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Patient Safety

Warfarin complications in the community

Investigators: John McNeil, Peter Cameron, Michael Dooley, Ellen Maxwell, Rory Wolfe, Sue Evans, Alison Street, Leon Piterman, Basia Diug, Judy Lowthian
Project Coordinator: Judy Lowthian
Background: Warfarin is the mainstay of prophylaxis against stroke in atrial fibrillation and valve replacement. Warfarin’s narrow therapeutic window necessitates close monitoring of the International Normalised Ratio (INR) as numerous factors are recognised to increase or reduce itsanticoagulation effect. Despite its efficacy, it remains one of the most common drug-related causes of death and morbidity, with increased bleeding tendency as the major adverse effect of warfarin.
Aims: The aim of this project is to reduce the amount of unnecessary bleeding due to warfarin, by identifying predisposing factors and potential system of care issues amongst patients with significantly elevated INR levels; and to develop a preliminary risk profile of patients being treated with warfarin who record elevated INR levels in the blood. We hypothesize that people with an elevated INR level will have a different profile compared to those people who maintain an INR level within a
therapeutic range.
Method: Based in metropolitan Melbourne this project is being conducted in collaboration with Melbourne Pathology, and consists of two phases. The pilot study was completed in 2007, and interviewed 40 patients with INRs ≥ 6, and their primary treating doctors. The current case control study comprises 450 patients, 150 cases and 300 controls. Patients are eligible if they are aged ≥18 years, reside in the community, provide informed consent and have been on warfarin for a minimum of 6 months. Additionally, cases have recently developed an INR ≥ 6.0, whilst controls have been well stabilised for a minimum of 3 months. Patient interviews investigate potential predisposing factors including demographic and clinical characteristics, comorbidities, diet, medication, and warfarin knowledge. Standardised measures evaluate cognition, mood, social support, functional independence, and adherence and medication complexity.
Status: Recruitment of patients and data collection phase.
Publications: 

  • Lowthian J, Evans S. Management of Atrial Fibrillation. Australian Family Physician 2007; 36(10):791;
  • Diug B, Lowthian J, Evans S. Warfarin versus Aspirin for Stroke Prevention. Lancet 2007; 370(9599):1606;
  • Lowthian J, Diug B. Lessons from the TAPS study- warfarin: a major cause of threats to patient safety. AFP 2008 37(12):983

Student/s: Basia Diug
Contact Person:Basia Diug - basia.diug@med.monash.edu.au

Determining health risks in older persons from extreme hot weather

Principal research category: Patient Safety
Project Coordinators: Prof Joe Ibrahim and Ms Judy McInnes
Background:  A literature review, site visit and field consultation were undertaken. Victorian data on relationship between temperature and morbidity/mortality in those aged 65 years and over was reviewed. A survey of GPs and carers was delivered to describe current knowledge and identify key knowledge gaps.
Findings: The key finding of this project was that there is a broad level of understanding of the dangers of heatwaves, the potential for heat related illness or death and of the protective factors. However, there is little being done in practice to actively plan, identify and intervene to protect the at risk groups. Most stakeholders provide reactive, advice directed to the individual who presents for care at the time of a heatwave. This leaves the vulnerable older persons in Victoria at risk of significant preventable harm in the event of a heatwave. To our knowledge, this study provides the first empirical evidence about the level of knowledge and awareness of six different stakeholder groups who work with aged person 65 years and older in Victoria, Australia and internationally. A limitation of this survey is the potential for response bias. This leads to an overestimate of the actual level of knowledge, interventions in practice and willingness to participate in future interventions. The other limitation is generalising and transferring the findings of the published research is predominant from the Northern hemisphere to Australia. There are obvious geographic, meteorological, social, community and health system differences. What is beyond doubt is that stakeholder organisations and individuals have expressed a willingness and readiness to contribute to a co-ordinated strategy that reduces the potential for and actual harm from heat waves in Victoria.
Progress towards minimisation of harm to the elderly in the event of extreme hot weather requires harnessing the interest of the key stakeholders and investment of resources to support the next step, developing a heat wave response plan for Victoria that meets the needs of each geographic area.
Project status: Completed
Publications: McInnes JA, Ibrahim JE. Minimising harm to elderly Victorians from heatwaves: a qualitative study of the role of community based health profession and carer organisations. Australia and New Zealand Journal of Public Health (submitted 2009)
Contact: Judy.McInnes - Judy.McInnes@med.monash.edu.au

Management of venous ulcers

Project Coordinator: Carolina Weller
Investigators: Professor John McNeil, Dr Sue Evans, Ass. Professor Chris Reid, Ass Professor Damien Jolley.
Background: Venous leg ulceration is a global health care problem imposing a growing burden on primary, sub acute and acute health care systems. It is estimated that up to 2% of the population in Western countries are affected. Prevalence increases with age and is higher in women than men at a ratio of 1.25:1. The most common cause of lower extremity ulceration is venous insufficiency which accounts for nearly 80% of all ulcers. Estimates of the prevalence and incidence of ulceration vary and the wide variations can probably be explained by the different survey and sampling methods used.
Although venous ulcers are not typically seen as a pressing health care problem, the impact of leg ulcers is felt both in physical suffering and reduced quality of life of those affected and in financial costs to the community. Because the cost and resource implication of management of venous ulcers will cause considerable strain on the health system, strategies to improve management and cost effectiveness of this condition must be seen as a priority.
Compression systems improve the healing of venous leg ulcers and should be used routinely for uncomplicated venous ulcers. Compression of the lower leg is an effective intervention in the prevention and treatment of venous ulcers but insufficient reliable evidence exists to indicate which system is the most effective and even though compression has been used for many decades in the treatment of venous ulcers its mode of action is still poorly understood.
Even though compression is the first line treatment to treat venous ulcers and best practice evidence has demonstrated that multilayer compression is the best way to heal uncomplicated venous ulcers and we know that many patients with venous ulcers are unable to tolerate compression but we have yet to find out why people are unable or unwilling to adhere to compression therapies or what types of specific interventions would help people to adhere to compression bandages.
Methods:
1. Sub-bandage pressure randomised controlled trial (RCT) in healthy volunteers ACTRN12609000941268
2. Pilot RCT comparing two compression systems in people with active venous ulcers ACTRN12608000599370
3. Cochrane Systematic review to find out what interventions help people adhere to compression therapies
4. A survey of current practice and role of Practice Nurses in the management of venous ulcers in General Practice settings
5.Economic analysis of two compression bandages used in pilot RCT
Results: Sub-bandage pressure RCT in healthy volunteers: The Inelastic and elastic compression bandages were randomised to opposite limbs of 42 healthy adult volunteers. Sub-bandage interface pressures for both bandages were compared within person. Interface sub-bandage pressures varied according to different activities but the mean difference in interface pressures between inelastic and elastic bandages was consistently at least 13 mmHg. Stiffness was 7.3 mmHg higher in the inelastic group (95% CI: 5.1 to 9.5). The estimated difference in amplitude of sub-bandage pressure between the bandages during exercise was 15.5 mmHg (95% CI 12.2 to 18.9). We found in vivo interface sub-bandage pressures varied with the type of bandage and activity phase.
Status:  Sub bandage RCT completed, Pilot RCT recruitment in progress, Cochrane Systematic protocol completed, Systematic review in progress, Practice Nurse Survey in progress, Economic evaluation in progress
Publications:

  • Weller, C.D., Jolley, D., Wolfe, R., Meyers, K. & McNeil, J. (submitted).  The effect of elasticity on sub-bandage pressure and stiffness of tubular compression bandages: a randomised controlled trial. Wound Repair and Regeneration journal  
  • Weller,C D., Evans, S., Reid, CM., Wolfe, R. McNeil, J. (2010). Protocol: A pilot randomised controlled clinical trial to compare the effectiveness of a graduated three layer straight tubular bandaging system when compared to a standard short stretch compression bandaging system in the management of people with venous ulceration: 3VSS2008. BMC Trials 2010, 11:26doi:10.1186/1745-6215-11-26 http://www.trialsjournal.com/content/11/1/26
  • Weller C, Buchbinder R, Johnston RV. Interventions for helping people adhere to compression treatments for venous leg ulceration. Cochrane Database of Systematic Reviews 2010, Issue 2. Art. No.: CD008378. DOI: 10.1002/14651858.CD008378. Interventions for helping people adhere to compression treatments for venous leg ulceration (Protocol),
  • Weller CD, McNeil J, Evans S, Reid C. Improving venous ulcer healing: designing and reporting randomised controlled trials. International Wound Journal 2010; 7:41-47
  • Improving venous ulcer healing: Designing and Reporting Randomised Controlled Trials.
  • Weller, C, D. A simple guide to randomised control trials in wound care. European Wound Management Association Journal, 2009 9(2), 5-13.
  • Weller, C, D. Een eenvoudige handleiding voor geranomiseerd gecontroleerd onderzoek in wondzorg. Nederlands Tijdschrift voor Wondverzorging. Dutch Journal of Wound Care. 2009 4(8), 20-29.
  • Weller, CD. (2009). ‘Interactive Dressings and their role in moist wound healing'. In S.Rajendran (Ed.), Advanced Textiles for wound care (pp. 97-111). Woodhead Publishing Cambridge UK.

Student/s: Carolina Weller
Contact Person: Carolina Weller - carolina.weller@med.monash.edu.au

Improving management of patients suffering ischaemic stroke

Project Coordinator: Dr Benjamin Clissold
Investigators: Professor John McNeil, Professor Peter Cameron, Associate Professor Vijaya Sundararajan, Dr Benjamin Clissold
Background: There is clear evidence that patients with stroke who are cared for in stroke units have better outcomes in terms of death and dependency.  This is because of a number of factors including having expert stroke and neurology physician care and decision-making, combined with trained nursing and allied health professionals.  There is also evidence of the benefit of acute treatments for ischaemic stroke in particular, using intravascular thrombolytic therapies, however, these need to be provided within a short time period for them to have maximum benefit and reduce the risk of haemorrhagic complications.  Integral to administering these treatments is reducing delays in arrival at hospital for medical assessment. Accurate pre-hospital assessment by paramedics is essential in reducing pre-hospital delays.  This is potentially one of the most important time intervals if we are to make significant differences in outcomes for these patients.Data is available from every hospital in Victoria, reported to the Department of Human Services (DHS), regarding diagnosis, demographic information and treatment, in the Victorian Emergency Minimum Dataset (VEMD) and the Victorian Admitted Episodes Database (VAED). 
Aims: To determine epidemiology of stroke, stroke incidence and hospital outcomes in Victoria and trends over time.To establish referral practices for admission of patients with stroke to hospitals in Victoria.To establish geographic distribution of stroke in Victoria.To determine whether present pre-hospital triage practices result in transport to appropriate hospitals.To determine present stroke therapy across Victorian hospitals.To establish methods of linkage of relevant datasets, to aid in better assessment of stroke patient treatment and outcomes.To model a system of stroke management, such as pre-hospital clinical indicators, to reflect different outcome variables in order to predict the effect of changes in aspects of stroke treatments.To model the benefits of a stroke management system.
Method: Data will be obtained through the Department of Human Services regarding stroke patients admitted to Victorian hospitals.  The information gathered will be specifically from the Victorian Emergency Minimum Dataset (VEMD) and Victorian Admitted Episodes dataset (VAED) and will include the data fields listed below. Death index data will also be gathered.  Data will be extracted from 1999 (the date of maturity of the VEMD data) to the present to examine trends in stroke incidence and management. This will be de-identified data.  Data will be analysed to examine present patient demographics, stroke type, treatment and outcomes and present distribution of patients across the health system.  It is planned that statistical modelling of outcomes based on certain acute stroke management variables may be performed to assist in planning and recommendations for future stroke patient care.
Results: To date, the data has been analysed to determine crude and age adjusted incident stroke rates for Victoria for the years 2003 - 2008, after allowing a lead in time of 5 years, allowing an incident dataset to be created.  These rates have been adjusted taking into account gender and also stroke type.  Age adjusted stroke rates have been determined for local government areas within Victoria, with differences across the years also assessed.  Logistic regression analysis is currently in progress, establishing factors which may increase the risk of death from stroke, including co-morbidities, admission to a stroke unit and care in rural versus urban regions.  Geographic maps have been created to depict stroke incidence across Victoria.  Ongoing modeling work is currently taking place.
Status: Current
Staff: N/A
Publications: Pending
Student/s: Dr Benjamin Clissold
Contact Person: Dr Benjamin Clissold - benjamin.clissold@med.monash.edu.au

Increasing demand for emergency patient services: underlying drivers, implications and solutions.

Project Coordinator:Judy Lowthian
Investigators: Judy Lowthian , John McNeil, Peter Cameron, Just Stoelwinder, Alex Currell
Background: Increasing demand for emergency patient services is the most important issue facing health policy makers in developed countries. To date, there has been limited analysis of factors underlying the increase in demand for services involving transport and treatment of patients requiring emergency care. Growing demand on ambulance emergency services in Victoria is evident with a 21% increase over the 6 year period to 2004-05 in metropolitan Melbourne, and a 65% increase in rural Victoria. Growth in demand for emergency department (ED) care has escalated simultaneously at a similar rate. Overcrowding in EDs results in delay receiving patients arriving by ambulance, thereby interrupting access to timely emergency care. Diversion to other EDs impedes the ambulance service's capacity to respond to other incidents.
Aims:The overall aim of this project is to determine the underlying drivers of growth in emergency patient services, and to identify potential solutions for future management.
Method: This research comprises multiple projects, and includes analysis of 15 years of deidentified emergency patient and population-based data.
Status: This project is in the research phase.
PhD Student: Judy Lowthian
Publications:

  • Lowthian J, Cameron P. Emergency demand access block and patient safety: a call for national leadership. 2009 EMA; 21(5)

Presentations:

  • Lowthian J, Jolley D, Cameron P, Curtis A ,Stoelwinder J, Currell A, McNeil J The accelerating demand by the elderly for emergency pre-hospital services in Australia: 1995-2008, International Conference for Emergency Medicine Singapore 2010
  • Lowthian J Emergency Demand and Patient Flow: Pre-hospital services. CREPS Emergency Management Course, Melbourne, 2010
  • Lowthian J, Cameron P, Jolley D, Currell A, Stoelwinder J, McNeil J. Changes in the metropolitan emergency workload of Ambulance Victoria: 1995 to 2005. Australasian College of Emergency Medicine Conference, Melbourne, 2009

Contact Person:Judy Lowthian

Reducing harm to older persons in Victoria from extreme hot weather

Title: Reducing harm to older persons in Victoria from extreme hot weather
Investigators: Joe Ibrahim, Judy McInnes
Project Coordinator: Judy McInnes
Background: A literature review of published and professional literature identifying current knowledge of risk factors and risk reduction strategies regarding the morbidity and mortality of elderly people in extreme hot weather was prepared. A stakeholder consultation was conducted for the purpose of identifying current practices and organisational capacity of these groups regarding the care of elderly clients in the event of extreme hot weather. A survey instrument was developed, in order to describe awareness, knowledge, knowledge gaps, and practices of selected health professionals and carers, regarding minimisation of harm to the elderly in the event of extreme hot weather.
Publications:

  • McInnes JA, Ibrahim JE. Minimising harm to elderly Victorians from heatwaves: a qualitative study of the role of community-based health profession and carer organisations" by McInnes JA & Ibrahim JE Australasian Journal on Ageing 2010 (in press)

Presentations:

  • Australasian College for Emergency Medicine 26th Annual Scientific Meeting 2009, 18 Nov 2009, Section: What's hot: "You'd think the rain would have cooled things down" Speakers: Professor Joseph E Ibrahim & Judith A McInnes
  • Glen Eira City Council Heatwave Strategy-Stakeholders Forum, 29 Sept 2009 Guest speaker: Judith McInnes "Current heatwave research and it's relevance for the community."
  • Bendigo Heatwave Strategy - Pilot Projects Forum" 10 July 2008, Bendigo Guest speaker: Judith McInnes "Reducing Harm to older persons in Victoria from extreme hot weather".
  • Wodonga Heatwave Strategy - Pilot Projects Forum"8 July 2008, Albury Guest speaker: Judith McInnes "Reducing Harm to older persons in Victoria from extreme hot weather".
  • "Victorian Heatwave Strategy - Pilot Projects Forum" 29 April 2008, Melbourne Guest speaker: Judith McInnes "Reducing Harm to older persons in Victoria from extreme hot weather".

Abstracts accepted for presentation at Conference

Accepted for poster presentations at ‘Safety 2010 World Conference' London, September 2010:

  • Ibrahim JE, McInnes JA, Andrianopoulas N, Evans S. ‘Minimising harm to older persons from heatwaves: a survey of the awareness, knowledge, and practices of community-based health professionals and care providers in Victoria, Australia.'
  • McInnes JA, Ibrahim JE. ‘Minimising harm to elderly Victorians from heatwaves: a qualitative study of the role of community-based health profession and carer organisations.'
  • Poster presented at "Climate Change and Human Health Conference"16-17 October, 2007, Melbourne. "Reducing Harm to older persons in Victoria from extreme hot weather".

Student/s: N/A
Contact Person: Judy McInnes - judy.mcinnes@med.monash.edu.au 

Advice on Methodology for Patient Safety Culture

Investigators: Caroline Brand, Judy Lowthian
Summary: The Victorian Quality Council (VQC) and the Victorian Managed Insurance Authority (VMIA) have partnered in this project. The VMIA is the state government insurer providing risk management and insurance advice and services to government. The VQC is an expert strategic advisory group formed to govern the safety and quality agenda for Victorian health care services.  The strategic planning processes undertaken by both VMIA and VQC in 2008 identified the importance of culture and its impact on patient safety.
In this project VQC/VMIA sought expert advice on appropriate instruments and survey methods to inform a pilot (stage 1) of the survey in a limited number of Victorian Hospitals and subsequent state-wide roll-out (stage 2). A literature review and stakeholder consultation process was undertaken to address the questions; which safety culture or safety climate survey tool/s would be recommended for a State based survey and what issues need to be considered in implementing such a survey? The literature review included a comprehensive analysis of peer reviewed and grey literature. Identified survey tools were subjected to critical appraisal of measurement and implementation attributes. Local and Interstate stakeholders were purposefully identified based on previous experience performing patient safety culture surveys. With their consent they provided information about their experience, and barriers and enablers to implementation within a telephone interview using a semi-structured interview tool.
The literature review and stakeholder consultation findings were summarised in a report to VMIA/VQC submitted February 26th 2010.