Gotowa bibliografia na temat „Queensland hospitals”

This study analysed medical record data from seven regional hospitals in Queenslandto determine the types of medical conditions and injuries that resulted in overseas andinterstate tourists being admitted to hospital. From a total of 135- 128 admissionsto the participating hospitals, 695 (0.51- per cent) were identified as overseas touristsand 3479 (2.57- per cent) were from interstate. The main reasons for admission ofoverseas tourists, based on principal diagnoses, were injuries and poisonings (37.6- percent), circulatory disorders (11.7- per cent), digestive conditions (9.8- per cent), andgenito-urinary disorders (8.8- per cent). For interstate tourists, the main reasons foradmission were genito-urinary disorders (19.8- per cent), injuries and poisonings(15.4- per cent), neoplasms (11.4- per cent) and circulatory disorders (10.6- per cent).These findings are discussed in relation to current literature in the field of travelmedicine, emphasising the burden of care placed on the admitting hospital?s resources,and the growing number of visitors to Queensland needing health care.Introduction

Purpose – The purpose of this paper is to investigate the quality of management practices of public hospitals in the Australian healthcare system, specifically those in the state-managed health systems of Queensland and New South Wales (NSW). Further, the authors assess the management practices of Queensland and NSW public hospitals jointly and globally benchmark against those in the health systems of seven other countries, namely, USA, UK, Sweden, France, Germany, Italy and Canada. Design/methodology/approach – In this study, the authors adapt the unique and globally deployed Bloom et al. (2009) survey instrument that uses a “double blind, double scored” methodology and an interview-based scoring grid to measure and internationally benchmark the management practices in Queensland and NSW public hospitals based on 21 management dimensions across four broad areas of management – operations, performance monitoring, targets and people management. Findings – The findings reveal the areas of strength and potential areas of improvement in the Queensland and NSW Health hospital management practices when compared with public hospitals in seven countries, namely, USA, UK, Sweden, France, Germany, Italy and Canada. Together, Queensland and NSW Health hospitals perform best in operations management followed by performance monitoring. While target management presents scope for improvement, people management is the sphere where these Australian hospitals lag the most. Practical implications – This paper is of interest to both hospital administrators and health care policy-makers aiming to lift management quality at the hospital level as well as at the institutional level, as a vehicle to consistently deliver sustainable high-quality health services. Originality/value – This study provides the first internationally comparable robust measure of management capability in Australian public hospitals, where hospitals are run independently by the state-run healthcare systems. Additionally, this research study contributes to the empirical evidence base on the quality of management practices in the Australian public healthcare systems of Queensland and NSW.

In response to concerns about the number of interstate and overseas visitors using Queensland hospital services, the present study examined a sample of 1,295 hospital records to determine the proportion of patients who were incorrectly identified as Queensland residents. Across six hospitals the overall detection rate was 4.6%. Rates varied between hospitals, with the highest detection recorded for Goondiwindi near the Queensland/New South Wales border; and the lowest for Prince Charles in Brisbane. There were also important variations across hospitals based on specific holiday periods. In particular, Goondiwindi and the Gold Coast had substantially higher detection rates for the Christmas holiday period (December-January) than for the mid-year period (June-August). These findings are discussed in terms of their implications for hospital services, especially lost revenue and increased patient load. Health information managers are identified as a key group for addressing some of the current problems in this area.

Introduction:Hospitals are fundamental infrastructure, and when well-designed can provide a trusted place of refuge and a central point for health and wellbeing services in the aftermath of disasters. The ability of hospitals to continue functioning is dependent on location, the resilience of buildings, critical systems, equipment, supplies, and resources as well as people. Working towards ensuring that the local hospital is resilient is essential in any disaster management system and the level of hospital resilience can be used as an indicator in measuring community resilience. The most popular measure of hospital resilience is the World Health Organisation’s Hospital Safety Index (HSI) used in over 100 countries to assess and guide improvements to achieve structurally and functionally disaster resilient hospitals. Its purpose is to promote safe hospitals where services “remain accessible and functioning at maximum capacity, and with the same infrastructure, before, during and immediately after the impact of emergencies and disasters.” It identifies likely high impact hazards, vulnerabilities, and mitigation/improvement actions.Aim:The HSI can be a valuable tool as part of the 2015-2030 Sendai Framework for Disaster Risk Reduction. However, to date, it has been used infrequently in developed countries. This project pilots the application of the HSI across seven facilities in a North Queensland health service (an area prone to cyclones and flooding), centered on a tertiary referral center, each providing 24-hour emergency health services.Results:Key indicators of resilience and the result of the audit will be discussed within geographical and cultural contexts, including the benefits of the HSI in augmenting existing hospital assessment and accreditation processes to identify vulnerabilities and mitigation strategies.Discussion:The research outcomes are to be used by the health service to improve infrastructure and provide anticipated community benefits, especially through the continuation of health services post disasters.

The efficient management of day surgery facilities benefits both patients and health administrators. Patients can benefit through minimisation of hospital stay while day surgery has the potential to increase elective surgery throughput and to reduce waiting times. This paper explores whether routinely collected morbidity data from Queensland public hospitals can be used to benchmark levels of day only surgery between hospitals. Thirteen procedures were identified that met criteria for inclusion in a day only surgery bench marking basket. Queensland public hospitals and individual procedures were benchmarked against one another and analysed to determine whether hospitals performing the 13 procedures demonstrate the same rates of day only surgery. With the development of a clinically meaningful and administratively simple tool for comparing hospital day surgery rates using routinely collected morbidity data, the opportunity now exists for health services to compare the performance of clinical services both within and between hospitals. It is also suggested that the basket of procedures identified in this study could form the basis of a national day only surgery benchmarking process.

Objective In 2011, the Australian Commission on Safety and Quality in Health Care (ACSQHC) recommended that all hospitals in Australia must have an Antimicrobial Stewardship (AMS) program by 2013. Nevertheless, little is known about current AMS activities. This study aimed to determine the AMS activities currently undertaken, and to identify gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. Methods The AMS activities of 26 facilities from 15 hospital and health services in Queensland were surveyed during June 2012 to address strategies for effective AMS: implementing clinical guidelines, formulary restriction, reviewing antimicrobial prescribing, auditing antimicrobial use and selective reporting of susceptibility results. Results The response rate was 62%. Nineteen percent had an AMS team (a dedicated multidisciplinary team consisting of a medically trained staff member and a pharmacist). All facilities had access to an electronic version of Therapeutic Guidelines: Antibiotic, with a further 50% developing local guidelines for antimicrobials. One-third of facilities had additional restrictions. Eighty-eight percent had advice for restricted antimicrobials from in-house infectious disease physicians or clinical microbiologists. Antimicrobials were monitored with feedback given to prescribers at point of care by 76% of facilities. Deficiencies reported as barriers to establishing AMS programs included: pharmacy resources, financial support by hospital management, and training and education in antimicrobial use. Conclusions Several areas for improvement were identified: reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use. There also appears to be a lack of resources to support AMS programs in some facilities. What is known about the topic? The ACSQHC has recommended that all hospitals implement an AMS program by 2013 as a requirement of Standard 3 (Preventing and Controlling Healthcare-Associated Infections) of the National Safety and Quality Health Service Standards. The intent of AMS is to ensure appropriate prescribing of antimicrobials as part of the broader systems within a health service organisation to prevent and manage healthcare-associated infections, and improve patient safety and quality of care. This criterion also aligns closely with Standard 4: Medication Safety. Despite this recommendation, little is known about what AMS activities are undertaken in these facilities and what additional resources would be required in order to meet these national standards. What does the paper add? This is the first survey that has been conducted of public hospital and health services in Queensland, a large decentralised state in Australia. This paper describes what AMS activities are currently being undertaken, identifies practice gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. What are the implications for practitioners? Several areas for improvement such as reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use have been identified. In addition, there appears to be a lack of resources to support AMS programs in some facilities.

Within Australia and in Europe. there is evidence of growth in the incidence of non¬standard forms of employment such as part-time and casual work. Part of this growth can be attributed to changes in the structure of the economy and the increasing importance of service industries where non-standard forms of employment proliferate. There is also evidence, however, that employers at the firm level are progressively expanding their use of non-standard employment and reducing their reliance on full-time labour. One explanation for this organisational-level phenomena has been suggested by Atkinson (1987) in his account of the ‘flexible firm’. Atkinson claims that employers are increasingly attempting to divide the workforce into two major segments: a skilled, full-time core labour force and an unskilled, non-standard segment. This thesis examines Atkinson’s ‘flexible firm’ model through a study of labour-use practices of three acute hospitals in Queensland. A main finding of this thesis is the generalised and substantial growth of non-standard employment in all types of Queensland hospitals. The growth of non-standard hospital labour is not as, Atkinson would suggest, largely the result of demand-side strategies of employers but is also conditioned by supply-side factors. Gender, rather than skill, is found to be an important determinant of the proliferation of non-standard employment. Non-standard employment is not the major labour adjustment mechanism in all sectors of the hospital industry. Labour intensification is a critical and overlooked form of labour adjustment in the public sector. Overall, this thesis concludes that employers’ labour-use practices need to be conceptualised within the context of the opportunities and constraints imposed by the interaction of demand and supply-side factors.

Within Australia and in Europe. there is evidence of growth in the incidence of non¬standard forms of employment such as part-time and casual work. Part of this growth can be attributed to changes in the structure of the economy and the increasing importance of service industries where non-standard forms of employment proliferate. There is also evidence, however, that employers at the firm level are progressively expanding their use of non-standard employment and reducing their reliance on full-time labour. One explanation for this organisational-level phenomena has been suggested by Atkinson (1987) in his account of the ‘flexible firm’. Atkinson claims that employers are increasingly attempting to divide the workforce into two major segments: a skilled, full-time core labour force and an unskilled, non-standard segment. This thesis examines Atkinson’s ‘flexible firm’ model through a study of labour-use practices of three acute hospitals in Queensland. A main finding of this thesis is the generalised and substantial growth of non-standard employment in all types of Queensland hospitals. The growth of non-standard hospital labour is not as, Atkinson would suggest, largely the result of demand-side strategies of employers but is also conditioned by supply-side factors. Gender, rather than skill, is found to be an important determinant of the proliferation of non-standard employment. Non-standard employment is not the major labour adjustment mechanism in all sectors of the hospital industry. Labour intensification is a critical and overlooked form of labour adjustment in the public sector. Overall, this thesis concludes that employers’ labour-use practices need to be conceptualised within the context of the opportunities and constraints imposed by the interaction of demand and supply-side factors.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
Griffith Business School
Griffith Business School
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New health technologies are undoubtedly one of the most significant contributors in improving health and quality of life. Nonetheless, they also create challenges in ensuring they provide value for money and that they are safe and effective. In order to address these issues, health technology assessment (HTA) processes have been developed. Today, HTA has become an essential tool for making decisions about choosing and introducing new health technologies. However, concern has been expressed about HTA dissemination and use by decision makers especially at the institutional level. There is little published research to date from the HTA users’ point of view in this area of concern. Thus, this study aims to investigate the effectiveness of the dissemination of HTA products at the institutional level using the diffusion of innovation theory supplemented by the promoting action on research implementation in health services (PARIHS) framework as the research conceptual framework in order to determine the major determinants. These determinants include the decision making processes for introducing new health technologies, and the organisational and individual factors that contribute to the adoption processes in hospitals.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Public Health
Griffith Health
Full Text

The demand for health care in Australia has been influenced by the numerous changes in financing arrangements at Federal Government, State Government and institutional levels during the last two decades. The task of performing empirical studies of health care demand has been made difficult by the frequent changes that have occurred with health insurance arrangements in particular. This research project commences at a macro level and traces the development of health insurance in Australia with particular emphasis on the issues that have influenced demand for primary health care. The debate on the appropriateness of voluntary and compulsory health insurance systems is discussed in the context of the theoretical issues that influence health care demand. An historical overview of the development of the Queensland's health care system is presented with the emphasis being on the provision of primary health care. Aspects of the provision of primary medical care through hospital outpatient services and community health centres are compared and contrasted. The paucity of information on outpatient activity is discussed and suggestions provided from the literature are offered to overcome this problem. The need for more adequate measures of activity is discussed in terms of this being a prerequisite for effective planning, evaluation and policy development. The theoretical aspects of utilisation are discussed with reference to empirical studies of demand and utilisation of primary health care services. As well, the influence of health insurance and provider behaviour on demand for health care are discussed. This leads into the development of the hypothesis to be tested, that outpatient utilisation of Queensland public hospitals has decreased since the introduction of Medicare in 1984. Statewide aggregate data of hospital outpatient activity were analysed concurrently with data obtained from surveys of patients attending outpatient clinics at two nearby Brisbane hospitals. The data from theses sources support the hypothesis proposed. The analysis of the data provides sufficient evidence on the attributes of the patients attending outpatient services to question the appropriateness of continuing to provide outpatient services as effective alternative forms of care.

Malnutrition is reported to be common in hospitals (10-60%), residential aged care facilities (up to 50% or more) and in free living individuals with severe or multiple disease (>10%) (Stratton et al., 2003). Published Australian studies indicate similar results (Beck et al., 2001, Ferguson et al., 1997, Lazarus and Hamlyn, 2005, Middleton et al., 2001, Visvanathan et al., 2003), but are generally limited in number, with none conducted across multiple centres or in residential aged care facilities. In Australia, there is a general lack of awareness and recognition of the problem of malnutrition, with currently no policy, standards or guidelines related to the identification, prevention and treatment of malnutrition. Malnutrition has been found to be associated with the development of pressure ulcers, but studies are limited. The consequences of the development of pressure ulcers include pain and discomfort for the patient, and considerable costs associated with treatment and increased length of stay. Pressure ulcers are considered largely preventable, and the demand for the establishment of appropriate policy, standards and guidelines regarding pressure ulcers has recently become important because the incidence and prevalence of pressure ulcers is increasingly being considered a parameter of quality of care. The aims of this study program were to firstly determine the prevalence of malnutrition and its association with pressure ulcers in Queensland Health hospitals and residential aged care facilities; and secondly to estimate the potential economic consequences of malnutrition by determining the costs arising from pressure ulcer attributable to malnutrition; and the economic outcomes of an intervention to address malnutrition in the prevention of pressure ulcers. The study program was conducted in two phases: an epidemiological study phase and an economic modelling study phase. In phase one, a multi centre, cross sectional audit of a convenience sample of subjects was carried out as part of a larger audit of pressure ulcers in Queensland public acute and residential aged care facilities in 2002 and again in 2003. Dietitians in 20 hospitals and six aged care facilities conducted single day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment, in either or both audits. Subjects excluded were obstetric, same day, paediatric and mental health patients. Weighted average proportions of nutritional status categories for acute and residential aged care facilities across the two audits were determined and compared. The effects of gender, age, facility location and medical specialty on malnutrition were determined via logistic regression. The effect of nutritional status on the presence of pressure ulcer was also determined via logistic regression. Logistic regression analyses were carried out using an analysis of correlated data approach with SUDAAN statistical package (Research Triangle Institute, USA) to account for the potential clustering effect of different facilities in the model. In phase two, an exploratory economic modelling framework was used to estimate the number of cases of pressure ulcer, total bed days lost to pressure ulcer and the economic cost of these lost bed days which could be attributed to malnutrition in Queensland public hospitals in 2002/2003. Data was obtained on the number of relevant separations, the incidence rate of pressure ulcer, the independent effect of pressure ulcers on length of stay, the cost of a bed day, and the attributable fraction of malnutrition in the development of pressure ulcers determined using the prevalence of malnutrition, the incidence rate of developing a pressure ulcer and the odds risk of developing a pressure ulcer when malnourished (as determined previously). A probabilistic sensitivity analysis approach was undertaken whereby probability distributions to the specified ranges for the key input parameters were assigned and 1000 Monte Carlo samples made from the input parameters. In an extension of the above model, an economic modelling framework was also used to predict the number of cases of pressure ulcer avoided, number of bed days not lost to pressure ulcer and economic costs if an intensive nutrition support intervention was provided to all nutritionally at risk patients in Queensland public hospitals in 2002/2003 compared to standard care. In addition to the above input parameters, data was obtained on the change in risk in developing a pressure ulcer associated with an intensive nutrition support intervention compared to standard care. The annual monetary cost of the provision of an intensive nutrition support intervention to at risk patients was modelled at a cost of AU$ 3.8-$5.4 million for additional food and nutritional supplements and staffing resources to assist patients with nutritional intake. A probabilistic sensitivity analysis approach was again taken. A mean of 34.7 + 4.0% and 31.4 + 9.5% of acute subjects and a median of 50.0% and 49.2% of residents of aged care facilities were found to be malnourished in Audits 1 and 2, respectively. Variables found to be significantly associated with an increased odds risk of malnutrition included: older age groups, metropolitan location of facility and medical specialty, in particular oncology and critical care. Malnutrition was found to be significantly associated with an increased odds risk of having a pressure ulcer, with the odds risk increasing with severity of malnutrition. In acute facilities moderate malnutrition had an odds risk of 2.2 (95% CI 1.6-3.0, p<0.001) and severe malnutrition had an odds risk of 4.8 (95% CI 3.2-7.2, p<0.001) of having a pressure ulcer. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in an acute facility was 2.6 (95% CI 1.8-3.5, p<0.001). In residential facilities, where the audit results were presented separately, the same pattern applied with moderate malnutrition having an odds risk of 1.7 (95% CI 1.2-2.2, p<0.001) and 2.0 (95% CI 1.5-2.8, p<0.001); and severe malnutrition having an odds risk of 2.8 (95% CI1.2-6.6, p=0.02) and 2.2 (95% CI 1.5-3.1, p<0.001), for Audits 1 and 2 respectively. There was no statistical difference between these odds risk ratios between the audits. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in a residential aged care facility was 1.9 (95% CI 1.3-2.7, p<0.001) and 2.0 (95% CI 1.5-2.7, p<0.001) for Audits 1 and 2 respectively. Being malnourished was also found to be significantly associated with an increased odds risk of having a higher stage and higher number of pressure ulcers, with the odds risk increasing with severity of malnutrition. The economic model predicted a mean of 3666 (Standard deviation 555) cases of pressure ulcer attributable to malnutrition out of a total mean of 11162 (Standard deviation 1210), or approximately 33%, in Queensland public acute hospitals in 2002/2003. The mean number of bed days lost to pressure ulcer that were attributable to malnutrition was predicted to be 16050, which represents approximately 0.67% of total patient bed days in Queensland public hospitals in 2002/2003. The corresponding mean economic costs of pressure ulcer attributable to malnutrition in Queensland public acute hospitals in 2002/2003 were estimated to be almost AU$13 million, out of a total mean estimated cost of pressure ulcer of AU$ 38 526 601. In the extension of the economic model, the mean economic cost of the implementation of an intensive nutrition support intervention was predicted to be a negative value ( -AU$ 5.4 million) with a standard deviation of $AU3.9 million, and interquartile range of –AU$ 7.7 million to –AU$ 2.5 million. Overall there were 951 of the 1000 re-samples where the economic cost is a negative value. This means there was a 95% chance that implementing an intensive nutrition support intervention was overall cost saving, due to reducing the cases of pressure ulcer and hospital bed days lost to pressure ulcer. This research program has demonstrated an independent association between malnutrition and pressure ulcers, on a background of a high prevalence of malnutrition, providing evidence to justify the elevation of malnutrition to a safety and quality issue for Australian healthcare organisations, similarly to pressure ulcers. In addition this research provides preliminary economic evidence to justify the requirement for consideration of healthcare policy, standards and guidelines regarding systems to identify, prevent and treat malnutrition, at least in the case of pressure ulcers in Australia.

Malnutrition is reported to be common in hospitals (10-60%), residential aged care facilities (up to 50% or more) and in free living individuals with severe or multiple disease (>10%) (Stratton et al., 2003). Published Australian studies indicate similar results (Beck et al., 2001, Ferguson et al., 1997, Lazarus and Hamlyn, 2005, Middleton et al., 2001, Visvanathan et al., 2003), but are generally limited in number, with none conducted across multiple centres or in residential aged care facilities. In Australia, there is a general lack of awareness and recognition of the problem of malnutrition, with currently no policy, standards or guidelines related to the identification, prevention and treatment of malnutrition. Malnutrition has been found to be associated with the development of pressure ulcers, but studies are limited. The consequences of the development of pressure ulcers include pain and discomfort for the patient, and considerable costs associated with treatment and increased length of stay. Pressure ulcers are considered largely preventable, and the demand for the establishment of appropriate policy, standards and guidelines regarding pressure ulcers has recently become important because the incidence and prevalence of pressure ulcers is increasingly being considered a parameter of quality of care. The aims of this study program were to firstly determine the prevalence of malnutrition and its association with pressure ulcers in Queensland Health hospitals and residential aged care facilities; and secondly to estimate the potential economic consequences of malnutrition by determining the costs arising from pressure ulcer attributable to malnutrition; and the economic outcomes of an intervention to address malnutrition in the prevention of pressure ulcers. The study program was conducted in two phases: an epidemiological study phase and an economic modelling study phase. In phase one, a multi centre, cross sectional audit of a convenience sample of subjects was carried out as part of a larger audit of pressure ulcers in Queensland public acute and residential aged care facilities in 2002 and again in 2003. Dietitians in 20 hospitals and six aged care facilities conducted single day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment, in either or both audits. Subjects excluded were obstetric, same day, paediatric and mental health patients. Weighted average proportions of nutritional status categories for acute and residential aged care facilities across the two audits were determined and compared. The effects of gender, age, facility location and medical specialty on malnutrition were determined via logistic regression. The effect of nutritional status on the presence of pressure ulcer was also determined via logistic regression. Logistic regression analyses were carried out using an analysis of correlated data approach with SUDAAN statistical package (Research Triangle Institute, USA) to account for the potential clustering effect of different facilities in the model. In phase two, an exploratory economic modelling framework was used to estimate the number of cases of pressure ulcer, total bed days lost to pressure ulcer and the economic cost of these lost bed days which could be attributed to malnutrition in Queensland public hospitals in 2002/2003. Data was obtained on the number of relevant separations, the incidence rate of pressure ulcer, the independent effect of pressure ulcers on length of stay, the cost of a bed day, and the attributable fraction of malnutrition in the development of pressure ulcers determined using the prevalence of malnutrition, the incidence rate of developing a pressure ulcer and the odds risk of developing a pressure ulcer when malnourished (as determined previously). A probabilistic sensitivity analysis approach was undertaken whereby probability distributions to the specified ranges for the key input parameters were assigned and 1000 Monte Carlo samples made from the input parameters. In an extension of the above model, an economic modelling framework was also used to predict the number of cases of pressure ulcer avoided, number of bed days not lost to pressure ulcer and economic costs if an intensive nutrition support intervention was provided to all nutritionally at risk patients in Queensland public hospitals in 2002/2003 compared to standard care. In addition to the above input parameters, data was obtained on the change in risk in developing a pressure ulcer associated with an intensive nutrition support intervention compared to standard care. The annual monetary cost of the provision of an intensive nutrition support intervention to at risk patients was modelled at a cost of AU$ 3.8-$5.4 million for additional food and nutritional supplements and staffing resources to assist patients with nutritional intake. A probabilistic sensitivity analysis approach was again taken. A mean of 34.7 + 4.0% and 31.4 + 9.5% of acute subjects and a median of 50.0% and 49.2% of residents of aged care facilities were found to be malnourished in Audits 1 and 2, respectively. Variables found to be significantly associated with an increased odds risk of malnutrition included: older age groups, metropolitan location of facility and medical specialty, in particular oncology and critical care. Malnutrition was found to be significantly associated with an increased odds risk of having a pressure ulcer, with the odds risk increasing with severity of malnutrition. In acute facilities moderate malnutrition had an odds risk of 2.2 (95% CI 1.6-3.0, p<0.001) and severe malnutrition had an odds risk of 4.8 (95% CI 3.2-7.2, p<0.001) of having a pressure ulcer. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in an acute facility was 2.6 (95% CI 1.8-3.5, p<0.001). In residential facilities, where the audit results were presented separately, the same pattern applied with moderate malnutrition having an odds risk of 1.7 (95% CI 1.2-2.2, p<0.001) and 2.0 (95% CI 1.5-2.8, p<0.001); and severe malnutrition having an odds risk of 2.8 (95% CI1.2-6.6, p=0.02) and 2.2 (95% CI 1.5-3.1, p<0.001), for Audits 1 and 2 respectively. There was no statistical difference between these odds risk ratios between the audits. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in a residential aged care facility was 1.9 (95% CI 1.3-2.7, p<0.001) and 2.0 (95% CI 1.5-2.7, p<0.001) for Audits 1 and 2 respectively. Being malnourished was also found to be significantly associated with an increased odds risk of having a higher stage and higher number of pressure ulcers, with the odds risk increasing with severity of malnutrition. The economic model predicted a mean of 3666 (Standard deviation 555) cases of pressure ulcer attributable to malnutrition out of a total mean of 11162 (Standard deviation 1210), or approximately 33%, in Queensland public acute hospitals in 2002/2003. The mean number of bed days lost to pressure ulcer that were attributable to malnutrition was predicted to be 16050, which represents approximately 0.67% of total patient bed days in Queensland public hospitals in 2002/2003. The corresponding mean economic costs of pressure ulcer attributable to malnutrition in Queensland public acute hospitals in 2002/2003 were estimated to be almost AU$13 million, out of a total mean estimated cost of pressure ulcer of AU$ 38 526 601. In the extension of the economic model, the mean economic cost of the implementation of an intensive nutrition support intervention was predicted to be a negative value ( -AU$ 5.4 million) with a standard deviation of $AU3.9 million, and interquartile range of –AU$ 7.7 million to –AU$ 2.5 million. Overall there were 951 of the 1000 re-samples where the economic cost is a negative value. This means there was a 95% chance that implementing an intensive nutrition support intervention was overall cost saving, due to reducing the cases of pressure ulcer and hospital bed days lost to pressure ulcer. This research program has demonstrated an independent association between malnutrition and pressure ulcers, on a background of a high prevalence of malnutrition, providing evidence to justify the elevation of malnutrition to a safety and quality issue for Australian healthcare organisations, similarly to pressure ulcers. In addition this research provides preliminary economic evidence to justify the requirement for consideration of healthcare policy, standards and guidelines regarding systems to identify, prevent and treat malnutrition, at least in the case of pressure ulcers in Australia.

This thesis describes the process of service provision and evaluates the non-invasive cardiac diagnostics of exercise stress testing and Holter monitoring between two Queensland rural and remote health facilities. A multi-site retrospective chart review was conducted to document testing process and quantitatively evaluate the impact of facility location on key test parameters including time frames, proportions, and the travel implications related to distance and cost to patients living in non-metropolitan areas. Findings demonstrate that patients requiring these investigations travel significantly longer distances, with a high proportion exceeding recommended process and outcome time frames compared to documented standards.

Pastoral care in our day has its origins in the Christian church and the religious (Soul) care of members. Pastoral care in the hospital has been, and continues to be articulated in the traditional terminology of religious care. This thesis argues that in our multicultural and multifaith society re-articulation of pastoral care is now required; taking account of the nature of belief, genuine valuing of story, and focused presence. Such benchmarks create authentic engagement through which pastoral care becomes capable of crossing religious boundaries to foster spiritual comfort. This thesis maps these factors – belief, story and presence - within the literature review, drawing on the experience of many researchers in pastoral care, and of those who in various ways have engaged with others in sharing their own lives, experiences and reflections. The review sources engage with pluralism, the differences between spiritual and religious care, the importance of authenticity and the way this might be discerned through a brief study of belief, story, and presence.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Humanities
Arts, Education and Law
Full Text

The aim of this thesis has been to map the ethical journey of experienced nurses now practising in rural and remote hospitals in central and south-west Queensland and in domiciliary services in Brisbane. One group of the experienced nurses in the study were Directors of Nursing in rural and remote hospitals. These nurses were “hands on”, “multi-skilled “ nurses who also had the task of managing the hospital. Also there were two Directors of Nursing from domiciliary services in Brisbane. A grounded theory method was used. The nurses were interviewed and the data retrieved from the interviews was coded, categorised and from these categories a conceptual framework was generated. The literature which dealt with the subject of ethical decision making and nurses also became part of the data. The study revealed that all these nurses experienced moral distress as they made ethical decisions. The decision making categories revealed in the data were: the area of financial management; issues as end of life approaches; allowing to die with dignity; emergency decisions; experience of unexpected death; the dilemma of providing care in very difficult circumstances. These categories were divided into two chapters: the category related to administrative and financial constraints and categories dealing with ethical issues in clinical settings. A further chapter discussed the overarching category of coping with moral distress. These experienced nurses suffered moral distress as they made ethical decisions, confirming many instances of moral distress in ethical decision making documented in the literature to date. Significantly, the nurses in their interviews never mentioned the ethical principles used in bioethics as an influence in their decision making. Only one referred to lectures on ethics as being an influence in her thinking. As they described their ethical problems and how they worked through them, they drew on their own previous experience rather than any knowledge of ethics gained from nursing education. They were concerned for their patients, they spoke from a caring responsibility towards their patients, but they were also concerned for justice for their patients. This study demonstrates that these nurses operated from the ethic of care, tempered with the ethic of responsibility as well as a concern for justice for their patients. Reflection on professional experience, rather than formal ethics education and training, was the primary influence on their ethical decision making.

St Stephen's Hospital in Hervey Bay, Queensland, Australia, is a new 96 bed state of the art digital hospital that opened on a greenfield site on 13 October 2014. The eHealth project was responsible for providing a fully integrated electronic medical record. The authors explore the unique challenges presented by the project and the solutions deployed. Key components related to the success of the project are identified. The results of the intense two and half year project timeline culminated in a successful go-live and certification as the first hospital in Australia to achieve Stage 6 HIMSS designation.

St Stephen's Hospital in Hervey Bay, Queensland, Australia, is a new 96 bed state of the art digital hospital that opened on a greenfield site on 13 October 2014. The eHealth project was responsible for providing a fully integrated electronic medical record. The authors explore the unique challenges presented by the project and the solutions deployed. Key components related to the success of the project are identified. The results of the intense two and half year project timeline culminated in a successful go-live and certification as the first hospital in Australia to achieve Stage 6 HIMSS designation.

Background Lung cancer is the number one cause of cancer death worldwide.(1) It is the fifth most commonly diagnosed cancer in Australia (12,741 cases diagnosed in 2018) and the leading cause of cancer death.(2) The number of years of potential life lost to lung cancer in Australia is estimated to be 58,450, similar to that of colorectal and breast cancer combined.(3) While tobacco control strategies are most effective for disease prevention in the general population, early detection via low dose computed tomography (LDCT) screening in high-risk populations is a viable option for detecting asymptomatic disease in current (13%) and former (24%) Australian smokers.(4) The purpose of this Evidence Check review is to identify and analyse existing and emerging evidence for LDCT lung cancer screening in high-risk individuals to guide future program and policy planning. Evidence Check questions This review aimed to address the following questions: 1. What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? 2. What is the evidence of potential harms from lung cancer screening for higher-risk individuals? 3. What are the main components of recent major lung cancer screening programs or trials? 4. What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Summary of methods The authors searched the peer-reviewed literature across three databases (MEDLINE, PsycINFO and Embase) for existing systematic reviews and original studies published between 1 January 2009 and 8 August 2019. Fifteen systematic reviews (of which 8 were contemporary) and 64 original publications met the inclusion criteria set across the four questions. Key findings Question 1: What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? There is sufficient evidence from systematic reviews and meta-analyses of combined (pooled) data from screening trials (of high-risk individuals) to indicate that LDCT examination is clinically effective in reducing lung cancer mortality. In 2011, the landmark National Lung Cancer Screening Trial (NLST, a large-scale randomised controlled trial [RCT] conducted in the US) reported a 20% (95% CI 6.8% – 26.7%; P=0.004) relative reduction in mortality among long-term heavy smokers over three rounds of annual screening. High-risk eligibility criteria was defined as people aged 55–74 years with a smoking history of ≥30 pack-years (years in which a smoker has consumed 20-plus cigarettes each day) and, for former smokers, ≥30 pack-years and have quit within the past 15 years.(5) All-cause mortality was reduced by 6.7% (95% CI, 1.2% – 13.6%; P=0.02). Initial data from the second landmark RCT, the NEderlands-Leuvens Longkanker Screenings ONderzoek (known as the NELSON trial), have found an even greater reduction of 26% (95% CI, 9% – 41%) in lung cancer mortality, with full trial results yet to be published.(6, 7) Pooled analyses, including several smaller-scale European LDCT screening trials insufficiently powered in their own right, collectively demonstrate a statistically significant reduction in lung cancer mortality (RR 0.82, 95% CI 0.73–0.91).(8) Despite the reduction in all-cause mortality found in the NLST, pooled analyses of seven trials found no statistically significant difference in all-cause mortality (RR 0.95, 95% CI 0.90–1.00).(8) However, cancer-specific mortality is currently the most relevant outcome in cancer screening trials. These seven trials demonstrated a significantly greater proportion of early stage cancers in LDCT groups compared with controls (RR 2.08, 95% CI 1.43–3.03). Thus, when considering results across mortality outcomes and early stage cancers diagnosed, LDCT screening is considered to be clinically effective. Question 2: What is the evidence of potential harms from lung cancer screening for higher-risk individuals? The harms of LDCT lung cancer screening include false positive tests and the consequences of unnecessary invasive follow-up procedures for conditions that are eventually diagnosed as benign. While LDCT screening leads to an increased frequency of invasive procedures, it does not result in greater mortality soon after an invasive procedure (in trial settings when compared with the control arm).(8) Overdiagnosis, exposure to radiation, psychological distress and an impact on quality of life are other known harms. Systematic review evidence indicates the benefits of LDCT screening are likely to outweigh the harms. The potential harms are likely to be reduced as refinements are made to LDCT screening protocols through: i) the application of risk predication models (e.g. the PLCOm2012), which enable a more accurate selection of the high-risk population through the use of specific criteria (beyond age and smoking history); ii) the use of nodule management algorithms (e.g. Lung-RADS, PanCan), which assist in the diagnostic evaluation of screen-detected nodules and cancers (e.g. more precise volumetric assessment of nodules); and, iii) more judicious selection of patients for invasive procedures. Recent evidence suggests a positive LDCT result may transiently increase psychological distress but does not have long-term adverse effects on psychological distress or health-related quality of life (HRQoL). With regards to smoking cessation, there is no evidence to suggest screening participation invokes a false sense of assurance in smokers, nor a reduction in motivation to quit. The NELSON and Danish trials found no difference in smoking cessation rates between LDCT screening and control groups. Higher net cessation rates, compared with general population, suggest those who participate in screening trials may already be motivated to quit. Question 3: What are the main components of recent major lung cancer screening programs or trials? There are no systematic reviews that capture the main components of recent major lung cancer screening trials and programs. We extracted evidence from original studies and clinical guidance documents and organised this into key groups to form a concise set of components for potential implementation of a national lung cancer screening program in Australia: 1. Identifying the high-risk population: recruitment, eligibility, selection and referral 2. Educating the public, people at high risk and healthcare providers; this includes creating awareness of lung cancer, the benefits and harms of LDCT screening, and shared decision-making 3. Components necessary for health services to deliver a screening program: a. Planning phase: e.g. human resources to coordinate the program, electronic data systems that integrate medical records information and link to an established national registry b. Implementation phase: e.g. human and technological resources required to conduct LDCT examinations, interpretation of reports and communication of results to participants c. Monitoring and evaluation phase: e.g. monitoring outcomes across patients, radiological reporting, compliance with established standards and a quality assurance program 4. Data reporting and research, e.g. audit and feedback to multidisciplinary teams, reporting outcomes to enhance international research into LDCT screening 5. Incorporation of smoking cessation interventions, e.g. specific programs designed for LDCT screening or referral to existing community or hospital-based services that deliver cessation interventions. Most original studies are single-institution evaluations that contain descriptive data about the processes required to establish and implement a high-risk population-based screening program. Across all studies there is a consistent message as to the challenges and complexities of establishing LDCT screening programs to attract people at high risk who will receive the greatest benefits from participation. With regards to smoking cessation, evidence from one systematic review indicates the optimal strategy for incorporating smoking cessation interventions into a LDCT screening program is unclear. There is widespread agreement that LDCT screening attendance presents a ‘teachable moment’ for cessation advice, especially among those people who receive a positive scan result. Smoking cessation is an area of significant research investment; for instance, eight US-based clinical trials are now underway that aim to address how best to design and deliver cessation programs within large-scale LDCT screening programs.(9) Question 4: What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Assessing the value or cost-effectiveness of LDCT screening involves a complex interplay of factors including data on effectiveness and costs, and institutional context. A key input is data about the effectiveness of potential and current screening programs with respect to case detection, and the likely outcomes of treating those cases sooner (in the presence of LDCT screening) as opposed to later (in the absence of LDCT screening). Evidence about the cost-effectiveness of LDCT screening programs has been summarised in two systematic reviews. We identified a further 13 studies—five modelling studies, one discrete choice experiment and seven articles—that used a variety of methods to assess cost-effectiveness. Three modelling studies indicated LDCT screening was cost-effective in the settings of the US and Europe. Two studies—one from Australia and one from New Zealand—reported LDCT screening would not be cost-effective using NLST-like protocols. We anticipate that, following the full publication of the NELSON trial, cost-effectiveness studies will likely be updated with new data that reduce uncertainty about factors that influence modelling outcomes, including the findings of indeterminate nodules. Gaps in the evidence There is a large and accessible body of evidence as to the effectiveness (Q1) and harms (Q2) of LDCT screening for lung cancer. Nevertheless, there are significant gaps in the evidence about the program components that are required to implement an effective LDCT screening program (Q3). Questions about LDCT screening acceptability and feasibility were not explicitly included in the scope. However, as the evidence is based primarily on US programs and UK pilot studies, the relevance to the local setting requires careful consideration. The Queensland Lung Cancer Screening Study provides feasibility data about clinical aspects of LDCT screening but little about program design. The International Lung Screening Trial is still in the recruitment phase and findings are not yet available for inclusion in this Evidence Check. The Australian Population Based Screening Framework was developed to “inform decision-makers on the key issues to be considered when assessing potential screening programs in Australia”.(10) As the Framework is specific to population-based, rather than high-risk, screening programs, there is a lack of clarity about transferability of criteria. However, the Framework criteria do stipulate that a screening program must be acceptable to “important subgroups such as target participants who are from culturally and linguistically diverse backgrounds, Aboriginal and Torres Strait Islander people, people from disadvantaged groups and people with a disability”.(10) An extensive search of the literature highlighted that there is very little information about the acceptability of LDCT screening to these population groups in Australia. Yet they are part of the high-risk population.(10) There are also considerable gaps in the evidence about the cost-effectiveness of LDCT screening in different settings, including Australia. The evidence base in this area is rapidly evolving and is likely to include new data from the NELSON trial and incorporate data about the costs of targeted- and immuno-therapies as these treatments become more widely available in Australia.