Patient Safety

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, Associate Professor Chris Reid
Background: Chronic leg ulcers affect 1% of the general population in Australia, and 3.6% of people older than 65 years. Venous ulceration represents the most prevalent form of difficult to heal wounds and these problematic wounds require a significant amount of health care resources for their treatment. The incidence of venous ulceration is rising with the increasing age of the general population. The most common cause of lower extremity ulcers is venous insufficiency. A meta-analysis of bandaging systems found that multilayer compression bandages seemed to be superior to single-layer bandages in promoting ulcer healing. Based on current knowledge the multi-layer high compression system is described as the current gold standard for treating venous ulcers. However, to date, despite our advances in venous ulcer therapy, no convincing low cost compression therapy studies have been conducted. And although we know that high compression is more effective than low compression there are no clear differences in the effectiveness of different types of high compression. Primary aim: To assess the rate of percentage reduction in wound size from baseline compared to week 12 following randomisation.
Method: This pilot study is a randomised, multi-centre clinical trial to evaluate the efficacy and safety of graduated three layer straight tubular bandaging (intervention arm) compared with standard compression therapy (control arm) in participants with chronic venous ulceration. Neither participants nor study staff will be blinded to treatment. Participants will be randomised (1:1) to either treatment arm. Australian New Zealand Clinical Trials Registry (ANZCTR) Trial No: 083163
Results: Pending
Status: Study in progress, recruitment continues to early 2010
Publications: A simple guide to randomised control trials in wound care (in press)
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: Pending
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: 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 development phase.
PhD Student: Judy Lowthian
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 2009 (in press)
Presentations: Australasian College for Emergency Medicine 26th Annual Scientific Meeting 2009 Section: What's hot: "You'd think the rain would have cooled things down"
Speakers: Professor Joseph E Ibrahim & Judith 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."
Student/s: N/A
Contact Person: Judy McInnes - judy.mcinnes@med.monash.edu.au