatments may impact on fertility, a high priority for young patients with breast cancer is access to evidence-based, personalised information for them and their healthcare providers to guide treatment and fertility-related decisions prior to cancer treatment. Current tools to predict fertility outcomes after breast cancer treatments are imprecise and do not offer individualised prediction. To address the gap, we are developing a novel personalised infertility risk prediction tool (FoRECAsT) for premenopausal patients with breast cancer that considers current reproductive status, planned chemotherapy and adjuvant endocrine therapy to determine likely post-treatment infertility. The aim of this study is to explore the feasibility of implementing this FoRECAsT tool into clinical practice by exploring the barriers and facilitators of its use among patients and healthcare providers.Methods and analysisA cross-sectional exploratory study is being conducted using semistructured in-depth telephone interviews with 15–20 participants each from the following groups: (1) premenopausal patients with breast cancer younger than 40, diagnosed within last 5 years, (2) breast surgeons, (3) breast medical oncologists, (4) breast care nurses (5) fertility specialists and (6) fertility preservation nurses. Patients with breast cancer are being recruited from the joint Breast Service of three affiliated institutions of Victorian Comprehensive Cancer Centre in Melbourne, Australia—Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Royal Women’s Hospital, and clinicians are being recruited from across Australia. Interviews are being audio recorded, transcribed verbatim and imported into qualitative data analysis software to facilitate data management and analyses.Ethics and disseminationThe study protocol has been approved by Melbourne Health Human Research Ethics Committee, Australia (HREC number: 2017.163). Confidentiality and privacy are maintained at every stage of the study. Findings will be disseminated through peer-reviewed scholarly and scientific journals, national and international conference presentations, social media, broadcast media, print media, internet and various community/stakeholder engagement activities.

Objective The aim of the present study was to examine the timing and outcomes of patients requiring an unplanned transfer from subacute to acute care. Methods Subacute care in-patients requiring unplanned transfer to an acute care facility within four Victorian health services from 1 January to 31 December 2010 were included in the study. Data were collected using retrospective audit. The primary outcome was transfer within 24 h of subacute care admission. Results In all, 431 patients (median age 81 years) had unplanned transfers; of these, 37.8% had a limitation of medical treatment (LOMT) order. The median subacute care length of stay was 43 h: 29.0% of patients were transferred within 24 h and 83.5% were transferred within 72 h of subacute care admission. Predictors of transfer within 24 h were comorbidity weighting (odds ratio (OR) 1.1, P = 0.02) and LOMT order (OR 2.1, P < 0.01). Hospital admission occurred in 87.2% of patients and 15.4% died in hospital. Predictors of in-hospital mortality were comorbidity weighting (OR 1.2, P < 0.01) and the number of physiological abnormalities in the 24 h preceding transfer (OR 1.3, P < 0.01). Conclusions There is a high rate of unplanned transfers to acute care within 24 h of admission to subacute care. Unplanned transfers are associated with high hospital admission and in-hospital mortality rates. What is known about the topic? Subacute care is becoming a high acuity environment where many patients are at significant risk of clinical deterioration. Systems for recognising and responding to deteriorating patients are well developed in acute care, but still developing in subacute care. What does this paper add? This is the first Australian multisite study of clinical deterioration in patients situated in subacute care facilities. One-third of unplanned transfers occur within 24 h of admission to subacute care. Patients who require unplanned transfer from subacute to acute care have unexpectedly high hospital admission rates and high in-hospital mortality rates. The frequency and completeness of physiological monitoring preceding transfer was low. What are the implications for practitioners? Patients in subacute care require regular physiological assessment and early escalation of care if there are physiological abnormalities. Risk of clinical deterioration should be a factor in the decision to admit patients to subacute care after an acute illness or injury. There is a need to improve systems for recognising and responding to deteriorating patients in subacute care settings.

OBJECTIVES/SPECIFIC AIMS: The goal of this study is to use patient-centered qualitative techniques to determine what strategies caregivers use to cope with the stress of a child having recently (ie, within the past month) undergone surgical removal of a brain tumor. Results will eventually be evaluated and compared with results of quantitative measures of psychosocial risk and distress as well as demographic and medical characteristics. METHODS/STUDY POPULATION: All caregivers of patients with a newly diagnosed brain tumor requiring neurosurgery admitted to Children’s of Alabama (with English or Spanish-speaking parents) are eligible for enrollment. Participants are enrolled during their child’s initial hospitalization for surgical removal of a brain tumor. Approximately 1 month after hospital discharge, during a routine follow-up clinic visit, caregivers participate in a semistructured interview with a research assistant. Interview questions are used to obtain information about parent and family coping by asking first broadly about stress management over the previous month and then specifically about individual coping strategies. Semistructured interviews are audio recorded, transcribed, and coded for common themes. Interviews are coded by using specific words or phrases to describe various domains of the experience from the caregiver’s perspective. Each participant is given a study ID and study IDs are logged with each code word or phrase endorsed during the interview. RESULTS/ANTICIPATED RESULTS: To date, 22 caregivers have been enrolled and 15 have completed interviews. The most common coping mechanisms fall into the domains of active, avoidance, emotion-focused, and spiritual coping. Active coping consists of information seeking (eg, taking notes, internet research, asking questions), openly communicating emotions, celebrating small victories (eg, focusing on a good scan or test result, thinking that the diagnosis or treatment could have been worse), planning (eg, focusing on 1 d at a time), and maintaining normalcy (eg, maintaining extracurricular activities, returning to school if possible, continuing to see family and friends). Avoidance coping consists of evading discussions about emotions, withdrawal from family members, denial (eg, keeping a cancer diagnosis from the child), and avoiding seeing people or participating in activities. Emotion-focused coping consists of crying, laughing, and staying strong in front of the patient. In general, those who self-identify as coping poorly tend to be those who utilized more avoidance-focused coping strategies. Further, caregivers tended to identify active coping strategies (eg, taking notes, focusing on 1 appointment or treatment at a time) as the most helpful. DISCUSSION/SIGNIFICANCE OF IMPACT: It will be helpful for providers to more deeply understand the experience of caregivers whose children have recently undergone brain tumor resection and the strategies used to cope with the stress of the first month postsurgery. This information can be used to create standardized interventions for use during posthospitalization clinic visits. For example, if families continue to endorse that active coping mechanisms are the most helpful, providers can assist caregivers in developing these strategies (eg, uniformly provide notebooks and encourage caregivers to keep track of questions and appointment information, pair caregivers who are struggling with others who use more active coping strategies). Those utilizing more avoidance coping strategies may need more coaching and recommendations. A brief assessment could potentially be developed for caregivers dealing with this diagnosis, in order to quickly assess coping strategies and provide appropriate recommendations. Future analyses will determine whether initial coping strategies and adjustment are predicted by child age or medical information.

ABSTRACT: Teacher performance has been the focus of educational policy reforms in recent decades for the professional development of teachers. The purpose of this study was to determine the effect of teaching experience and peer teaching skills on basic training on ECE teacher performance. This research uses ex-post facto quantitative method of comparative analysis and design by level. The population is all ECE teachers who attend basic-level education and training in Tangerang Regency, totaling 3358 people consisting of 116 male teachers and 3,242 female teachers. Data collection techniques using a questionnaire with data analysis include descriptive analysis. Requirements test analysis and inferential analysis. The results show that there are differences in the performance of ECE teachers between teachers with more than five years of teaching experience and less than five years, in the group of ECE teachers with high peer teaching skills and low peer teaching skills. The implication of this research is that it is hoped that various parties will become more active in aligning ECE teacher training so that it can improve the performance of ECE teachers. Keywords: teaching experience, peer teaching ability, tiered basic training, ECE teacher performance References: Adeyemi, T. (2008). Influence of Teachers’ Teaching Experience on Students’ Learning Outcomes in Secondary Schools in Ondo State, Nigeria. African Journal of Educational Studies in Mathematics and Sciences, 5(1), 9–19. https://doi.org/10.4314/ajesms.v5i1.38609 Ahmad, N. J., Ishak, N. A., Samsudin, M. A., Meylani, V., & Said, H. M. (2019). Pre-service science teachers in international teaching practicum: Reflection of the experience. Jurnal Pendidikan IPA Indonesia, 8(3), 308–316. https://doi.org/10.15294/jpii.v8i3.18907 Andrin, G. R., Etcuban, J. O., Watin, A. K. O., Maluya, R., Rocha, E. D. V, & Maulit, A. A. (2017). Professional Preparation and Performance of Preschool Teachers in the Public and Private Schools of Cebu City, Philippines. ACADEME, 10. Andrin, Glenn R, Etcuban, J. O., Watin, A. K. O., Maluya, R., Rocha, E. D. V, & Maulit, A. A. (2017). Professional Preparation and Performance of Preschool Teachers in the Public and Private Schools of Cebu City, Philippines. ACADEME, 10. Armytage, P. (2018). Review of the Victorian Institute of Teaching. Bichi, A. A. (2019). Evaluation of Teacher Performance in Schools: Implication for Sustainable Evaluation of Teacher Performance in Schools: Implication for Sustainable Development Goals. December 2017. Campolo, M., Maritz, C. A., Thielman, G., & Packel, L. (2013). An Evaluation of Peer Teaching Across the Curriculum: Student Perspectives. International Journal of Therapies and Rehabilitation Research, 2(1), 1. https://doi.org/10.5455/ijtrr.00000016 Clearinghouse, W. W. (2018). National Board for Professional Teaching Standards Certification. Colthart, I., Bagnall, G., Evans, A., Allbutt, H., Haig, A., Illing, J., & McKinstry, B. (2008). The effectiveness of self-assessment on the identification of learner needs, learner activity, and impact on clinical practice: BEME Guide no. 10. Medical Teacher, 30(2), 124–145. Darling-Hammond, L. (2011). Teacher quality and student achievement. Teacher Quality and Student Achievement, 8(1), 1–215. https://doi.org/10.14507/epaa.v8n1.2000 Donaldson, M. L. (2009). So long, Lake Wobegon? Using teacher evaluation to raise teacher quality. Center for American Progress, 1–32. Fogaça, N., Rego, M. C. B., Melo, M. C. C., Armond, L. P., & Coelho, F. A. (2018). Job Performance Analysis: Scientific Studies in the Main Journals of Management and Psychology from 2006 to 2015. Performance Improvement Quarterly, 30(4), 231–247. https://doi.org/10.1002/piq.21248 Frye, E. M., Trathen, W., & Koppenhaver, D. A. (2010). Internet workshop and blog publishing: Meeting student (and teacher) learning needs to achieve best practice in the twenty-first-century social studies classroom. The Social Studies, 101(2), 46–53. Hanushek, E. A. (2011). The economic value of higher teacher quality. Economics of Education Review, 30(3), 466–479. Heryati, Y., & Rusdiana, A. (2015). Pendidikan Profesi Keguruan. Bandung: CV Pustaka Setia. John P. Papay Eric S. Taylor John H. Tyler Mary Laski. (2016). Learning Job Skills From Colleagues At Work: Evidence From A Field Experiment Using Teacher Performance Data (p. 49). Katz, L. G., & Raths, J. D. (1985). Dispositions as goals for teacher education. Teaching and Teacher Education, 1(4), 301–307. Kavanoz, S., & Yüksel, G. (2015). An Investigation of Peer-Teaching Technique in Student Teacher Development An Investigation of Peer-Teaching Technique in Student Teacher Development. June 2010. Kurniawan, A. R., Chan, F., Sargandi, M., Yolanda, S., Karomah, R., Setianingtyas, W., & Irani, S. (2019). Kebijakan Sekolah Dalam Penggunaan Gadget di Sekolah Dasar. Jurnal Tunas Pendidikan, 2(1), 72–81. Lim, L. L. (2014). A case study on peer-teaching. Open Journal of Social Sciences, 2(08), 35. Manchishi, P. C., & Mwanza, D. S. (2016). Teacher Preparation at the University of Zambia: Is Peer Teaching Still a Useful Strategy? International Journal of Humanities, Social Sciences and Education, 3(11), 88–100. https://doi.org/10.20431/2349-0381.0311012 Mansur, M. (2007). KTSP: Pembelajaran Berbasis Kompetensi dan Kontekstual, Jakarta: PT. Bumi. Marais, P., & Meier, C. (2004). Hear our voices: Student teachers’ experiences during practical teaching. Africa Education Review, 1(2), 220–233. https://doi.org/10.1080/18146620408566281 McFarland, J., Hussar, B., Wang, X., Zhang, J., Wang, K., Rathbun, A., Barmer, A., Cataldi, E. F., & Mann, F. B. (2018). The Condition of Education 2018. NCES 2018-144. National Center for Education Statistics. Meilanie, R. S. M., & Syamsiatin, E. (2020). Multi Perspectives on Play Based Curriculum Quality Standards in the Center Learning Model. Jurnal Pendidikan Usia Dini, 14(1), 15–31. Michael Luna, S. (2016). (Re)defining “good teaching”: Teacher performance assessments and critical race theory in early childhood teacher education. Contemporary Issues in Early Childhood, 17(4), 442–446. https://doi.org/10.1177/1463949116677932 Morgan, G. B., Hodge, K. J., Trepinski, T. M., & Anderson, L. W. (2014). The Stability of Teacher Performance and Effectiveness: Implications for Policies Concerning Teacher Evaluation Grant. Mulyasa, E. (2013). Uji kompetensi dan Penilaian Kinerja guru. Bandung: PT Remaja Rosdakarya. Nasrun, Dr., & Ambarita, D. F. P. (2017). The Effect of Organizational Culture and Work Motivation on Teachers Performance of Public Senior High School in Tebing Tinggi. Atlantis Press, 118, 320–326. https://doi.org/10.2991/icset-17.2017.53 Nguyen, M. (2013). Peer tutoring as a strategy to promote academic success. Research Brief. Noelke, C., & Horn, D. (2010). OECD Review on Evaluation and Assessment Frameworks for Improving School Outcomes-Hungary Country Background Report. OECD: PARIS. OECD. (2005). Teacher’s matter. Attracting, developing, and retaining effective teachers. Paris. OECD-Education Committee. Pablo Fraser, Gabor Fülöp, M. L. and M. S. D. (2018). I.  What teachers and school leaders say about their jobs. TALIS, 2, 1–7. Parihar, K. S., Campus, D., Principal, J., & Campus, D. (2017). Study Of Effect Of Pre Teaching Training Experience On. 5, 59–62. https://doi.org/10.5281/zenodo.1039595 Parsons, S. A., Vaughn, M., Scales, R. Q., Gallagher, M. A., Parsons, A. W., Davis, S. G., Pierczynski, M., & Allen, M. (2018). Teachers’ instructional adaptations: A research synthesis. Review of Educational Research, 88(2), 205–242. Pillay, R., & Laeequddin, M. (2019). Peer teaching: A pedagogic method for higher education. International Journal of Innovative Technology and Exploring Engineering, 9(1), 2907–2913. https://doi.org/10.35940/ijitee.A9106.119119 Popova, A., Evans, D. K., & Arancibia, V. (2018). Training Teachers on the Job What Works and How to Measure It. Policy Research Working Paper, September 2016. Ramadoni, W., Kusmintardjo, K., & Arifin, I. (2016). Kepemimpinan Kepala Sekolah dalam Upaya Peningkatan Kinerja Guru (Studi Multi Kasus di Paud Islam Sabilillah dan Sdn Tanjungsari 1 Kabupaten Sidoarjo). Jurnal Pendidikan: Teori, Penelitian, Dan Pengembangan, 1(8), 1500–1504. Rees, E. L., Quinn, P. J., Davies, B., & Fotheringham, V. (2016). How does peer teaching compare to faculty teaching? A systematic review and meta-analysis. Medical Teacher, 38(8), 829–837. Sawchuk, S. (2015). Teacher evaluation: An issue overview. Education Week, 35(3), 1–6. Skourdoumbis, A. (2018). Theorising teacher performance dispositions in an age of audit. 1–16. https://doi.org/10.1002/berj.3492 Springer, M. G., Swain, W. A., & Rodriguez, L. A. (2016). Effective teacher retention bonuses: Evidence from Tennessee. Educational Evaluation and Policy Analysis, 38(2), 199–221. Staiger, D. O., & Rockoff, J. E. (2010). Searching for effective teachers with imperfect information. Journal of Economic Perspectives, 24(3), 97–118. Suyatno, H., & Pd, M. (2008). Panduan sertifikasi guru. Jakarta: PT Macanan Jaya Cemerlang. ten Cate, O. (2017). Practice Report / Bericht aus der Praxis: Peer teaching: From method to philosophy. Zeitschrift Fur Evidenz, Fortbildung Und Qualitat Im Gesundheitswesen, 127–128, 85–87. https://doi.org/10.1016/j.zefq.2017.10.005 Thurlings, M., & den Brok, P. (2018). Student teachers’ and in-service teachers’ peer learning: A realist synthesis. Educational Research and Evaluation, 24(1–2), 13–50. https://doi.org/10.1080/13803611.2018.1509719 Toch, T., & Rothman, R. (2008). Rush to Judgment: Teacher Evaluation in Public Education. Education Sector Reports. Education Sector. Ünal, Z., & Unal, A. (2012). The Impact of Years of Teaching Experience on the Classroom Management Approaches of Elementary School Teachers. International Journal of Instruction, 5(2), 41–60. Vasay, E. T. (2010). The effects of peer teaching in the performance of students in mathematics. E-International Scientific Research Journal, 2(2), 161–171. Weisberg, D., Sexton, S., Mulhern, J., Keeling, D., Schunck, J., Palcisco, A., & Morgan, K. (2009). The widget effect: Our national failure to acknowledge and act on differences in teacher effectiveness. New Teacher Project. Winters, M. A., & Cowen, J. M. (2013). Would a value‐added system of retention improve the distribution of teacher quality? A Simulation of Alternative Policies. Journal of Policy Analysis and Management, 32(3), 634–654.

Objective Off-protocol prescribing of systemic anti-cancer therapy (SACT) can lead to concerns about effectiveness of patient care. To identify variations in practice, a toolkit was developed for health services to address patient safety and the risk of sub-optimal outcomes for patients. Data sources Following significant incidents with SACT in South Australia and New South Wales, the Department of Health and Human Services, Victoria (the department) conducted an assessment of Victorian public health services to understand current practice regarding SACT protocol governance. A literature review examining SACT auditing was also undertaken to guide improvements. A department supported Chemotherapy Audit Toolkit (CAT) was created for implementation at public hospitals in Victoria. A post-implementation survey was done on uptake and issue identification. Data summary An initial assessment showed that 27% of Victorian public health services were undertaking retrospective review of SACT dosing, which was targeted for improvement. The literature review identified little guidance, however an audit of current sector practices found several audit methodologies. A process that involved audits by health services assessing their own practice was adopted. The toolkit was developed and piloted with health services. A post-implementation survey showed that 20% of services were using the toolkit, 35% were implementing the toolkit and 45% did not use the toolkit. Conclusions The VicTAG CAT has been adopted by more than half of Victorian public health services and is being used to influence prescribing. Implementation of the toolkit has been affected by resource reallocation due to the COVID-19 pandemic. The CAT is available online.

Objectives: The main objective of the study is to clinically audit and analyse the acute asthma exacerbations in children younger than 12 years regarding management of emergency department. Methods: This clinical audit was done in Bahawal Victoria Hospital, Bahawalpur during January 2020 till June 2020. We retrospectively revised all the files of children aged 0–12 years who were visited for acute asthma in the Paediatric ED of Hospital. All the patients with a diagnosis of “acute asthma,” “wheezing bronchitis,” and “bronchospasm” were included. Results: A total of 864 patients were seen in the Emergency Department during the study. Of these, a total of 293 patients were seen for a presentation of acute asthma. As some patients had multiple visits, the 293 records represented 278 unique patients. For assessing age and gender distribution of the patients, only data from the first visit were used. Otherwise, each record was treated independently for the purpose of analyses. Conclusion: It is concluded that acute asthma management still remains an area of medical practice that continues to have long-standing difficulties.

Abstract Background Benchmarking outcomes across settings commonly requires risk-adjustment for co-morbidities that must be derived from extant sources that were designed for other purposes. A question arises as to the extent to which differing available sources for health data will be concordant when inferring the type and severity of co-morbidities, how close are these to the “truth”. We studied the level of concordance for same-patient comorbidity data extracted from administrative data (coded from International Classification of Diseases, Australian modification,10th edition [ICD-10 AM]), from the medical chart audit, and data self-reported by men with prostate cancer who had undergone a radical prostatectomy. Methods We included six hospitals (5 public and 1 private) contributing to the Prostate Cancer Outcomes Registry-Victoria (PCOR-Vic) in the study. Eligible patients from the PCOR-Vic underwent a radical prostatectomy between January 2017 and April 2018.Health Information Manager’s in each hospital, provided each patient’s associated administrative ICD-10 AM comorbidity codes. Medical charts were reviewed to extract comorbidity data. The self-reported comorbidity questionnaire (SCQ) was distributed through PCOR-Vic to eligible men. Results The percentage agreement between the administrative data, medical charts and self-reports ranged from 92 to 99% in the 122 patients from the 217 eligible participants who responded to the questionnaire. The presence of comorbidities showed a poor level of agreement between data sources. Conclusion Relying on a single data source to generate comorbidity indices for risk-modelling purposes may fail to capture the reality of a patient’s disease profile. There does not appear to be a ‘gold-standard’ data source for the collection of data on comorbidities.

Pressure injuries (PIs) substantively impact quality of care during hospital stays, although only when they are severe or acquired as a result of the hospital stay are they reported as quality indicators. Globally, researchers have repeatedly highlighted the need to invest more in quality improvement, risk assessment, prevention, early detection, and care for PI to avoid the higher costs associated with treatment of PI. Coders' perspectives on quality assurance of the clinical coded PI data have never been investigated. This study aimed to explore challenges that hospital coders face in accurately coding and reporting PI data and subsequently, explore reasons why data sources may vary in their reporting of PI data. This article is based upon data collected as part of a multi-phase collaborative project to build capacity for optimizing PI prevention across Monash Partners health services. We have conducted 16 semi-structured phone interviews with clinical coders recruited from four participating health services located in Melbourne, Australia. One of the main findings was that hospital coders often lacked vital information in clinicians' records needed to code PI and report quality indicators accurately and highlighted the need for quality improvement processes for PI clinical documentation. Nursing documentation improvement is a vital component of the complex capacity building programs on PI prevention in acute care services and is relied on by coders. Coders reported the benefit of inter-professional collaborative workshops, where nurses and coders shared their perspectives. Collaborative workshops had the potential to improve coders' knowledge of PI classification and clinicians' understanding of what information should be included when documenting PI in the medical notes. Our findings identified three methods of quality assurance were important to coders to ensure accuracy of PI reporting: (1) training prior to initiation of coding activity and (2) continued education, and (3) audit and feedback communication about how to handle specific complex cases and complex documentation. From a behavioral perspective, most of the coders reported confidence in their own abilities and were open to changes in coding standards. Transitioning from paper-based to electronic records highlighted the need to improve training of both clinicians and coders.

Abstract Aim In Northern Ireland on 31/12/19 90,514 patients were awaiting admission/day case procedure. The 2019/2020 Ministerial waiting time target states that by March 2020, 55% of patients should not wait longer than 13 weeks for inpatient/day case treatment, and no patient should wait longer than 52 weeks. This audit investigates the impact of long waiting times in endocrine surgery and how they impact patient safety. Method Data was collected from the endocrine surgery waiting list in the Royal Victoria Hospital, Belfast, up to 6/2/20. Number of days spent on the waiting list, disease complications and the number of days before they occurred were collated. Results 118 patients were awaiting endocrine surgery. The average waiting time was 533 days. 21 patients experience 27 complications related to their endocrine disease whilst waiting for surgery. The average duration before complications was 490 days; 4 required admission, 11 required medical intervention and 3 required a surgical intervention. Conclusions The average waiting time for endocrine surgery is greater than 52 weeks. In Northern Ireland no one should be waiting more than 52 weeks. The length of the waiting list has resulted in 1 in 5 experiencing complications and prolonged suffering from under-treated disease. This is a significant patient safety concern. Urgent action to address waiting lists is required and the disruption caused by COVID-19 should be used as a catalyst for reform.

Background: Health information governance (IG) in Australian hospitals was hitherto unexplored. Objectives: To determine hospitals’ health IG status and maturity in Victoria, Australia, identify drivers and barriers affecting IG adoption, examine electronic health data breach response plan usage and assess employees’ electronic data breach awareness. Method: Mixed-methods descriptive study utilising an online survey of directors – clinical/health information services and chief health information managers (HIMs) in Victorian hospitals, ≥50 beds. Results: Response rate: 42.9% ( n = 36). Fifty percent ( n = 17) of respondent-hospitals had an IG program. IG equally supported decision-making and risk identification and prevention. The greatest potential organisational damages from system disruption or failure were information loss (66.7%) and clinical risks (63.9%). HIMs in 15 (55.6%) hospitals had knowledge to monitor and detect electronic data breaches. Staff in 19 (70.4%) hospitals knew who to inform about a suspected breach. Most hospitals had mature health information-related IG practices, most (88.9%, n = 24) provided IG-related education, 77.8% ( n = 21) regularly reviewed data breach response plans. The strongest IG drivers were privacy-security compliance and changes to data capture or documentation practices (82.8%, n = 24); the greatest barriers were implementation complexity (57.1%, n = 16) and cost (55.6%, n = 15). Conclusion: These baseline Australian data show 50% of respondent-hospitals had no formal health IG program. Privacy-security compliance, and audits, needed improvement; however, most hospitals had well-developed medical record/health information IG-relevant schedules, policies and practices. HIMs, the professionals most engaged in IG, required upskilling in electronic data breach detection.

Objectives: In the new era of voluntary assisted dying (VAD) legislation in Australia, this study aimed to explore (1) underlying reasons for desire to die statements (DTDSs), (2) clinician responses to DTDSs and (3) whether DTDSs were a true request for VAD. Methods: Clinical audit using an existing prospectively collected quality assurance database, supplemented by electronic medical records. Patients known to a consultation-liaison palliative care service who expressed a DTDS between October 2019 and September 2020 were included. Results: Forty-one patients were included; 29 (71%) were male, 29 (71%) had a malignancy and 31 (76%) expressed a DTDS more than once. Uncontrolled psychological symptoms were present more often than physical (n = 30 vs 19 [73% vs 46%]), yet physical symptoms were addressed more frequently than psychological (80% vs 63% of the time). Based on available data, the VAD assessment process was commenced by 7 patients, and death by VAD occurred for 2 patients. Conclusions: In our study, DTDSs were complex, multi-layered requests that more commonly reflected psychological rather than physical suffering. Though VAD is now legally possible, a DTDS was not always synonymous with a request for VAD. Key to responding to these requests are high levels of clinician confidence and communication skills. Training in this area remains critical for the experience of both patients and clinicians.

ABSTRACTObjective:To explore the impact of psychiatric comorbidities on all-cause mortality in adults with epilepsy from a cohort of patients admitted for video-electroencephalogram monitoring (VEM) over two decades.Methods:A retrospective medical records audit was conducted on 2709 adults admitted for VEM and diagnosed with epilepsy at three Victorian comprehensive epilepsy programs from 1995-2015. 1805 patients were identified in whom the record of a clinical evaluation by a neuropsychiatrist was available, excluding 27 patients who died from a malignant brain tumour known at the time of VEM admission. Epilepsy and lifetime psychiatric diagnoses were determined from consensus opinion of epileptologists and neuropsychiatrists involved in the care of each patient. Mortality and cause of death were determined by linkage to the Australian National Death Index and National Coronial Information System.Results:Compared to the general population, mortality was higher in people with epilepsy (PWE) with a psychiatric illness (standardised mortality ratio [SMR] 3.6) and without a psychiatric illness (SMR 2.5). PWE with a psychiatric illness had greater mortality compared to PWE without (hazards ratio 1.41, 95% confidence interval 1.02-1.97) after adjusting for age and sex. No single psychiatric disorder by itself conferred increased mortality in PWE. The distribution of causes of death remained similar between PWE with psychiatric comorbidities and those without.Conclusion:The presence of comorbid psychiatric disorders in adults with epilepsy is associated with increased mortality, highlighting the importance of identifying and treating psychiatric comorbidities in these patients.

BackgroundDiabetes distress, experienced by up to 40% of people with type two diabetes, is the negative emotional response to the burden of living with and managing diabetes. It is associated with sub-optimal glycaemia and diabetes self-management. Research indicates that people with diabetes do not recall being asked about emotional distress by health care professionals.AimExplore the experiences, needs and expectations of people with type two diabetes regarding emotional support received in Australian general practice.Design & SettingExploratory qualitative study in Victoria, Australia.MethodSemi-structured interviews exploring emotional health and support received in general practice in twelve adults with type two diabetes who primarily attend general practice. Interviews were audio-recorded, transcribed verbatim, and analysed using the framework approach.ResultsThree major themes were identified: 1) Beneath the surface of diabetes care; 2) Importance of GP-patient relationship; 3) Communication counts. Participants experienced diabetes care as focused primarily on medical management, rather than the emotional aspects of living with type two diabetes. While people’s experiences of diabetes care in general practice primarily focused on physical health, the GP care beyond the presenting complaint has an essential role in identifying emotional issues and enabling support. Emotional issues were more likely to be discussed and acknowledged by the GP where there was a long-standing relationship between GP and patient.ConclusionPre-existing positive GP-patient relationships and supportive communication enable people with type two diabetes to raise emotional issues as part of diabetes care.

Background: Globally, tuberculosis (TB) is the second major cause of death from infectious diseases, particularly in developing countries. A multidisciplinary approach to the management of TB may help to curb the disease burden.Objective: The objective of this study was to outline the perceptions of healthcare professionals and patients regarding the potential role of pharmacists in TB management in Pakistan.Method: This was a large-scale qualitative study conducted at the Chest Disease Unit (CDU) of the Bahawal Victoria Hospital (BVH), Punjab, Pakistan. Data were collected through semi-structured interviews with physicians, pharmacists, and patients recruited using a mix of convenient and snowball sampling. The sample size was decided through standard saturation point criteria. All interviews were audio recorded and transcribed verbatim. The data were analyzed to draw conclusions using a thematic analysis approach.Results: Analysis of the data yielded 19 categories and seven themes. Physicians considered pharmacists qualified healthcare professionals, whereas patients considered them merely dispensers. Inventory management and dispensing of medicines were considered as major responsibilities of pharmacists. Physicians were extremely overburdened and wanted to delegate certain duties to pharmacists, subject to their prior extensive trainings. However, most of the physicians were unaware of the legal scope of pharmacy practice in Pakistan. With regard to the potential duties of pharmacists, physicians, pharmacists, and patients (patients—upon explaining the potential roles during the interview) endorsed monitoring, counseling, medicine brand selection, dose adjustment, inventory management, dispensing, and polypharmacy assessment as their potential roles. In view of all stakeholders, the rationale for integrating pharmacists in TB management included overburdened physicians, sub-standard patient care, medication safety issues, and patient dissatisfaction. The healthcare professionals highlighted that the major barriers to integrating pharmacists within the TB management system were limited interest of regulatory authorities and policy makers, followed by inadequate training and experience-driven questionable competency of pharmacists.Conclusion: The study participants acknowledged the potential role of pharmacists in TB management. However, it was emphasized that healthcare policy makers should devise strategies to overcome the underlying barriers before assigning medicine-related clinical roles to pharmacists.

In the last months of his life, 86-year-old Albert Facey became a best-selling author and revered cultural figure following the publication of his autobiography, A Fortunate Life. Released on Anzac Day 1981, it was praised for its “plain, unembellished, utterly sincere and un-self-pitying account of the privations of childhood and youth” (Semmler) and “extremely powerful description of Gallipoli” (Dutton 16). Within weeks, critic Nancy Keesing declared it an “Enduring Classic.” Within six months, it was announced as the winner of two prestigious non-fiction awards, with judges acknowledging Facey’s “extraordinary memory” and “ability to describe scenes and characters with great precision” (“NBC” 4). A Fortunate Life also transformed the fortunes of its publisher. Founded in 1976 as an independent, not-for-profit publishing house, Fremantle Arts Centre Press (FACP) might have been expected, given the Australian average, to survive for just a few years. Former managing editor Ray Coffey attributes the Press’s ongoing viability, in no small measure, to Facey’s success (King 29). Along with Wendy Jenkins, Coffey edited Facey’s manuscript through to publication; only five months after its release, with demand outstripping the capabilities, FACP licensed Penguin to take over the book’s production and distribution. Adaptations soon followed. In 1984, Kerry Packer’s PBL launched a prospectus for a mini-series, which raised a record $6.3 million (PBL 7–8). Aired in 1986 with a high-rating documentary called The Facey Phenomenon, the series became the most watched television event of the year (Lucas). Syndication of chapters to national and regional newspapers, stage and radio productions, audio- and e-books, abridged editions for young readers, and inclusion on secondary school curricula extended the range and influence of Facey’s life writing. Recently, an option was taken out for a new television series (Fraser).A hundred reprints and two million readers on from initial publication, A Fortunate Life continues to rate among the most appreciated Australian books of all time. Commenting on a reader survey in 2012, writer and critic Marieke Hardy enthused, “I really loved it [. . .] I felt like I was seeing a part of my country and my country’s history through a very human voice . . .” (First Tuesday Book Club). Registering a transformed reading, Hardy’s reference to Australian “history” is unproblematically juxtaposed with amused delight in an autobiography that invents and embellishes: not believing “half” of what Facey wrote, she insists he was foremost a yarn spinner. While the work’s status as a witness account has become less authoritative over time, it seems appreciation of the author’s imagination and literary skill has increased (Williamson). A Fortunate Life has been read more commonly as an uncomplicated, first-hand account, such that editor Wendy Jenkins felt it necessary to refute as an “utter mirage” that memoir is “transferred to the page by an act of perfect dictation.” Sidonie Smith and Julia Watson argue of life narratives that some “autobiographical claims [. . .] can be verified or discounted by recourse to documentation outside the text. But autobiographical truth is a different matter” (16). With increased access to archives, especially digitised personnel records, historians have asserted that key elements of Facey’s autobiography are incorrect or “fabricated” (Roberts), including his enlistment in 1914 and participation in the Gallipoli Landing on 25 April 1915. We have researched various sources relevant to Facey’s early years and war service, including hard-copy medical and repatriation records released in 2012, and find A Fortunate Life in a range of ways deviates from “documentation outside of the text,” revealing intriguing, layered storytelling. We agree with Smith and Watson that “autobiographical acts” are “anything but simple or transparent” (63). As “symbolic interactions in the world,” they are “culturally and historically specific” and “engaged in an argument about identity” (63). Inevitably, they are also “fractured by the play of meaning” (63). Our approach, therefore, includes textual analysis of Facey’s drafts alongside the published narrative and his medical records. We do not privilege institutional records as impartial but rather interpret them in terms of their hierarchies and organisation of knowledge. This leads us to speculate on alternative readings of A Fortunate Life as an illness narrative that variously resists and subscribes to dominant cultural plots, tropes, and attitudes. Facey set about writing in earnest in the 1970s and generated (at least) three handwritten drafts, along with a typescript based on the third draft. FACP produced its own working copy from the typescript. Our comparison of the drafts offers insights into the production of Facey’s final text and the otherwise “hidden” roles of editors as transformers and enablers (Munro 1). The notion that a working man with basic literacy could produce a highly readable book in part explains Facey’s enduring appeal. His grandson and literary executor, John Rose, observed in early interviews that Facey was a “natural storyteller” who had related details of his life at every opportunity over a period of more than six decades (McLeod). Jenkins points out that Facey belonged to a vivid oral culture within which he “told and retold stories to himself and others,” so that they eventually “rubbed down into the lines and shapes that would so memorably underpin the extended memoir that became A Fortunate Life.” A mystique was thereby established that “time” was Albert Facey’s “first editor” (Jenkins). The publisher expressly aimed to retain Facey’s voice, content, and meaning, though editing included much correcting of grammar and punctuation, eradication of internal inconsistencies and anomalies, and structural reorganisation into six sections and 68 chapters. We find across Facey’s drafts a broadly similar chronology detailing childhood abandonment, life-threatening incidents, youthful resourcefulness, physical prowess, and participation in the Gallipoli Landing. However, there are also shifts and changed details, including varying descriptions of childhood abuse at a place called Cave Rock; the introduction of (incompatible accounts of) interstate boxing tours in drafts two and three which replace shearing activities in Draft One; divergent tales of Facey as a world-standard athlete, league footballer, expert marksman, and powerful swimmer; and changing stories of enlistment and war service (see Murphy and Nile, “Wounded”; “Naked”).Jenkins edited those sections concerned with childhood and youth, while Coffey attended to Facey’s war and post-war life. Drawing on C.E.W. Bean’s official war history, Coffey introduced specificity to the draft’s otherwise vague descriptions of battle and amended errors, such as Facey’s claim to have witnessed Lord Kitchener on the beach at Gallipoli. Importantly, Coffey suggested the now famous title, “A Fortunate Life,” and encouraged the author to alter the ending. When asked to suggest a title, Facey offered “Cave Rock” (Interview)—the site of his violent abuse and humiliation as a boy. Draft One concluded with Facey’s repatriation from the war and marriage in 1916 (106); Draft Two with a brief account of continuing post-war illness and ultimate defeat: “My war injuries caught up with me again” (107). The submitted typescript concludes: “I have often thought that going to War has caused my life to be wasted” (Typescript 206). This ending differs dramatically from the redemptive vision of the published narrative: “I have lived a very good life, it has been very rich and full. I have been very fortunate and I am thrilled by it when I look back” (412).In The Wounded Storyteller, Arthur Frank argues that literary markets exist for stories of “narrative wreckage” (196) that are redeemed by reconciliation, resistance, recovery, or rehabilitation, which is precisely the shape of Facey’s published life story and a source of its popularity. Musing on his post-war experiences in A Fortunate Life, Facey focuses on his ability to transform the material world around him: “I liked the challenge of building up a place from nothing and making a success where another fellow had failed” (409). If Facey’s challenge was building up something from nothing, something he could set to work on and improve, his life-writing might reasonably be regarded as a part of this broader project and desire for transformation, so that editorial interventions helped him realise this purpose. Facey’s narrative was produced within a specific zeitgeist, which historian Joy Damousi notes was signalled by publication in 1974 of Bill Gammage’s influential, multiply-reprinted study of front-line soldiers, The Broken Years, which drew on the letters and diaries of a thousand Great War veterans, and also the release in 1981 of Peter Weir’s film Gallipoli, for which Gammage was the historical advisor. The story of Australia’s war now conceptualised fallen soldiers as “innocent victims” (Damousi 101), while survivors were left to “compose” memories consistent with their sacrifice (Thomson 237–54). Viewing Facey’s drafts reminds us that life narratives are works of imagination, that the past is not fixed and memory is created in the present. Facey’s autobiographical efforts and those of his publisher to improve the work’s intelligibility and relevance together constitute an attempt to “objectify the self—to present it as a knowable object—through a narrative that re-structures [. . .] the self as history and conclusions” (Foster 10). Yet, such histories almost invariably leave “a crucial gap” or “censored chapter.” Dennis Foster argues that conceiving of narration as confession, rather than expression, “allows us to see the pathos of the simultaneous pursuit and evasion of meaning” (10); we believe a significant lacuna in Facey’s life writing is intimated by its various transformations.In a defining episode, A Fortunate Life proposes that Facey was taken from Gallipoli on 19 August 1915 due to wounding that day from a shell blast that caused sandbags to fall on him, crush his leg, and hurt him “badly inside,” and a bullet to the shoulder (348). The typescript, however, includes an additional but narratively irreconcilable date of 28 June for the same wounding. The later date, 19 August, was settled on for publication despite the author’s compelling claim for the earlier one: “I had been blown up by a shell and some 7 or 8 sandbags had fallen on top of me, the day was the 28th of June 1915, how I remembered this date, it was the day my brother Roy had been killed by a shell burst.” He adds: “I was very ill for about six weeks after the incident but never reported it to our Battalion doctor because I was afraid he would send me away” (Typescript 205). This account accords with Facey’s first draft and his medical records but is inconsistent with other parts of the typescript that depict an uninjured Facey taking a leading role in fierce fighting throughout July and August. It appears, furthermore, that Facey was not badly wounded at any time. His war service record indicates that he was removed from Gallipoli due to “heart troubles” (Repatriation), which he also claims in his first draft. Facey’s editors did not have ready access to military files in Canberra, while medical files were not released until 2012. There existed, therefore, virtually no opportunity to corroborate the author’s version of events, while the official war history and the records of the State Library of Western Australia, which were consulted, contain no reference to Facey or his war service (Interview). As a consequence, the editors were almost entirely dependent on narrative logic and clarifications by an author whose eyesight and memory had deteriorated to such an extent he was unable to read his amended text. A Fortunate Life depicts men with “nerve sickness” who were not permitted to “stay at the Front because they would be upsetting to the others, especially those who were inclined that way themselves” (350). By cross referencing the draft manuscripts against medical records, we can now perceive that Facey was regarded as one of those nerve cases. According to Facey’s published account, his wounds “baffled” doctors in Egypt and Fremantle (353). His medical records reveal that in September 1915, while hospitalised in Egypt, his “palpitations” were diagnosed as “Tachycardia” triggered by war-induced neuroses that began on 28 June. This suggests that Facey endured seven weeks in the field in this condition, with the implication being that his debility worsened, resulting in his hospitalisation. A diagnosis of “debility,” “nerves,” and “strain” placed Facey in a medical category of “Special Invalids” (Butler 541). Major A.W. Campbell noted in the Medical Journal of Australia in 1916 that the war was creating “many cases of little understood nervous and mental affections, not only where a definite wound has been received, but in many cases where nothing of the sort appears” (323). Enlisted doctors were either physicians or surgeons and sometimes both. None had any experience of trauma on the scale of the First World War. In 1915, Campbell was one of only two Australian doctors with any pre-war experience of “mental diseases” (Lindstrom 30). On staff at the Australian Base Hospital at Heliopolis throughout the Gallipoli campaign, he claimed that at times nerve cases “almost monopolised” the wards under his charge (319). Bearing out Facey’s description, Campbell also reported that affected men “received no sympathy” and, as “carriers of psychic contagion,” were treated as a “source of danger” to themselves and others (323). Credentialed by royal colleges in London and coming under British command, Australian medical teams followed the practice of classifying men presenting “nervous or mental symptoms” as “battle casualties” only if they had also been wounded by “enemy action” (Loughran 106). By contrast, functional disability, with no accompanying physical wounds, was treated as unmanly and a “hysterical” reaction to the pressures of war. Mental debility was something to be feared in the trenches and diagnosis almost invariably invoked charges of predisposition or malingering (Tyquin 148–49). This shifted responsibility (and blame) from the war to the individual. Even as late as the 1950s, medical notes referred to Facey’s condition as being “constitutional” (Repatriation).Facey’s narrative demonstrates awareness of how harshly sufferers were treated. We believe that he defended himself against this with stories of physical injury that his doctors never fully accepted and that he may have experienced conversion disorder, where irreconcilable experience finds somatic expression. His medical diagnosis in 1915 and later life writing establish a causal link with the explosion and his partial burial on 28 June, consistent with opinion at the time that linked concussive blasts with destabilisation of the nervous system (Eager 422). Facey was also badly shaken by exposure to the violence and abjection of war, including hand-to-hand combat and retrieving for burial shattered and often decomposed bodies, and, in particular, by the death of his brother Roy, whose body was blown to pieces on 28 June. (A second brother, Joseph, was killed by multiple bayonet wounds while Facey was convalescing in Egypt.) Such experiences cast a different light on Facey’s observation of men suffering nerves on board the hospital ship: “I have seen men doze off into a light sleep and suddenly jump up shouting, ‘Here they come! Quick! Thousands of them. We’re doomed!’” (350). Facey had escaped the danger of death by explosion or bayonet but at a cost, and the war haunted him for the rest of his days. On disembarkation at Fremantle on 20 November 1915, he was admitted to hospital where he remained on and off for several months. Forty-one other sick and wounded disembarked with him (HMAT). Around one third, experiencing nerve-related illness, had been sent home for rest; while none returned to the war, some of the physically wounded did (War Service Records). During this time, Facey continued to present with “frequent attacks of palpitation and giddiness,” was often “short winded,” and had “heart trouble” (Repatriation). He was discharged from the army in June 1916 but, his drafts suggest, his war never really ended. He began a new life as a wounded Anzac. His dependent and often fractious relationship with the Repatriation Department ended only with his death 66 years later. Historian Marina Larsson persuasively argues that repatriated sick and wounded servicemen from the First World War represented a displaced presence at home. Many led liminal lives of “disenfranchised grief” (80). Stephen Garton observes a distinctive Australian use of repatriation to describe “all policies involved in returning, discharging, pensioning, assisting and training returned men and women, and continuing to assist them throughout their lives” (74). Its primary definition invokes coming home but to repatriate also implies banishment from a place that is not home, so that Facey was in this sense expelled from Gallipoli and, by extension, excluded from the myth of Anzac. Unlike his two brothers, he would not join history as one of the glorious dead; his name would appear on no roll of honour. Return home is not equivalent to restoration of his prior state and identity, for baggage from the other place perpetually weighs. Furthermore, failure to regain health and independence strains hospitality and gratitude for the soldier’s service to King and country. This might be exacerbated where there is no evident or visible injury, creating suspicion of resistance, cowardice, or malingering. Over 26 assessments between 1916 and 1958, when Facey was granted a full war pension, the Repatriation Department observed him as a “neuropathic personality” exhibiting “paroxysmal tachycardia” and “neurocirculatory asthenia.” In 1954, doctors wrote, “We consider the condition is a real handicap and hindrance to his getting employment.” They noted that after “attacks,” Facey had a “busted depressed feeling,” but continued to find “no underlying myocardial disease” (Repatriation) and no validity in Facey’s claims that he had been seriously physically wounded in the war (though A Fortunate Life suggests a happier outcome, where an independent medical panel finally locates the cause of his ongoing illness—rupture of his spleen in the war—which results in an increased war pension). Facey’s condition was, at times, a source of frustration for the doctors and, we suspect, disappointment and shame to him, though this appeared to reduce on both sides when the Repatriation Department began easing proof of disability from the 1950s (Thomson 287), and the Department of Veteran’s Affairs was created in 1976. This had the effect of shifting public and media scrutiny back onto a system that had until then deprived some “innocent victims of the compensation that was their due” (Garton 249). Such changes anticipated the introduction of Post-Traumatic Shock Disorder (PTSD) to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. Revisions to the DSM established a “genealogy of trauma” and “panic disorders” (100, 33), so that diagnoses such as “neuropathic personality” (Echterling, Field, and Stewart 192) and “soldier’s heart,” that is, disorders considered “neurotic,” were “retrospectively reinterpreted” as a form of PTSD. However, Alberti points out that, despite such developments, war-related trauma continues to be contested (80). We propose that Albert Facey spent his adult life troubled by a sense of regret and failure because of his removal from Gallipoli and that he attempted to compensate through storytelling, which included his being an original Anzac and seriously wounded in action. By writing, Facey could shore up his rectitude, work ethic, and sense of loyalty to other servicemen, which became necessary, we believe, because repatriation doctors (and probably others) had doubted him. In 1927 and again in 1933, an examining doctor concluded: “The existence of a disability depends entirely on his own unsupported statements” (Repatriation). We argue that Facey’s Gallipoli experiences transformed his life. By his own account, he enlisted for war as a physically robust and supremely athletic young man and returned nine months later to life-long anxiety and ill-health. Publication transformed him into a national sage, earning him, in his final months, the credibility, empathy, and affirmation he had long sought. Exploring different accounts of Facey, in the shape of his drafts and institutional records, gives rise to new interpretations. In this context, we believe it is time for a new edition of A Fortunate Life that recognises it as a complex testimonial narrative and theorises Facey’s deployment of national legends and motifs in relation to his “wounded storytelling” as well as to shifting cultural and medical conceptualisations and treatments of shame and trauma. ReferencesAlberti, Fay Bound. Matters of the Heart: History, Medicine, and Emotions. Oxford: Oxford UP, 2010. Butler, A.G. Official History of the Australian Medical Services 1814-1918: Vol I Gallipoli, Palestine and New Guinea. Canberra: Australian War Memorial, 1930.Campbell, A.W. “Remarks on Some Neuroses and Psychoses in War.” Medical Journal of Australia 15 April (1916): 319–23.Damousi, Joy. “Why Do We Get So Emotional about Anzac.” What’s Wrong with Anzac. Ed. Marilyn Lake and Henry Reynolds. Sydney: UNSWP, 2015. 94–109.Dutton, Geoffrey. “Fremantle Arts Centre Press Publicity.” Australian Book Review May (1981): 16.Eager, R. “War Neuroses Occurring in Cases with a Definitive History of Shell Shock.” British Medical Journal 13 Apr. 1918): 422–25.Echterling, L.G., Thomas A. Field, and Anne L. Stewart. “Evolution of PTSD in the DSM.” Future Directions in Post-Traumatic Stress Disorder: Prevention, Diagnosis, and Treatment. Ed. Marilyn P. Safir and Helene S. Wallach. New York: Springer, 2015. 189–212.Facey, A.B. A Fortunate Life. 1981. Ringwood: Penguin, 2005.———. Drafts 1–3. University of Western Australia, Special Collections.———. Transcript. University of Western Australia, Special Collections.First Tuesday Book Club. ABC Splash. 4 Dec. 2012. <http://splash.abc.net.au/home#!/media/1454096/http&>.Foster, Dennis. Confession and Complicity in Narrative. Cambridge: Cambridge UP, 1987.Frank, Arthur. The Wounded Storyteller. London: U of Chicago P, 1995.Fraser, Jane. “CEO Says.” Fremantle Press. 7 July 2015. <https://www.fremantlepress.com.au/c/news/3747-ceo-says-9>.Garton, Stephen. The Cost of War: Australians Return. Melbourne: Oxford UP, 1994.HMAT Aeneas. “Report of Passengers for the Port of Fremantle from Ports Beyond the Commonwealth.” 20 Nov. 1915. <http://recordsearch.naa.gov.au/SearchNRetrieve/Interface/ViewImage.aspx?B=9870708&S=1>.“Interview with Ray Coffey.” Personal interview. 6 May 2016. Follow-up correspondence. 12 May 2016.Jenkins, Wendy. “Tales from the Backlist: A Fortunate Life Turns 30.” Fremantle Press, 14 April 2011. <https://www.fremantlepress.com.au/c/bookclubs/574-tales-from-the-backlist-a-fortunate-life-turns-30>.Keesing, Nancy. ‘An Enduring Classic.’ Australian Book Review (May 1981). FACP Press Clippings. Fremantle. n. pag.King, Noel. “‘I Can’t Go On … I’ll Go On’: Interview with Ray Coffey, Fremantle Arts Centre Press, 22 Dec. 2004; 24 May 2006.” Westerly 51 (2006): 31–54.Larsson, Marina. “A Disenfranchised Grief: Post War Death and Memorialisation in Australia after the First World War.” Australian Historical Studies 40.1 (2009): 79–95.Lindstrom, Richard. “The Australian Experience of Psychological Casualties in War: 1915-1939.” PhD dissertation. Victoria University, Feb. 1997.Loughran, Tracey. “Shell Shock, Trauma, and the First World War: The Making of a Diagnosis and its Histories.” Journal of the History of Medical and Allied Sciences 67.1 (2012): 99–119.Lucas, Anne. “Curator’s Notes.” A Fortunate Life. Australian Screen. <http://aso.gov.au/titles/tv/a-fortunate-life/notes/>.McLeod, Steve. “My Fortunate Life with Grandad.” Western Magazine Dec. (1983): 8.Munro, Craig. Under Cover: Adventures in the Art of Editing. Brunswick: Scribe, 2015.Murphy, Ffion, and Richard Nile. “The Naked Anzac: Exposure and Concealment in A.B. Facey’s A Fortunate Life.” Southerly 75.3 (2015): 219–37.———. “Wounded Storyteller: Revisiting Albert Facey’s Fortunate Life.” Westerly 60.2 (2015): 87–100.“NBC Book Awards.” Australian Book Review Oct. (1981): 1–4.PBL. Prospectus: A Fortunate Life, the Extraordinary Life of an Ordinary Bloke. 1–8.Repatriation Records. Albert Facey. National Archives of Australia.Roberts, Chris. “Turkish Machine Guns at the Landing.” Wartime: Official Magazine of the Australian War Memorial 50 (2010). <https://www.awm.gov.au/wartime/50/roberts_machinegun/>.Semmler, Clement. “The Way We Were before the Good Life.” Courier Mail 10 Oct. 1981. FACP Press Clippings. Fremantle. n. pag.Smith, Sidonie, and Julia Watson. Reading Autobiography: A Guide for Interpreting Life Narratives. 2001. 2nd ed. U of Minnesota P, 2010.Thomson, Alistair. Anzac Memories: Living with the Legend. 1994. 2nd ed. Melbourne: Monash UP, 2013. Tyquin, Michael. Gallipoli, the Medical War: The Australian Army Services in the Dardanelles Campaign of 1915. Kensington: UNSWP, 1993.War Service Records. National Archives of Australia. <http://recordsearch.naa.gov.au/NameSearch/Interface/NameSearchForm.aspx>.Williamson, Geordie. “A Fortunate Life.” Copyright Agency. <http://readingaustralia.com.au/essays/a-fortunate-life/>.

The continual (re)development associated with urban spaces results in the demand that heritage spaces be preserved. This raises a number of questions to be considered such as: which spaces will be preserved, what stories will be associated with these, and how will the embodied experience of these spaces be mediated? Since Foucault, it has been accepted that knowledge, power and truth are inextricably interwoven. There are no golden sands of freedom, there is no transcendent truth free from composing discourses. The construction of truth and history as discursive practice has a strong spatial component in museums. Objects are taken out of their original contexts, placed into knowledge regimes that delimit how these shall be known and then fixed in a stasis that regulates any change or flow in the meanings that might be constructed around these. Figure 1 - Skeleton of a middle age woman on display in the Dublinia MuseumThe body in the museum becomes either an object to be displayed or a nuisance to be excluded from contact with 'artefacts'. The picture above is of the skeleton of a middle age woman who died in Dublin hundreds of years ago and is now on display in the Dublinia Museum. Once the decision is made that this skeleton is no longer a body but an artefact it is placed behind glass so that the living bodies which come to view it may not 'interfere' with its discursive or physical existence. Once 'preserved' in this way, 'she' becomes an 'it', an object translated and removed from the everyday. In this case, the skeleton is placed within a scientific-medical discourse where the fact that it once belonged to an old woman who had worn away teeth tells us that she lived in a time when the people of Dublin had a poor diet. Similar undertakings are accepted practice in the Hyde Park Barracks Museum. All 'real' artefacts are kept behind glass, preserved in carefully controlled conditions that prevent human physical contact. Only replicas or reconstructions are available for everyday handling by the general public. In the example below, the item discussed was kept behind glass, a thing to be observed, revered, a relic to lend authority to the power-knowledge-truth regime of the Hyde Park Barracks Museum. Figure 2 - box containing a lock of Captain James Cook's hair and a rendition of his death scene in Hawaii on display at the Hyde Park Barracks MuseumSo 'precious' was this object that it was kept doubly removed, a small wooden casket within a timber and glass case behind the display panel of the museum. Figure 3 - closer view of box containing a lock of Captain James Cook's hair and a rendition of his death scene in Hawaii on display at the Hyde Park Barracks MuseumThis particular item contains a lock of Captain James Cook's hair and a rendition of his death scene in Hawaii. The case is made from the wood of the Resolution (his ship at the time of his death) and the entire item was a memento given to his widow upon the Resolution's return to Britain. This 'relic' is iconic of the approach adopted by the presentation of the Barracks as a museum. But what happens when the history being 'preserved' is the fabric of a built space? The spatial process of 'encasing', 'preserving' and physically removing 'artefacts' from everyday contact is an ongoing aspect of the presentation of the Barracks. In 1996, not long after I began my employ with the Barracks as part of an extended engagement with the embodied experience of cityspace, the curator decided that each guide should have their skills at presenting the Barracks in an appropriate light assessed. The result was that each guide was required to prepare and present a 'wall talk'. The 'wall talk' was literally that. Each guide was assigned a physical section of the museum to research and then discuss for ten minutes to an audience composed of other guides, the curator, the manager and education staff. The aims were to get each guide to re-assess their lecture presentation technique and to spread awareness amongst the guides that each physical section of the museum held its own unique part in the story of the Barracks. My assignment was a piece of wall on the second floor directly above the reception area. Deep into the persona I created so that I could 'pass' in this environment, I began by examining the wall. It was constructed of the convict made brick laid down in 1818 held together by Aboriginal midden material that dated back thousands of years, overlaid with whitewash applied in 1848 when the men moved out and the women moved in, the whitewash was overlaid with plaster held in place by cows hair in 1887 when the building was converted to a courts complex which was topped with remnants of wall paper that dated back to 1952 when the room was renovated as a Judge's chambers. On a section of the wall that had once been covered by this wallpaper was a pencil drawn outline of a pair of scissors, the name Max Fry and the date 1952 was written next to these. Both the floor and ceiling above and below the wall had sections that had been replaced when air conditioning was installed in the first incarnation of the building as a museum under the management of the Museum of Applied Arts and Sciences. A red builders' chalk mark showing where this was to installed remained even though the ducting had been removed in a later enactment of this museum space under the auspices of the Historic Houses Trust. In the rebated corner closest to this wall, out of sight to any but the closest inspection, there was a pencil drawing of a boxer shaping up to an unseen opponent. The skirting board was two inches higher than in the next room and of an Edwardian rather than a Victorian style. 'Ghosts' from zinc tiles were etched upon the ceiling and scratch marks from the iron beds used by the immigrant women remained upon the floors. I considered the wall carefully and even more carefully thought about the discourses of this institution, the personality of the curator and the predilections of the manager and other guides. If I was to continue 'passing', which story should I tell? How should it be told? What emphasis should be made and, most importantly of all, what must be elided? I considered raising the awareness that anthrax spores had been found in similar cow-hair reinforced plaster in the London Tube system but this somehow seemed irreverent. Starting with an statement about the mortar, Aboriginal land claims and how the entire Historic Houses Trust functioned to legitimate European seizure of Aboriginal land and that this was reflected by the way in which Aboriginal artefacts were ignored seemed equally inadvisable. Perhaps a discussion of the judge who inspired the boxer was in order. Rumour had it that he used to pay 'taxi-drivers' to join him in his rooms and engage in a little 'wrestling' and 'boxing'. This was reputedly such a physical activity that grunts, groans and cries of pain (?) were heard throughout the building. I could talk about the rats that had infested the ceilings above and below the room from the time that false ceilings were put in place during the renovation of the building into a courts complex and perhaps even display some of the 'artefacts' that had been stolen by the rats and hidden under the floor or in the ceiling space. A straight 'history' of the wall that simply discussed its physical composition would have 'passed', but that was perhaps more superficial than I felt the material warranted. Instead, set to a background audio tape of Tracey Chapman singing "Talking Bout a Revolution", a selection from Pink Floyd's The Wall and The Beatles Revolution 9, I told a story about the scissors. The scissors tale began by introducing Max Fry as a humble paperhanger working in the chambers of a powerful Judge in the 1950's. Oppressed, voiceless, the only impact he could make within the Barracks was to trace his scissors, sign his name, date it and then paper over this minor act of rebellion. For nearly thirty years his legacy remained hidden under the paper as judge after judge used the room to write the judgements that ordered the lives of those unfortunate enough to pass before them. In 1979 this legacy was unveiled but ignored, covered over by an air-conditioning system decreed necessary to preserve the artefacts displayed in the building. This oversight was rectified (so my story went) by the current generation of carers for the heritage of the building when the air conditioning was removed and the slice of social history and iniquitous power relations that Max Fry's rebellion illustrated was put on display for all to see. The talk was received well by all except for the chief guide who felt the music was distracting. He wanted me to do another wall some other time and 'get it right this time'. The curator was delighted and over-ruled the chief guide and the wall talks were over as far as I was concerned. A few months later, I was surprised to discover that on one of my 'time in lieu' breaks from the Barracks, that the wall had been encased in glass. The original scissors whose outline was traced upon the now preserved wall had been 'rescued' from Max's tool shed and hung behind the glass along with a picture of himself and some other of his tools. A story panel iterated a simplified version of the story I had told that elided any reference to class inequality or the powerlessness of his position. History's truth and permanence was now safely assured and no meddling fingers would ever again touch the pencilled scissored outline or smudge the bleary red chalk-line. The boxer, however, remains un-encased, a few hands-breadths from Max's sanitised and now unapproachable history, awaiting the right 'story' to bring it to prominence and preservation. Citation reference for this article MLA Style Darrell, Aaron. "Whose History?" M/C: A Journal of Media and Culture 5.2 (2002). [your date of access] < http://www.media-culture.org.au/0205/history.php>. Chicago Style Darrell, Aaron, "Whose History?" M/C: A Journal of Media and Culture 5, no. 2 (2002), < http://www.media-culture.org.au/0205/history.php> ([your date of access]). APA Style Darrell, Aaron. (2002) Whose History?. M/C: A Journal of Media and Culture 5(2). < http://www.media-culture.org.au/0205/history.php> ([your date of access]).

There is a moment in Al Gore’s 2006 documentary An Inconvenient Truth devised to expose the sheer audacity of fossil fuel lobby groups in the United States. In their attempts to address significant scientific consensus and growing public concern over climate change, these groups are resorting to what Gore’s film suggests are grotesque distortions of fact. A particular example highlighted in the film is the Competitive Enterprise Institute’s (CPE—a lobby group funded by ExxonMobil) “pro” energy industry advertisement: “Carbon dioxide”, the ad states. “They call it pollution, we call it life.” While on the one hand employing rhetoric against the “inconvenient truth” that carbon dioxide emissions are ratcheting up the Earth’s temperature, these advertisements also pose a question – though perhaps unintended – that is worth addressing. Where does life reside? This is not an issue of essentialism, but relates to the claims, materials and technologies through which life as a political object emerges. The danger of entertaining the vested interests of polluting industry in a discussion of climate change and its biopolitics is countered by an imperative to acknowledge the ways in which multiple positions in the climate change debate invoke and appeal to ‘life’ as the bottom line, or inviolable interest, of their political, social or economic work. In doing so, other questions come to the fore that a politics of climate change framed in terms of moral positions or competing values will tend to overlook. These questions concern the manifold practices of life that constitute the contemporary terrain of the political, and the actors and instruments put in this employ. Who speaks for life? And who or what produces it? Climate change as a matter of concern (Latour) has gathered and generated a host of experts, communities, narratives and technical devices all invested in the administration of life. It is, as Malcom Bull argues, “the paradigmatic issue of the new politics,” a politics which “draws people towards the public realm and makes life itself subject to the caprices of state and market” (2). This paper seeks to highlight the politics of life that have emerged around climate change as a public issue. It will argue that these politics appear in incremental and multiple ways that situate an array of actors and interests as active in both contesting and generating the terms of life: what life is and how we come to know it. This way of thinking about climate change debates opposes a prevalent moralistic framework that reads the practices and discourses of debate in terms of oppositional positions alone. While sympathies may flow in varying directions, especially when it comes to such a highly charged and massively consequential issue as climate change, there is little insight to be had from charging the CPE (for example) with manipulating consumers, or misrepresenting well-known facts. Where new and more productive understandings open up is in relation to the fields through which these gathering actors play out their claims to the project of life. These fields, from the state, to the corporation, to the domestic sphere, reveal a complex network of strategies and devices that seek to secure life in constantly renovated terms. Life Politics Biopolitical scholarship in the wake of Foucault has challenged life as a pre-given uncritical category, and sought to highlight the means through which it is put under question and constituted through varying and composing assemblages of practitioners and practices. Such work regards the project of human well-being as highly complex and technical, and has undertaken to document this empirically through close attention to the everyday ecologies in which humans are enmeshed. This is a political and theoretical project in itself, situating political processes in micro, as well as macro, registers, including daily life as a site of (self) management and governance. Rabinow and Rose refer to biopolitical circuits that draw together and inter-relate the multiple sites and scales operative in the administration of life. These involve not just technologies, rationalities and regimes of authority and control, but also politics “from below” in the form of rights claims and community formation and agitation (198). Active in these circuits, too, are corporate and non-state interests for whom the pursuit of maximising life’s qualities and capabilities has become a concern through which “market relations and shareholder value” are negotiated (Rabinow and Rose 211). As many biopolitical scholars argue, biopower—the strategies through which biopolitics are enacted—is characteristic of the “disciplinary neo-liberalism” that has come to define the modern state, and through which the conduct of conduct is practiced (Di Muzio 305). Foucault’s concept of governmentality describes the devolution of state-based disciplinarity and sovereignty to a host of non-state actors, rationalities and strategies of governing, including the self-managing subject, not in opposition to the state, but contributing to its form. According to Bratich, Packer and McCarthy, everyday life is thus “saturated with governmental techniques” (18) in which we are all enrolled. Unlike regimes of biopolitics identified with what Agamben terms “thanopolitics”—the exercise of biopower “which ultimately rests on the power of some to threaten the death of others” (Rabinow and Rose 198), such as the Nazi’s National Socialism and other eugenic campaigns—governmental arts in the service of “vitalist” biopolitics (Rose 1) are increasingly diffused amongst all those with an “interest” in sustaining life, from organisations to individuals. The integration of techniques of self-governance which ask the individual to work on themselves and their own dispositions with State functions has broadened the base by which life is governed, and foregrounded an unsettled terrain of life claims. Rose argues that medical science is at the forefront of these contemporary biopolitics, and to this effect “has […] been fully engaged in the ethical questions of how we should live—of what kinds of creatures we are, of the kinds of obligations that we have to ourselves and to others, of the kinds of techniques we can and should use to improve ourselves” (20). Asking individuals to self-identify through their medical histories and bodily specificities, medical cultures are also shaping new political arrangements, as communities connected by shared genetics or physical conditions, for instance, emerge, evolve and agitate according to the latest medical knowledge. Yet it is not just medicine that provokes ethical work and new political forms. The environment is a key site for life politics that entails a multi-faceted discourse of obligations and entitlements, across fields and scales of engagement. Calculating Environments In line with neo-liberal logic, environmental discourse concerned with ameliorating climate change has increasingly focused upon the individual as an agent of self-monitoring, to both facilitate government agendas at a distance, and to “self-fashion” in the mode of the autonomous subject, securing against external risks (Ong 501). Climate change is commonly represented as such a risk, to both human and non-human life. A recent letter published by the Royal Australasian College of Physicians in two leading British medical journals, named climate change as the “biggest global health threat of the twenty-first century” (Morton). As I have argued elsewhere (Potter), security is central to dominant cultures of environmental governance in the West; these cultures tie sustainability goals to various and interrelated regimes of monitoring which attach to concepts of what Clark and Stevenson call “the good ecological citizen” (238). Citizenship is thus practiced through strategies of governmentality which call on individuals to invest not just in their own well-being, but in the broader project of life. Calculation is a primary technique through which modern environmental governance is enacted; calculative strategies are seen to mediate risk, according to Foucault, and consequently to “assure living” (Elden 575). Rationalised schemes for self-monitoring are proliferating under climate change and the project of environmentalism more broadly, something which critics of neo-liberalism have identified as symptomatic of the privatisation of politics that liberal governmentality has fostered. As we have seen in Australia, an evolving policy emphasis on individual practices and the domestic sphere as crucial sites of environmental action – for instance, the introduction of domestic water restrictions, and the phasing out of energy-inefficient light bulbs in the home—provides a leading discourse of ethico-political responsibility. The rise of carbon dioxide counting is symptomatic of this culture, and indicates the distributed fields of life management in contemporary governmentality. Carbon dioxide, as the CPE is keen to point out, is crucial to life, but it is also—in too large an amount—a force of destruction. Its management, in vitalist terms, is thus established as an effort to protect life in the face of death. The concept of “carbon footprinting” has been promoted by governments, NGOs, industry and individuals as a way of securing this goal, and a host of calculative techniques and strategies are employed to this end, across a spectrum of activities and contexts all framed in the interests of life. The footprinting measure seeks to secure living via self-policed limits, which also—in classic biopolitical form—shift previously private practices into a public realm of count-ability and accountability. The carbon footprint, like its associates the ecological footprint and the water footprint, has developed as a multi-faceted tool of citizenship beyond the traditional boundaries of the state. Suggesting an ecological conception of territory and of our relationships and responsibilities to this, the footprint, as a measure of resource use and emissions relative to the Earth’s capacities to absorb these, calculates and visualises the “specific qualities” (Elden 575) that, in a spatialised understanding of security, constitute and define this territory. The carbon footprint’s relatively simple remit of measuring carbon emissions per unit of assessment—be that the individual, the corporation, or the nation—belies the ways in which life is formatted and produced through its calculations. A tangled set of devices, practices and discourses is employed to make carbon and thus life calculable and manageable. Treading Lightly The old environmental adage to “tread lightly upon the Earth” has been literalised in the metaphor of the footprint, which attempts both to symbolise environmental practice and to directly translate data in order to meaningfully communicate necessary boundaries for our living. The World Wildlife Fund’s Living Planet Report 2008 exemplifies the growing popularity of the footprint as a political and poetic hook: speaking in terms of our “ecological overshoot,” and the move from “ecological credit to ecological deficit”, the report urges an attendance to our “global footprint” which “now exceeds the world’s capacity to regenerate by about 30 per cent” (1). Angela Crombie’s A Lighter Footprint, an instruction manual for sustainable living, is one of a host of media through which individuals are educated in modes of footprint calculation and management. She presents a range of techniques, including carbon offsetting, shifting to sustainable modes of transport, eating and buying differently, recycling and conserving water, to mediate our carbon dioxide output, and to “show […] politicians how easy it is” (13). Governments however, need no persuading from citizens that carbon calculation is an exercise to be harnessed. As governments around the world move (slowly) to address climate change, policies that instrumentalise carbon dioxide emission and reduction via an auditing of credits and deficits have come to the fore—for example, the European Union Emissions Trading Scheme and the Chicago Climate Exchange. In Australia, we have the currently-under-debate Carbon Pollution Reduction Scheme, a part of which is the Australian Emissions Trading Scheme (AETS) that will introduce a system of “carbon credits” and trading in a market-based model of supply and demand. This initiative will put a price on carbon dioxide emissions, and cap the amount of emissions any one polluter can produce without purchasing further credits. In readiness for the scheme, business initiatives are forming to take advantage of this new carbon market. Industries in carbon auditing and off-setting services are consolidating; hectares of trees, already active in the carbon sequestration market, are being cultivated as “carbon sinks” and key sites of compliance for polluters under the AETS. Governments are also planning to turn their tracts of forested public land into carbon credits worth billions of dollars (Arup 7). The attachment of emission measures to goods and services requires a range of calculative experts, and the implementation of new marketing and branding strategies, aimed at conveying the carbon “health” of a product. The introduction of “food mile” labelling (the amount of carbon dioxide emitted in the transportation of the food from source to consumer) in certain supermarkets in the United Kingdom is an example of this. Carbon risk analysis and management programs are being introduced across businesses in readiness for the forthcoming “carbon economy”. As one flyer selling “a suite of carbon related services” explains, “early action will give you the edge in understanding and mitigating the risks, and puts you in a prime position to capitalise on the rewards” (MGI Business Solutions Worldwide). In addition, lobby groups are working to ensure exclusions from or the free allocation of permits within the proposed AETS, with degrees of compulsion applied to different industries – the Federal Government, for instance, will provide a $3.9 billion compensation package for the electric power sector when the AETS commences, to enable their “adjustment” to this carbon regime. Performing Life Noortje Mares provides a further means of thinking through the politics of life in the context of climate change by complicating the distinction between public and private interest. Her study of “green living experiments” describes the rise of carbon calculation in the home in recent years, and the implementation of technologies such as the smart electricity meter that provides a constantly updating display of data relating to amounts and cost of energy consumed and the carbon dioxide emitted in the routines of domestic life. Her research tracks the entry of these personal calculative regimes into public life via internet forums such as blogs, where individuals notate or discuss their experiences of pursing low-carbon lifestyles. On the one hand, these calculative practices of living and their public representation can be read as evidencing the pervasive neo-liberal governmentality at work in contemporary environmental practice, where individuals are encouraged to scrupulously monitor their domestic cultures. The rise of auditing as a technology of self, and more broadly as a technique of public accountability, has come under fire for its “immunity-granting role” (Charkiewicz 79), where internal audits become substituted for external compliance and regulation. Mares challenges this reading, however, by demonstrating the ways in which green living experiments “transform everyday material practices into practices of public involvement” that (118) don’t resolve or pin down relations between the individual, the non-human environment, and the social, or reveal a mappable flow of actions and effects between the public realm and the home. The empirical modes of publicity that these individuals employ, “the careful recording of measurements and the reliable descriptions of sensory observation, so as to enable ‘virtual witnessing’ by wider audiences”, open up to much more complex understandings than one of calculative self-discipline at work. As “instrument[s] of public involvement” (120), the experiments that Mares describe locate the politics of life in the embodied socio-material entanglements of the domestic sphere, in arrangements of humans and non-human technologies. Such arrangements, she suggests, are ontologically productive in that they introduce “not only new knowledge, but also new entities […] to society” (119), and as such these experiments and the modes of calculation they employ become active in the composition of reality. Recent work in economic sociology and cultural studies has similarly contended that calculation, far from either a naturalised or thoroughly abstract process, relies upon a host of devices, relations, and techniques: that is, as Gay Hawkins explains, calculative processes “have to be enacted” (108). Environmental governmentality in the service of securing life is a networked practice that draws in a host of actors, not a top-down imposition. The institution of carbon economies and carbon emissions as a new register of public accountability, brings alternative ways to calculate the world into being, and consequently re-calibrates life as it emerges from these heterogeneous arrangements. All That Gathers Latour writes that we come to know a matter of concern by all the things that gather around it (Latour). This includes the human, as well as the non-human actors, policies, practices and technologies that are put to work in the making of our realities. Climate change is routinely represented as a threat to life, with predicted (and occurring) species extinction, growing numbers of climate change refugees, dispossessed from uninhabitable lands, and the rise of diseases and extreme weather scenarios that put human life in peril. There is no doubt, of course, that climate change does mean death for some: indeed, there are thanopolitical overtones in inequitable relations between the fall-out of impacts from major polluting nations on poorer countries, or those much more susceptible to rising sea levels. Biosocial equity, as Bull points out, is a “matter of being equally alive and equally dead” (2). Yet in the biopolitical project of assuring living, life is burgeoning around the problem of climate change. The critique of neo-liberalism as a blanketing system that subjects all aspects of life to market logic, and in which the cynical techniques of industry seek to appropriate ethico-political stances for their own material ends, are insufficient responses to what is actually unfolding in the messy terrain of climate change and its biopolitics. What this paper has attempted to show is that there is no particular purchase on life that can be had by any one actor who gathers around this concern. Varying interests, ambitions, and intentions, without moral hierarchy, stake their claim in life as a constantly constituting site in which they participate, and from this perspective, the ways in which we understand life to be both produced and managed expand. This is to refuse either an opposition or a conflation between the market and nature, or the market and life. It is also to argue that we cannot essentialise human-ness in the climate change debate. For while human relations with animals, plants and weathers may make us what we are, so too do our relations with (in a much less romantic view) non-human things, technologies, schemes, and even markets—from carbon auditing services, to the label on a tin on the supermarket shelf. As these intersect and entangle, the project of life, in the new politics of climate change, is far from straightforward. References An Inconvenient Truth. Dir. Davis Guggenheim. Village Roadshow, 2006. Arup, Tom. “Victoria Makes Enormous Carbon Stocktake in Bid for Offset Billions.” The Age 24 Sep. 2009: 7. Bratich, Jack Z., Jeremy Packer, and Cameron McCarthy. “Governing the Present.” Foucault, Cultural Studies and Governmentality. Ed. Bratich, Packer and McCarthy. Albany: State University of New York Press, 2003. 3-21. Bull, Malcolm. “Globalization and Biopolitics.” New Left Review 45 (2007): 12 May 2009 . < http://newleftreview.org/?page=article&view=2675 >. Charkiewicz, Ewa. “Corporations, the UN and Neo-liberal Bio-politics.” Development 48.1 (2005): 75-83. Clark, Nigel, and Nick Stevenson. “Care in a Time of Catastrophe: Citizenship, Community and the Ecological Imagination.” Journal of Human Rights 2.2 (2003): 235-246. Crombie, Angela. A Lighter Footprint: A Practical Guide to Minimising Your Impact on the Planet. Carlton North, Vic.: Scribe, 2007. Di Muzio, Tim. “Governing Global Slums: The Biopolitics of Target 11.” Global Governance. 14.3 (2008): 305-326. Elden, Stuart. “Governmentality, Calculation and Territory.” Environment and Planning D: Society and Space 25 (2007): 562-580. Hawkins, Gay. The Ethics of Waste: How We Relate to Rubbish. Sydney: University of New South Wales Press, 2006. Latour, Bruno. “Why Has Critique Run Out of Steam?: From Matters of Fact to Matters of Concern.” Critical Inquiry 30.2 (2004): 225-248. Mares, Noortje. “Testing Powers of Engagement: Green Living Experiments, the Ontological Turn and the Undoability and Involvement.” European Journal of Social Theory 12.1 (2009): 117-133. MGI Business Solutions Worldwide. “Carbon News.” Adelaide. 2 Aug. 2009. Ong, Aihwa. “Mutations in Citizenship.” Theory, Culture and Society 23.2-3 (2006): 499-505. Potter, Emily. “Footprints in the Mallee: Climate Change, Sustaining Communities, and the Nature of Place.” Landscapes and Learning: Place Studies in a Global World. Ed. Margaret Somerville, Kerith Power and Phoenix de Carteret. Sense Publishers. Forthcoming. Rabinow, Paul, and Nikolas Rose. “Biopower Today.” Biosocieties 1 (2006): 195-217. Rose, Nikolas. “The Politics of Life Itself.” Theory, Culture and Society 18.6 (2001): 1-30. World Wildlife Fund. Living Planet Report 2008. Switzerland, 2008.