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Background Older people living in residential aged care facilities are at high risk of acquiring infections such as influenza, gastroenteritis, and more recently COVID-19. These infections are a major cause of morbidity and mortality among this cohort. Quality infection prevention and control practice in residential aged care is therefore imperative. Although appointment of a dedicated infection prevention and control (IPC) lead in every Australian residential aged care facility is now mandated, all people working in this setting have a role to play in IPC. The COVID-19 pandemic revealed inadequacies in IPC in this sector and highlighted the need for interventions to improve implementation of best practice. Methods Using mixed methods, this four-phase implementation study will use theory-informed approaches to: (1) assess residential aged care facilities’ readiness for IPC practice change, (2) explore current practice using scenario-based assessments, (3) investigate barriers to best practice IPC, and (4) determine and evaluate feasible and locally tailored solutions to overcome the identified barriers. IPC leads will be upskilled and supported to operationalise the selected solutions. Staff working in residential aged care facilities, residents and their families will be recruited for participation in surveys and semi-structured interviews. Data will be analysed and triangulated at each phase, with findings informing the subsequent phases. Stakeholder groups at each facility and the IMMERSE project’s Reference Group will contribute to the interpretation of findings at each phase of the project. Discussion This multi-site study will comprehensively explore infection prevention and control practices in residential aged care. It will inform and support locally appropriate evidence-based strategies for enhancing infection prevention and control practice.

The Questionnaire on Palliative Care for Advanced Dementia (qPAD) is increasingly being used to assess residential aged care workers' knowledge and attitudes about palliative care for people with dementia. The qPAD developers performed an exploratory factor analysis and assessed the internal consistency using a small sample.The aim of this study was to further assess the structural validity of the qPAD using a large sample of qPAD responses from staff who work in residential aged care homes in Australia.Data from 727 care staff who participated in an Australian dementia palliative care training project were used for exploratory factor analyses, assessment of internal consistency, and confirmatory factor analysis of the knowledge test and attitude scale components of the qPAD.The exploratory factor analysis of the knowledge test produced a four-factor solution. One item loaded weakly, and four items had cross-loadings. Factor labels for the knowledge test were difficult to define. Factor analysis of the attitude scale produced a three-factor structure with good internal consistency-Feeling valued and part of the care team (α = 0.88), Family and team engagement (α = 0.75) and Perceptions and beliefs (α = 0.83). Confirmatory factor analysis indicated improvements in model fit were needed for both the knowledge test and attitude scale.The findings of this factor analysis differed from the original study. The attitude scale produced a three-factor structure, but the knowledge test requires further development due to weak and cross-loadings of several items, inadequate internal consistency of factors and poor model fit.

Background With increasing numbers of people living with dementia relying on family to care for them at home, there is an urgent need for practical and evidence-based programs to support carers in maintaining their mental health and well-being. The objective of this study was to evaluate the acceptability and feasibility of a modified STrAtegies for RelaTives (START) program delivered online (START-online). Method A mixed-methods non-blinded evaluation of START-online (using Zoom as videoconferencing platform) for acceptability and feasibility (completion rates and qualitative feedback through surveys and focus groups) and quantitative evaluation. This occurred at the National Ageing Research Institute, in metropolitan Victoria, Australia. Results Twenty-nine eligible carers were referred, 20 (70%) consented to the study. Of these, 16 (80%) completed all 8 sessions, 2 completed only 3 sessions, and 2 withdrew. Carers’ qualitative feedback indicated that the therapist interaction was valued, content and online delivery of the program was acceptable. Feedback was mixed on the appropriate stage of caring. Conclusion START-online was feasible and acceptable for carers, including those living outside of metropolitan areas who might otherwise be unable to access face-to-face programs. With the recent COVID-19 pandemic necessitating social distancing to avoid infection, interventions such as this one have increasing relevance in the provision of flexible services.

Background People with dementia have unique palliative and end-of-life needs. However, access to quality palliative and end-of-life care for people with dementia living in nursing homes is often suboptimal. There is a recognised need for nursing home staff training in dementia-specific palliative care to equip them with knowledge and skills to deliver high quality care. Objective The primary aim was to evaluate the effectiveness of a simulation training intervention (IMPETUS-D) aimed at nursing home staff on reducing unplanned transfers to hospital and/or deaths in hospital among residents living with dementia. Design Cluster randomised controlled trial of nursing homes with process evaluation conducted alongside. Subjects & setting One thousand three hundred four people with dementia living in 24 nursing homes (12 intervention/12 control) in three Australian cities, their families and direct care staff. Methods Randomisation was conducted at the level of the nursing home (cluster). The allocation sequence was generated by an independent statistician using a computer-generated allocation sequence. Staff from intervention nursing homes had access to the IMPETUS-D training intervention, and staff from control nursing homes had access to usual training opportunities. The predicted primary outcome measure was a 20% reduction in the proportion of people with dementia who had an unplanned transfer to hospital and/or death in hospital at 6-months follow-up in the intervention nursing homes compared to the control nursing homes. Results At 6-months follow-up, 128 (21.1%) people with dementia from the intervention group had an unplanned transfer or death in hospital compared to 132 (19.0%) residents from the control group; odds ratio 1.14 (95% CI, 0.82-1.59). There were suboptimal levels of staff participation in the training intervention and several barriers to participation identified. Conclusion This study of a dementia-specific palliative care staff training intervention found no difference in the proportion of residents with dementia who had an unplanned hospital transfer. Implementation of the intervention was challenging and likely did not achieve adequate staff coverage to improve staff practice or resident outcomes. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618002012257. Registered 14 December 2018.

Background Many people with advanced dementia live in residential aged care homes. Care home staff need the knowledge and skills to provide high-quality end-of-life (EOL) dementia care. However, several studies have found EOL dementia care to be suboptimal, and care staff have reported they would benefit from training in palliative care and dementia. Simulation offers an immersive learning environment and has been shown to improve learners’ knowledge and skills. However, there is little research on simulation training for residential care staff. This article presents the development and evaluation protocol of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) - a screen-based simulation training program on palliative dementia care, targeted at residential care staff. IMPETUS-D aims to improve the quality of palliative care provided to people living with dementia in residential care homes, including avoiding unnecessary transfers to hospital. Methods A cluster RCT will assess the effect of IMPETUS-D. Twenty-four care homes (clusters) in three Australian cities will be randomised to receive either the IMPETUS-D intervention or usual training opportunities (control). The primary outcome is to reduce transfers to hospital and deaths in hospital by 20% over 6-months in the intervention compared to the control group. Secondary outcomes include uptake of goals of care plans over 6 and 12 months, change in staff knowledge and attitudes towards palliative dementia care over 6 months, change in transfers to hospital and deaths in hospital over 12 months. For the primary analysis logistic regression models will be used with standard errors weighted by the cluster effects. A mixed methods process evaluation will be conducted alongside the cluster RCT to assess the mechanisms of impact, the implementation processes and contextual factors that may influence the delivery and effects of the intervention. Discussion In Australia, the need for high-quality advanced dementia care delivered in residential aged care is growing. This study will assess the effect of IMPETUS-D a new simulation-based training program on dementia palliative and EOL care. This large multisite trial will provide robust evidence about the impact of the intervention. If successful, it will be distributed to the broader residential care sector. Trial registration ANZCTR, ACTRN12618002012257. Registered 14 December 2018.

Objective: To compare healthcare utilisation outcomes among older hospitalised patients with and without cognitive impairment, and to compare the costs associated with these outcomes. Methods: Retrospective cohort study of administrative data from a large teaching hospital in Melbourne, Australia from 1 July 2006 to 30 June 2012. People with cognitive impairment were defined as having dementia or delirium coded during the admission. Outcome measures included length of stay, unplanned readmissions within 28 days and costs associated with these outcomes. Regression analysis was used to compare differences between those with and without cognitive impairment. Results: There were 93 300 hospital admissions included in the analysis. 6459 (6.9%) involved cognitively impaired patients. The adjusted median length of stay was significantly higher for the cognitively impaired group compared with the non‐cognitively impaired group (7.4 days 6.7–10.0 vs 6.6 days, interquartile range 5.7–8.3; p

BackgroundThe need for healthcare workers (HCWs) to have skills and knowledge in non-cancer palliative care has been recognised. Simulation is increasingly being used for palliative care training, offering participants the opportunity to learn in a realistic environment and fully interactive way.ObjectiveThe aim of this systematic review was to summarise and critically appraise controlled studies on simulation training in non-cancer palliative care for HCWs.SelectionMedline, CINAHL, PubMed and Cochrane Library databases were searched using palliative care and simulation terms. Randomised controlled trials (RCTs), non-randomised RCTs and controlled before-and-after (CBA) studies were included. Two reviewers independently screened titles and abstracts and undertook full article review using predefined selection criteria. Studies that met the inclusion criteria had data extracted and risk of bias assessed using the Cochrane Effective Practice and Organisation of Care risk of bias criteria.FindingsFive articles were included: three RCTs and two CBA studies. All studies assessed learners’ palliative care communication skills, most studies evaluated learners’ perception of change in skills and one study assessed impact on patient outcomes and learners’ change in behaviour when applied in practice. There was variation in intervention content, intensity and duration, outcome measures and study design, making it difficult to compare and synthesise results.ConclusionThere is a paucity of evidence to support simulation training to improve non-cancer palliative care. This review highlights the need for more robust research, including multicentre studies that use standardised outcome measures to assess clinician skills, changes in clinical practice and patient-related outcomes.

UNSTRUCTURED Background: Evaluation of appropriate methodologies for imputation of missing risk factor or outcome data from electronic medical records (EMRs) is crucial but lacking for comparative effectiveness studies. Robust imputation of missing data relies on the understanding of the predictors of missingness in the risk factor data, especially in patients with chronic diseases. These two aspects have not been explored simultaneously to support methodological developments in clinical epidemiological studies with real-world data. Methods: Using disease-biomarker data (glycated haemoglobin, HbA1c) from large EMR database in patients with diabetes, exploratory analyses were conducted to ascertain the possible predictors of missingness. Three approaches based on multiple imputation (MI) technique, namely two-fold MI, MI by chained equations, and MI with Monte Carlo Markov Chain, were evaluated in terms of their robustness in imputing missing data. The value of using imputed data for drawing robust inferences on comparative effectiveness of two anti-diabetes therapies were compared with the complete-case analyses. Results: Older patients and patients with higher disease-severity were less likely to have missing HbA1c data longitudinally over 12 months, while gender and pre-existing comorbidities were not associated with the likelihood of missingness. No significant differences in the distributions of follow-up imputed data with the three methods were observed. Conclusion: While complete case analyses were prone to bias by indication, use of three MI techniques for large proportion of missing primary outcome data under unknown patterns of missingness appeared to be valid, and able to provide consistent and reliable clinical inferences.

OBJECTIVE: To describe management of osteoarthritis (OA) of the hip (OA-hip) and knee (OA-knee) by Australian general practitioners (GPs). METHODS: We analyzed data from the Bettering the Evaluation and Care of Health program, from April 1, 2005 to March 31, 2010. Patient and GP characteristics and encounter management data were extracted. Data were classified by the International Classification of Primary Care, version 2, and summarized using descriptive statistics and 95% confidence intervals around point estimates. RESULTS: There were 489,900 GP encounters at which OA was managed (rate of 26.4 per 1,000 encounters). OA-hip was managed at a rate of 2.3 per 1,000 encounters (n = 1,106, 8.6% OA) and OA-knee at a rate of 6.2 per 1,000 (n = 3,058, 23.7% OA). The encounter management rate per 1,000 for OA-hip was higher among non-metropolitan dwellers (2.85 per 1,000 versus 1.97 per 1,000) and lower for non-English-speaking people (1.53 per 1,000 encounters versus 2.39 per 1,000). The rate for OA-knee was higher for non-English-speaking background (8.50 per 1,000 encounters versus 6.24 per 1,000) and lower among indigenous people (3.16 per 1,000 encounters versus 6.46 per 1,000). Referral to an orthopedic surgeon was the most frequently used nonpharmacologic management (OA-knee 17.4 per 100 contacts and OA-hip 17.7 per 100), followed by advice, education, and counselling. As first-line treatment, medication prescription rates (OA-knee 78.7 per 100 contacts and OA-hip 73.2 per 100) were substantially higher than rates of lifestyle management (OA-knee 20.7 per 100 contacts and OA-hip 14.8 per 100). CONCLUSION: OA-hip and OA-knee encounters and management differ. Nonpharmacologic treatments as first-line management were low compared with pharmacologic management rates, and surgical referral rates were high. However, lack of longitudinal data limits definitive assessment of appropriateness of care.

Chronic disease management (CDM) service models are being developed for many conditions; however, there is limited evidence to support their effectiveness in osteoarthritis (OA). A systematic review was undertaken to examine effectiveness, cost effectiveness and barriers to the use of osteoarthritis-chronic disease management (OA-CDM) service models. Thirteen eligible studies (eight randomised controlled trial (RCTs)) were identified. The majority focussed on delivery system design (n = 9) and/or providing self-management support (SMS) (n = 8). Overall, reported model effectiveness varied, and where positive impacts on process or health outcomes were observed, they were of small to moderate effect. There was no information about cost effectiveness. There is some evidence to support the use of collaborative care/multidisciplinary case management models in primary and community care and evidence-based pathways/standardisation of care in hospital settings. Multiple barriers were identified. Future research should focus on identifying the effective components of multi-faceted interventions and evaluating cost-effectiveness to support clinical and policy decision-making.

Background Rheumatoid arthritis (RA) is associated with an increased risk of myocardial infarction (MI) and post-MI fatality compared with the general population. In a previous study examining post-MI treatment in RA compared with controls we noted that a higher proportion of the RA patients had experienced MI following a surgical procedure. The aim of this study was to compare the risk of MI and mortality at 6 weeks and 12 months following joint surgery in patients with RA compared with the general population. Methods Individuals who had undergone joint surgery in Victoria, Australia between 1 July 2000 and 30 June 2007 were identified from routinely collected hospital administrative data. Logistic regression analysis was performed to examine odds of 6 week and 12 month MI and mortality in RA versus non-RA patients with adjustment for age, sex, comorbidities, socioeconomic status, patient type and admission type. Subgroup analysis of total hip and knee arthroplasty episodes was undertaken. Results A total of 308,589 episodes of joint surgery occurred among 240,571 individuals, with 3654 (1.2 %) occurring among patients with RA. At 6 weeks post joint surgery the adjusted odds ratio (OR) for MI was 1.50 (95 % CI 0.96–2.33), all-cause death was 1.85 (95 % CI 1.09–3.13) and cardiovascular death was 1.90 (95 % CI 1.07–3.37). At 12 months post joint surgery the adjusted OR of MI was 1.70 (95 % CI 1.27–2.28), all-cause death was 2.18 (95 % CI 1.66–2.86) and cardiovascular death was 2.30 (95 % CI 1.65–3.22). On analysis of joint surgeries other than hip or knee arthroplasty, people with RA were at greater risk of MI within 6 weeks (adjusted OR 2.32; 95 % CI 1.24–4.34) and 12 months (adjusted OR 2.20; 95 % CI 1.47–3.30) compared to those without RA, but no difference in odds of short term mortality were found. Conclusions Following an episode of joint surgery RA patients have a significantly increased risk of death at 6 weeks, and MI and death at 12 months, compared to the general population. The reasons for this remain to be elucidated but in the meantime RA patients should be considered at higher risk in the perioperative period. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-0958-5) contains supplementary material, which is available to authorized users.

Objective The aim was to develop an electronic adverse event (AE) screening tool applicable to acute care hospital episodes for patients admitted with chronic heart failure (CHF) and pneumonia. Design Consensus building using a modified Delphi method and descriptive analysis of hospital discharge data. Participants Consultant physicians in general medicine ( n = 38). Intervention In-hospital acquired (C-prefix) diagnoses associated with CHF and pneumonia admissions to 230 hospitals in Victoria, Australia, were extracted from the Victorian Admitted Episodes Data Set between July 2004 and June 2007. A 9-point rating scale was used to prioritize diagnoses acquired during hospitalization (routinely coded as a ‘C-prefix’ diagnosis to distinguish from diagnoses present on admission) for inclusion within an AE screening tool. Diagnoses rated a group median score between 7 and 9 by the physician panel were included. Main Outcome Measures Selection of C-prefix diagnoses with a group median rating of 7–9 in a screening tool, and the level of physician agreement, as assessed using the Interpercentile Range Adjusted for Symmetry. Results Of 697 initial C-prefix diagnoses, there were high levels of agreement to include 113 (16.2%) in the AE screening tool. Using these selected diagnoses, a potential AE was flagged in 14% of all admissions for the two index conditions. Intra-rater reliability for each clinician ranged from kappa 0.482 to 1.0. Conclusions A high level of physician agreement was obtained in selecting in-hospital diagnoses for inclusion in an AE screening tool based on routinely collected data. These results support further tool validation.

To compare healthcare utilisation outcomes among older hospitalised patients with and without cognitive impairment, and to compare the costs associated with these outcomes.Retrospective cohort study of administrative data from a large teaching hospital in Melbourne, Australia from 1 July 2006 to 30 June 2012. People with cognitive impairment were defined as having dementia or delirium coded during the admission. Outcome measures included length of stay, unplanned readmissions within 28 days and costs associated with these outcomes. Regression analysis was used to compare differences between those with and without cognitive impairment.There were 93 300 hospital admissions included in the analysis. 6459 (6.9%) involved cognitively impaired patients. The adjusted median length of stay was significantly higher for the cognitively impaired group compared with the non-cognitively impaired group (7.4 days 6.7-10.0 vs 6.6 days, interquartile range 5.7-8.3; p 0.001). There were no differences in odds of 28-day readmission. When only those discharged back to their usual residence were included in the analysis, the risk of 28-day readmission was significantly higher for those with cognitive impairment compared with those without. The cost of admissions involving patients with cognitive impairment was 51% higher than the cost of those without cognitive impairment.Hospitalised people with cognitive impairment experience significantly greater length of stay and when discharged to their usual residence are more likely to be readmitted to hospital within 28 days compared with those without cognitive impairment. The costs associated with hospital episodes and 28-day readmissions are significantly higher for those with cognitive impairment. Copyright © 2016 John WileySons, Ltd.

To describe management of osteoarthritis (OA) of the hip (OA-hip) and knee (OA-knee) by Australian general practitioners (GPs).We analyzed data from the Bettering the Evaluation and Care of Health program, from April 1, 2005 to March 31, 2010. Patient and GP characteristics and encounter management data were extracted. Data were classified by the International Classification of Primary Care, version 2, and summarized using descriptive statistics and 95% confidence intervals around point estimates.There were 489,900 GP encounters at which OA was managed (rate of 26.4 per 1,000 encounters). OA-hip was managed at a rate of 2.3 per 1,000 encounters (n = 1,106, 8.6% OA) and OA-knee at a rate of 6.2 per 1,000 (n = 3,058, 23.7% OA). The encounter management rate per 1,000 for OA-hip was higher among non-metropolitan dwellers (2.85 per 1,000 versus 1.97 per 1,000) and lower for non-English-speaking people (1.53 per 1,000 encounters versus 2.39 per 1,000). The rate for OA-knee was higher for non-English-speaking background (8.50 per 1,000 encounters versus 6.24 per 1,000) and lower among indigenous people (3.16 per 1,000 encounters versus 6.46 per 1,000). Referral to an orthopedic surgeon was the most frequently used nonpharmacologic management (OA-knee 17.4 per 100 contacts and OA-hip 17.7 per 100), followed by advice, education, and counselling. As first-line treatment, medication prescription rates (OA-knee 78.7 per 100 contacts and OA-hip 73.2 per 100) were substantially higher than rates of lifestyle management (OA-knee 20.7 per 100 contacts and OA-hip 14.8 per 100).OA-hip and OA-knee encounters and management differ. Nonpharmacologic treatments as first-line management were low compared with pharmacologic management rates, and surgical referral rates were high. However, lack of longitudinal data limits definitive assessment of appropriateness of care.

The objective was to identify predictive factors and outcomes associated with patients who leave emergency departments (EDs) without being seen in Victoria, Australia.This was a retrospective observational study of Victorian ED patient visits between July 1, 2000, and June 30, 2005, using linked hospital, ED, and death registration data. Index ED visits were identified for patients who left without being seen (LWBS) and for those who completed ED treatment and were discharged home. Statistical analyses included a general description and univariate analysis of patient, ED visit, temporal, and hospital-level factors. Logistic regression models were developed to assess risk factors associated with LWBS status compared to patients who completed treatment, to assess 48 hour re-presentations to ED; 48-hour hospital admissions; and 2-,7-, and 30-day mortality among those who LWBS compared to those who completed treatment. Adjusted odds ratios (ORs) and 99% confidence intervals (CIs) are presented.There were 239,305 LWBS episodes, for 205,500 patients over the 5-year period. Independent factors associated with LWBS patients in comparison to those who completed treatment include patients who are younger (15 to 24 years, OR = 2.46, 99% CI = 2.37 to 2.56), male (OR = 1.07, 99% CI = 1.05 to 1.08), of Australian indigenous background (OR = 1.63, 99% CI = 1.53 to 1.73), of non-English-speaking background (OR = 1.08, 99% CI = 1.06 to 1.10), noncompensable status (OR = 1.73, 99% CI = 1.68 to 1.79), self-referring (OR = 1.46, 99% CI = 1.43 to 1.49), nonassisted arrival mode (OR = 1.35, 99% CI = 1.30 to 1.40), and those with a hospital admission in the 12 months before the ED presentation (OR = 1.53, 99% CI = 1.51 to 1.55). Patients who LWBS had triage categories of lower urgency (nonurgent, OR = 8.21, 99% CI = 8.00 to 8.43), attended during the evening (OR = 1.10, 99% CI = 1.08 to 1.12), on either Sunday (OR = 1.20, 99% CI = 1.18 to 1.23) or Monday (OR = 1.20, 99% CI = 1.17 to 1.23), in winter (OR = 1.14, 99% CI = 1.12 to 1.16), with higher rates occurring in higher volume EDs (OR = 2.20, 99% CI = 2.15 to 2.26). There was no greater risk of mortality for LWBS patients compared to patients who completed treatment. The risk of hospital admission within 48 hours of discharge was lower for LWBS patients (OR = 0.60, 99% CI = 0.58 to 0.62); however, ED re-presentation risk was higher (OR = 1.63, 99% CI = 1.60 to 1.67).Patients who leave EDs in Victoria, Australia, without being seen are at lower risk of hospital admission and at no greater risk of mortality, but are at higher risk of re-presenting to an ED compared to patients who complete treatment and are discharged home.

Objective: the aim of this study was to systematically review and compare the measurement attributes of multidimensional, patient-reported outcome measures used in hip and knee arthroplasty rehabilitation. Methods: A search of PubMed, ciNAHl, cochrane central Registry, ScOPUS and PeDro databases up to December 2009 identified the validation studies. The quality of the measurement properties were assessed based on the t erwee and Bot criteria, and Scientific Advisory Committee of the Medical Outcomes t rust guidelines. Results: A total of 68 studies examining 28 instruments were identified. Three instruments had positive ratings for content validity. None of the instruments satisfied both factor analysis and cronbach’s α criteria for internal consistency. Four measures were positively-rated for agreement. Nine tools had positive ratings for construct validity. t wenty-four of the instruments had indeterminate ratings for responsiveness to clinical change. Only certain subscales of 2 instruments were positively-rated for responsiveness to clinical change. Conclusion: A wide variety of multidimensional patientreported instruments has been used to assess rehabilitation outcomes after hip and knee arthroplasty, but information about their measurement attributes in these populations is inadequate. More data are needed to clarify their reproducibility and responsiveness to clinical change.

Objectives. The study aimed to develop a set of clinical indicators to minimise the risk and adverse outcomes of functional decline in older hospitalised people. Methods. Existing Australian and international clinical indicators relevant to cognition and emotional health, mobility, vigour and self care, continence, nutrition, skin integrity, person-centred care, assessment and medication management were identified by literature and electronic website review. A multidisciplinary expert advisory group used modified Delphi methods, including two anonymous voting rounds and a group discussion, to gain consensus for a prioritised set of clinical indicators. For each indicator, experts voted on a scale of 1 (low level of prioritisation) to 9 (high level of prioritisation) based on measurement attributes and utility for use at the level of clinical teams, hospital managers and jurisdictional policy makers. Results. There were 55 existing clinical indicator sets identified, from which 63 relevant indicators were extracted. The final prioritised set covered all domains and included 19 indicators of which 17 were process indicators and 2 were outcome indicators. Scores for scientific measurement attributes and practicality for implementation were only moderate. Conclusion. These clinical indicators offer a consistent basis for monitoring hospital performance and improving care of older people in Victoria and other jurisdictions. What is known about the topic? Older hospitalised patients are at risk of functional decline and associated adverse outcomes such as falls and pressure ulcers. Clinical indicators to measure healthcare structures, processes and outcomes can be used to monitor quality of care among this vulnerable patient group. What does this paper add? This paper describes the process used to identify and select indicators for the Victorian government’s Council of Australian Governments Long Stay Older Persons initiative. It presents the use of a modified Delphi technique to gain group consensus for the indicator selection process; a technique being increasingly used in healthcare. What are the implications for practitioners? The indicators provide a set of measures that can be used by organisations, clinical teams and government level to assess the effect of quality improvement activities and initiatives aimed at minimising functional decline.

Objective: Despite delirium being common in older hospitalized people, little is known about its management. The aims of this study are (1) to describe the pharmacological management of delirium in an acute care setting as a baseline measure prior to the implementation of newly developed Australian guidelines; and (2) to determine what areas of delirium pharmacological management need to be targeted for future practical guideline implementation and quality improvement activities. Methods: A medical record audit was conducted using a structured audit form. All patients aged 65 years and over who were admitted to a general medical or orthopaedic unit of the Royal Melbourne Hospital between 1 March 2006 and 28 February 2007 and coded with delirium were included. Data on the use of antipsychotic medications for the management of delirium in relation to best practice recommendations were assessed. Results: Overall 174 episodes of care were included in the analysis. Antipsychotic medications were used for the management of most patients with severe behavioral and or emotional disturbance associated with delirium. There was variation in the prescribing patterns of antipsychotic agents and the documentation of medication management plans. Less than a quarter of patients prescribed antipsychotic medication were started on a low dose and very few were reviewed on a regular basis. Conclusion: A wide range of practice is seen in the use of antipsychotic agents to manage older patients with severe symptoms associated with delirium. The findings highlight the need to implement evidence-based guideline recommendations with a focus on improving the consistency in the pharmacological management and documentation processes.

Delirium is a common and serious condition which is often overlooked or misdiagnosed in older people. In 2006, the first set of national clinical practice guidelines for the management of delirium in older people were developed. This paper provides an abbreviated version of the guideline document which includes recommendations for the detection of delirium (diagnosis and screening), assessment and prediction of risk factors for delirium, prevention of delirium and interventions to manage people with delirium. The guidelines reflect the available evidence base and highlight the limited high level research in delirium care, particularly in the areas of symptom management and screening for delirium.

Objective : To identify patient safety measurement tools in use in Australian public hospitals and to determine barriers to their use. Design : Structured survey, conducted between 4 March and 19 May 2005, designed to identify tools, and to assess current use of, levels of satisfaction with, and barriers to use of tools for measuring the domains and subdomains of: organisational capacity to provide safe health care; patient safety incidents; and clinical performance. Participants and setting : Hospital executives, managers and clinicians from a nationwide random sample of Australian public hospitals stratified by state and hospital peer grouping. Main outcome measures : Tools used by hospitals within the three domains and their subdomains; patient safety tools and processes identified by individuals at these hospitals; satisfaction with the tools; and barriers to their use. Results : Eighty-two of 167 invited hospitals (49%) responded. The survey ascertained a comprehensive list of patient safety measurement tools that are in current use for measuring all patient safety domains. Overall, there was a focus on use of processes rather than quantitative measurement tools. Approximately half the 182 individual respondents from participating hospitals reported satisfaction with existing tools. The main reported barriers were lack of integrated supportive systems, resource constraints and inadequate access to robust measurement tools validated in the Australian context. Measurement of organisational capacity was reported by 50 (61%), of patient safety incidents by 81 (99%) and of clinical performance by 81 (99%). Conclusion : Australian public hospitals are measuring the safety of their health care, with some variation in measurement of patient safety domains and their subdomains. Improved access to robust tools may support future standardisation of measurement for improvement.