Improving evidence-based management and outcomes in community-acquired pneumonia: Effectiveness of a multidisciplinary bundle of care

Ms Melanie Lloyd1, Dr Amalia Karahalios2, Professor Edward Janus1, Ms Stephanie Lowe1, Ms Melina Shackell1, Professor  Terry Haines3, Dr Elizabeth Skinner1, Dr  So Ko1, Dr Lucy Desmond1, Dr Anurika De Silva2, Associate Professor Harin Karunajeewa1

1Western Health, St Albans, Australia, 2University of Melbourne, Parkville, Australia, 3Monash University, Frankston, Australia

Abstract:

Aim:
To evaluate a multidisciplinary approach to management of hospitalised patients with community-acquired pneumonia (CAP), designed to improve adherence to interventions with prior proven efficacy (early mobilisation, routine malnutrition screening, routine corticosteroids, and early switch to oral antibiotics).

Design:
Pragmatic, stepped-wedge, randomised effectiveness study.

Method:
Patients hospitalised under a General Internal Medical (GIM) unit meeting a standard case-definition for CAP were eligible. Eight GIM units at two Australian hospitals were randomised to either: i) usual care, or ii) care supported by a dedicated “CAP Service”: a multidisciplinary team deploying algorithm-based implementation of four evidence-based interventions. Outcome measures included: i) length of hospital stay (LOS), ii) mortality, iii) readmission rates, and iv) compliance with evidence-based practice.

Results:
415 and 401 individuals were randomised to usual care and the CAP Service respectively. Under the CAP Service, adherence to evidence-based protocols improved across all four interventions (early mobilisation: 19% (usual care) vs. 72% (CAP Service), malnutrition screening: 55% vs. 83%, corticosteroids: 2% vs. 53%, switch to oral antibiotics: 69% vs. 77%). However, no difference in outcome was observed for LOS (predicted mean 3.5 vs 3.4 days, odds ratio [95% CI] 0.95 [0.79-1.16]), 90-day mortality (16% vs 16%, 0.92 [0.49-1.75]) or 90-day readmissions (26% vs 30%, 1.17 [0.70-1.94]).

Conclusion:
This study demonstrates an innovative, analytically robust approach to translational health services research, where effectiveness can be evaluated in a generalisable “real-world” setting. A multidisciplinary team was able to significantly increase adherence to evidence-based practice, however, there was no associated improvement in study outcomes.

Biography:

Melanie has over 10 years experience working as a Physiotherapist in Melbourne, Brisbane and the UK. Her clincial interest areas include acute illness in multimorbid individuals, exercise rehabilitation and vestibular rehabilitation. She is currently leading a program of research that aims to explore novel methodologies for evaluating interventions in highly representative patient groups, and is a PhD candidate at the University of Melbourne.

 

When do allied health professionals lose confidence to perform evidence-based practice activities? A cross-sectional study

Dr Marlena Klaic1,2, Associate Professor Fiona McDermott2, Professor Terry Haines2

1Royal Melbourne Hospital, Parkville, Australia, 2Monash University, Frankston, Australia

Abstract:

Background:
Australian allied health professional groups typically have accreditation or registration requirements which mandate training in EBP skills within undergraduate courses. It is likely that recent Australian graduates from the allied health professions are equipped to undertake a range of EBP activities. However, published research continues to find that clinicians report a lack of skills as a significant barrier to EBP, despite the commitment of education providers and registration bodies to facilitate this.

Aim:
To examine the relationship between allied health professionals’ confidence to perform a range of EBP activities and the number of years worked clinically and highest level of qualification received.

Method:
Analytical cross-sectional survey using a validated instrument that measured attitudes, skills and behaviour. Allied health professionals from two  metropolitan hospitals in Australia were eligible to participate in the study. A multivariable regression with adjustment for the highest level of qualification received was completed.

Results:
288 surveys were completed, representing a 58% response rate. Allied health professionals begin to lose confidence related to EBP activities within the first five years of practice, particularly for critical analysis of published studies. Higher level qualifications protect against the effect of degradation of EBP skills and confidence over time

Significance:
Recently graduated allied health professionals are equipped with the knowledge and skills to confidently participate in EBP activities. However, these skills degrade quickly. If allied health professionals are to provide a practice that is evidence based, there must be investment in strategies which ensure maintenance of EBP skills.

Biography:

Dr Marlena Klaic is the DHHS appointed Allied Health Research & Translation Leader at the Royal Melbourne Hospital. She has 20 years’ experience working clinically in neurological rehabilitation, research and project management. Marlena completed her PhD on “Enhancing the uptake of evidence-based practice with allied health professionals: A quasi-experimental study”.

Transforming the teaching and use of evidence-based practice with CrowdCARE: Crowdsourcing Critical Appraisal of Research Evidence

Dr Laura Downie1, Dr Michael Pianta1

1Department of Optometry and Vision Sciences, The University Of Melbourne, Parkville, Australia

Abstract:

Aim:
We developed a free, online tool that teaches critical appraisal and facilitates the sharing of appraisals amongst a global community (CrowdCARE, crowdcare.unimelb.edu.au). Our aim was to investigate the rigour of crowdsourced appraisals from trained novice raters.

Method:
Systematic reviews (n=71) were appraised in CrowdCARE by five trained novices and two expert raters. Appraisals were performed using a validated tool (AMSTAR) to yield: (i) an aggregate quality score, and (ii) domain-specific responses for each of the 11 assessment items. Appraisal quality was investigated by assessing the variability in AMSTAR scoring and calculating the concordance of ratings using Cohen’s Kappa (κ).

Results:
Variability in aggregate AMSTAR scores was similar between expert raters, and between the expert consensus and mean novice ratings. A strong correlation was evident between the expert consensus and mean novice rating (r2=0.89, p<0.0001). There was good agreement (κ=0.67, 95%CI: 0.61 to 0.73) between the aggregate score of the expert consensus rating and mean novice rating.

Significance of the findings to allied health:
These data demonstrate the merit of our novel crowdsourcing approach for appraising research quality. Allied health students can be trained to critically appraise systematic reviews and there is moderate agreement between expert and novice raters. CrowdCARE provides students and clinicians with the skills to appraise research quality and contributes to making evidence-based practice more efficient by removing the substantial duplication of effort made by individual clinicians across the globe.

Biography:

Dr Laura Downie is a tenured Senior Lecturer in the Department of Optometry and Vision Sciences at the University of Melbourne. In this role, she provides didactic and clinical training to Doctor of Optometry students, leads the sub-specialty cornea clinic at University of Melbourne eyecare clinic and heads her own research laboratory, the ‘Downie Anterior Eye, Clinical Trials and Research Translation Unit.’ Laura completed both her undergraduate optometry degree (2003) and doctorate (2008) at the University of Melbourne. In 2014, she was awarded two fellowships from the National Health and Medical Research Council and achieved international recognition for her clinical research achievements with the award of the Irvin and Beatrice Borish Award from the American Academy of Optometry. Dr Downie’s research laboratory adopts an integrated approach to research in ocular disease that combines laboratory, clinical and behavioural science as a foundation for evidence-based practice, to improve clinical outcomes. She possesses high level expertise in critical appraisal, research synthesis, translation and implementation science.

Dr Michael Pianta is a Senior Lecturer in the Department of Optometry and Vision Sciences and the Director of Learning and Teaching in the Melbourne School of Health Sciences at the University of Melbourne. Michael completed his undergraduate degree (1991), masters degree (1994), and doctorate (2000) at the University of Melbourne. He is the coordinator of the Doctor of Optometry (OD) program, and has led innovative curriculum design in that program, including use of the CrowdCARE platform. His reputation in competency-based assessment led to his appointment as a consultant for the Optometric Council of Australia & New Zealand, the independent accreditation body for optometry programs in the region.

Communicating Health – Understanding the Aspects of an Engaging Social Media Post

Ms Emma Herron1, Ms Annika Molenaar1, Mr Jamie Choong1, Dr Karen Klassen1, Dr Megan Lim2, Prof Linda Brennan3, Prof Mike Reid4, Prof Helen Truby1, Dr Tracy McCaffrey1

1Department of Nutrition, Dietetics & Food, Monash University, Notting Hill, Australia, 2Behaviours and Health Risks, Burnet Institute, Melbourne, Australia, 3School of Media & Communication, RMIT University , Melbourne, Australia, 4School of Economics, Finance & Marketing, RMIT University, Melbourne, Australia

Abstract:

Aim:
People are increasingly using social media (SM) to seek health and nutrition information, with some content increasing audience engagement (likes, comments, share etc). We aimed to identify strategies used on SM associated with higher engagement, across popular profiles in Australia, from food industry (n=10); lifestyle personalities (n=10); health organisations (n=7); and nutrition professionals (n=10).

Method:
An exploratory content analysis, using a coding framework was conducted on SM content (n=524 SM posts) across Instagram, Facebook and Twitter for 4 weeks (February to March) in 2018. The association between content strategies and engagement metrics was explored using multivariate linear regression.

Results:
Engagement was higher for lifestyle personalities on all platforms. Strategies most associated with higher engagement were content “Showing People” on Instagram (β 0.233, 95% CI (0.298 to 1.041), p<0.001) and a “Positive Tone” on Twitter (β 0.218, 95% Cl (0.037 to 0.246), p<0.009). Other strategies associated with increased engagement included “Fast-Paced” videos (e.g. recipes) on Facebook, “Body Image” related content on Instagram and “Visually Appealing” content on Twitter. Strategies associated with lower engagement were posts of “Health Success” on both Facebook (β= -0.208, 95% CI (-0.274 to -0.065), p <0.002) and Instagram (β= -0.228, 95% CI (-1.017 to -0.265), p<0.001) and Twitter content with “Links to Health Information” (β= -0.251, 95% CI (-0.265 to -0.067), p<0.001).

Significance of the findings to allied health:
Nutrition professionals and health organisations could learn from successful engagement strategies of online personalities as to how to increase reach and interactions with social media content.

Biography:

Dr Tracy McCaffrey is a Senior Lecturer in the Department of Nutrition, Dietetics and Food at Monash University. She is a Registered Nutritionist (UK) with a research focus in Public Health Nutrition. At Monash, she leads the research stream on Dietary Assessment Methodologies to provide specialist analysis and advice on suitable methods to assess dietary intake. She has advised government departments in Australia, New Zealand, UK and Ireland on the assessment of dietary intakes and consumer understanding of portion size. Dr McCaffrey is currently chair of the Melbourne group for the Nutrition Society of Australia and Trustee of the Australian Nutrition Trust Fund. She is co-investigator and project co-ordinator on Communicating Health.

Can I eat that? – Nutrition knowledge and behaviours or practices of pregnant women and clinicians

Dr Amelia Lee1, Dr Jessica Radcliffe2, Dr Michelle Newton2, Dr Regina Belski2

1Royal Women’s Hospital, Parkville, Australia, 2La Trobe University, Bundoora, Australia

Abstract:

Aim:
To measure pregnancy nutrition recommendation knowledge in pregnant women and clinicians and to explore how nutrition information influences food choice or nutrition counselling practices.

Method:
Participants self-administered a nutrition knowledge questionnaire asking about nutrition recommendations and source of nutrition information.  Interviews were then conducted to explore dietary behaviour and/or practices.

Results:
Clinicians nutrition knowledge score was higher than for women.  Gaps in knowledge included food group recommendations, weight gain recommendations and identifying high risk foods.  Clinicians procure their information from dietitians and print materials whereas women obtain their information from clinicians and the internet.  Interviews revealed that clinicians reported providing nutrition advice; however, few women reported receiving it.  When women did receive nutrition advice, it was brief, in general terms and at times conflicting.  Women want to know about the nutrition recommendations and the reasons for them.  Lack of nutrition knowledge, inadequate nutrition training and time constraints were associated with clinician’s ability to provide adequate and accurate nutrition advice.

Significance of the findings to allied health:
Enhancing nutrition knowledge is a cost-effective approach to optimising maternal and infant health outcomes.  Until knowledge deficits are addressed, opportunities for nutrition education, and the prevention of adverse health outcomes, will be limited.  Findings of this study highlight the need to develop accurate and comprehensive pregnancy nutrition education programs suitable for both women and clinicians.

Biography:

Move Baby Move: Physical activity ‘messaging’ needs of women with gestational diabetes mellitus: a qualitative study

Ms Anne Harrison1,2, Professor Nicholas Taylor2,3, Associate Professor Helena Frawley4,5, Professor Nora Shields2

1Werribee Mercy Hospital, Werribee, Australia, 2La Trobe University, Melbourne, Australia, 3Eastern Health, Box Hill, Australia, 4Monash University, Frankston, Australia, 5Cabrini Health, Malvern, Australia

Abstract:

Aim:
To identify the perceptions of women diagnosed with gestational diabetes mellitus (GDM) to physical activity during pregnancy?

Design:
A qualitative study with phenomenology and interpretative description as theoretical frameworks.

Method:
Pregnant women, with GDM, aged 18 to 40 years were purposively recruited. Recruitment continued until data saturation. Semi-structured interviews were recorded, transcribed verbatim and returned to participants for checking. Qualitative data were analysed thematically by three researchers independently. Data were coded, compared and themes developed, discussed and defined. Emergent themes were sent to participants and peer-reviewed for confirmation.

Results:
Twenty-seven women participated who were of mean age 32 years (SD 3), mean gestation 30 weeks (SD 5), mean pre-pregnancy body mass index 26 kg/m2 (SD 5) and born in 10 different countries. The process of communicating information about physical activity (messaging) was the main theme to emerge. Sub-themes included receiving information about physical activity from credible sources (‘who’), knowing what type and how much physical activity was safe for their pregnancy (‘what’), receiving information at GDM diagnosis as this triggered women’s desire to be more physically active (‘when’), understanding the positive effects of physical activity on pregnancy outcome (‘why’), and identifying flexible, individually-tailored physical activity options (‘how’).

Significance of findings for Allied Health:
Women with GDM wanted clear, simple and GDM-specific messages from credible sources to feel confident and safe being physically active. Health professionals can support women with a GDM pregnancy with targeted physical activity messages.

Biography:

Anne Harrison is a physiotherapist with over 30 year’s clinical experience including 20 years of health management experience. She is currently manager of physiotherapy services at Werribee Mercy Hospital in Melbourne. She has interests in women’s health and translating research into practice as well as health service planning. Anne’s present research is investigating physical activity participation for women diagnosed with GDM and has several publications in this area. Her qualifications include a Bachelor of Applied Science in Physiotherapy, a Master of Health Administration and she is currently a Professional Doctoral candidate.

 

Frameworks for Embedding a Research Culture in Allied Health Practice

Dr Susan Slade1, Ms Kathleen Philip2, Prof Meg Morris1,3

1La Trobe University, Bundoora, Australia, 2Department of Health and Human Services, Melbourne, Australia, 3Healthscope Northeastern  Rehabilitation Centre, Ivanhoe, Australia

Abstract:

Aim:
Embedding a culture of research within public and private health systems remains challenging. A rapid review was conducted to evaluate frameworks designed to create and embed research into routine allied health practice.

Method:
Full text English-language, peer-reviewed publications or Government reports were included. Eight electronic databases and four government websites were searched. Two independent researchers conducted all review stages and used content and thematic data analysis.

Results:
Sixteen frameworks papers were included. Content analysis identified 44 system and regulatory level items that informed research frameworks, 125 healthcare organisation items and 76 individual clinician items. Thematic analysis identified four major themes: (1) sustainable change requires allied health research policies, regulation and organizational structures; (2) research literacy of policy makers and managers are essential; (3) a whole-of-organisation approach facilitates a research culture; and (4) individual clinician attributes, such as motivation and research skills, are essential. Theoretical frameworks were identified that informed processes to embed a culture of allied health research into healthcare services. Research-led and evidence-informed allied health practice enables optimisation of workforce capability and high quality care.

Significance of the findings to allied health:
Sustainable change requires allied health research policies, regulation and organizational structures that support evidence-based practice. Research advocacy and literacy of managers are key to successful implementation. Organisational factors that facilitate a research culture include dedicated research positions, professional education, infrastructure and university partnerships. “Research ready” graduates and clinicians are essential to embedding research into practice.

Biography:

Dr Susan Slade is a La Trobe University postdoctoral research fellow, provisional fellow of the Australian College of Physiotherapy and musculoskeletal physiotherapist. Dr Slade has over 40 peer-reviewed publications and has presented at 20 international conferences. She has strong collaborative networks including the University of Southern Denmark and Warwick University and is member of the Cochrane back and neck and qualitative and implementation review groups. Her research expertise is in systematic reviews, qualitative research and exercise prescription. Her research interests are chronic health conditions, translation and implementation into clinical practice, reporting guidelines and method quality assessment.

Guardianship in Hospitals: A Health Services/OPA Pilot Project

Dr Rob Hoffman1, Sally Costar1, Tass Kostopoulos2, Justine Little3, Aaron Livingstone4, Fiona McAlinden3, Paul Newland4, Jacinta Re3, Dina Watterson1, Prof Terry Haines5

1Alfred Health, Melbourne, Australia, 2Eastern Health, Melbourne, Australia, 3Monash Health, Melbourne, Australia, 4Office of the Public Advocate (Victoria), Melbourne, Australia, 5Monash University, Melbourne, Australia

Abstract:

Aim:
This collaborative project between three metropolitan health services and the Office of Public Advocate Victoria (OPA) explores the impact of increased availability of advocate guardians delegated by the Public Advocate on healthcare system sustainability and outcomes.

The pilot targets a particularly-vulnerable group: hospital-based recipients of VCAT guardianship orders, made on evidence of a cognitive impairment indicating a lack of capacity to make important lifestyle and personal decisions.

The primary aim of the pilot is to reduce the time these patients spend waiting for allocation of a guardian, decreasing patient risk and releasing healthcare system resources.

Method:
A multi-institutional, cross-sectional pilot program created a dedicated hospital guardian team within OPA, funded by the partner health services, to reduce the time to guardian allocation for patients within these services.

The impact of the pilot was measured through an historical control group design, with initial data collection over 12 months, followed by yearly cohorts of post-implementation patients.

Results:
Under this pilot the time from guardianship order lodgement to guardian allocation has significantly decreased from 46.5 to 23.1 days, halving the average time hospital-based patients spend waiting for a guardian. Estimated cost savings are $15,355 per patient, or over $5 of healthcare system resources released per $1 spent on increased staffing.

Significance of the findings to allied health:
These findings demonstrate how collaboration and investment by healthcare providers in non-health areas can deliver substantial benefits for healthcare system sustainability in an area of patient vulnerability and growing demand.

Biography:

Dina Watterson is Associate Director of Allied Health at Alfred Health in Melbourne, Victoria.

Tass Kostopoulos is Director of Social Work and Associate Program Director of Allied Health at Eastern Health in Melbourne, Victoria.

Fiona McAlinden is Director of Sub Acute Care and Community Health at Monash Health in Melbourne, Victoria.

Paul Newland is Manager of Advocacy and Guardianship at the Office of the Public Advocate in Melbourne, Victoria.

The STAT model improves access to sub-acute rehabilitation and outpatient services: A stepped wedge randomised controlled trial

Dr Katherine Harding1

1Eastern Health / La Trobe University, Box Hill, Australia

Abstract:

Aim:
Long wait lists for allied health services in ambulatory and community settings have negative health consequences. The STAT model (Specific Timely Appointments for Triage) was designed to improve access to these services using initial targeted strategies to reduce the existing wait list coupled with protected appointments for new patients that aim to maintain flow at the rate of demand.

This trial aimed to determine whether the STAT model could work beyond isolated pilot trials to reduce waiting time in a fully powered stepped wedge trial with multiple sites.

Method:
We conducted a stepped wedge cluster randomised controlled trial involving 8 sites (n=3116 patients), registered prospectively (ACTRN no. 12615001016527). The primary outcome was time from referral to first appointment; secondary outcomes included time to second appointment, rate of discharge at 12 weeks and number of appointments provided.

Results:
Median time from referral to first appointment reduced from 60 days pre-intervention to 36 days in the post-intervention period across all sites (IRR 0.66, 95% CI 0.52 to 0.85) with no change in secondary outcomes. Variation in waiting time was also reduced.

Significance of findings for Allied Health:
Allied Health professionals frequently provide services in community health and ambulatory settings with long waiting lists. Improvements in access to these services can be achieved by addressing inefficiencies and encouraging service providers to make priority decisions about service delivery in the context of demand.

Biography:

Katherine began her working life as an Occupational Therapist before completing a PhD in and shifting focus to the world of health services research.  She is a  Research Fellow with the Allied Health Research Office at Eastern Health, where she provides research support for allied health clinicians, promotes research activity and leads a range of projects. Katherine also holds an an adjunct position with La Trobe University and serves on the Executive Committee of the Health Services Research Association of Australia and New Zealand.

Early Rehabilitation Team (ERT): patient and service outcomes evaluation

Freya Coker1, Amy Stichling2, Rebekah Clutterbuck2, Dr Cylie Williams1, Professor Terry Haines1

1Monash University, Peninsula, Australia, 2Monash Health, , Australia

Abstract:

Aim:
To understand the Early Rehabilitation Team’s (ERT) impact on patient and service outcomes in acute and subacute at Monash Health.

Method:
Whole of service length of stay (LOS), readmission and costing data were extracted. Data extracted were within 2017 (ERT implementation) and compared to 2015-2016 for equivalent time points. Staff perspectives were sought through interview and online survey. Regression analyses were used to compare outcomes between time points, clustering by patient UR. Qualitative data were thematically analysed.

Results:
During 2017, when compared against 2015-2016 combined, patients had a statistically significant higher likelihood of admission to subacute (OR=1.34,95%CI=1.22 to 1.47, p<0.01), greater LOS in acute (Coef=0.12,95%CI=0.09 to 0.14, p<0.001) and greater total length of hospital stay for patients admitted to acute and subacute (Coef=0.15,95%CI=0.12 to 0.18, p<0.001). There was no significant difference in subacute LOS between time points (Coef=0.05,95%CI= -0.03 to 0.13, p=0.245). Cost analyses for the three years indicated a difference in funding (favouring increasing costs each year) for total costs (Coef=461.02,95%CI=178.80 to 743.24, p=0.001), acute only costs (Coef=260.26,95%CI=29.27 to 491.45, p=0.027) and subacute only costs (Coef=200.76,95%CI=80.10 to 321.43, p=0.001). Average total cost increased each year from 2015, even with CPI adjustment. This was expected given the differences in LOS. Qualitative findings indicated challenges that may have contributed to a finding of no health service change in outcomes.

Significance of the findings to allied health: It appears this particular model of care did not have patient or service impact.

Biography:

Freya Coker is an occupational therapist and currently completing her PhD with Monash University. Today she is presenting the Early Rehabilitation Team: patient and service outcomes evaluation.

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