abstract booklet 2005 - peninsula health · 2009. 10. 14. · arginine supplementation accelerates...

PENINSULA HEALTH RESEARCH WEEK 2005

ABSTRACT BOOKLET

Poster Display

Allied Health Research Prize

Nursing Research Prize

Registrar Research Prize

21st November 2005 to 26th November 2005

Table of Contents

TABLE OF CONTENTS

ABSTRACTS – POSTER DISPLAY

EVALUATING THE EFFECTIVENESS OF DIETETIC INTERVENTION IN A CHEMOTHERAPY DAY UNIT .........................................................................................................................................................6

KARINGAL HUB HEALTH WALKS - EXERCISE IN A SUPPORTED ENVIRONMENT...........................7

IMPROVING THE QUALITY OF DVT THROMBOPROPHYLAXIS IN MEDICAL PATIENTS AT FRANKSTON HOSPITAL .........................................................................................................................8

THE DEVELOPMENT OF A FALLS RISK ASSESSMENT TOOL FOR AGED SUB-ACUTE AND RESIDENTIAL CARE FACILITIES ...........................................................................................................9

SELF MANAGING CHRONIC HEART FAILURE....................................................................................10

ARGININE SUPPLEMENTATION ACCELERATES WOUND HEALING (COMPARATIVE CASE STUDY). ARGININE’S ROLE IN PRESSURE ULCER HEALING AND REDUCED LENGTH OF STAY................................................................................................................................................................11

A DIABETES WEBSITE TARGETED TO LOCAL HEALTH PROFESSIONALS AND INDIVIDUALS ....12

ECHOCARDIOGRAPHY ENHANCES MANAGEMENT OF CRITICALLY ILL PATIENTS .....................13

CASE STUDY: PREGNANT AND PUMPING… .....................................................................................14

REALISING POTENTIAL: IMPROVING ACCESS BY UTILISING PARENTS KNOWLEDGE OF THEIR CHILDREN’S COMMUNICATION DIFFICULTIES .................................................................................15

WORKING IN PARTNERSHIP TO IMPROVE MEDICATION SAFETY: PHARMACY DEPARTMENT AT PENINSULA HEALTH ............................................................................................................................16

THE “BE AWARE” CAMPAIGN: PROMOTING THE THERAPEUTIC GUIDELINES FOR WARFARIN OVER-ANTICOAGULATION ..................................................................................................................17

THE EFFECT OF GROUP STRENGTHENING EXERCISE ON STANDING BALANCE IN THE FRAIL ELDERLY- A PILOT STUDY...................................................................................................................18

WAITING TIMES FOR ELECTIVE SURGERY: THE PERSPECTIVES OF MEDICAL PRACTITIONERS, LAY PEOPLE AND PATIENTS...............................................................................................................19

MYOCLONUS DOES NOT ALWAYS PREDICT POOR NEURO-RECOVERY AFTER CARDIO PULMONARY RESUSCITATION ...........................................................................................................20

OXFORD MINIATURE VAPORISER FOR HALOTHANE IN MECHANICALLY VENTILATED ASTHMATICS.........................................................................................................................................21

PENINSULA HEALTH INTENSIVE CARE UNIT (ICU) SURVEILLANCE FOR CENTRAL VENOUS CATHETER (CVC) RELATED BACTERAEMIA RATE ...........................................................................22

RADIAL VERSUS FEMORAL ARTERY ACCESS CORONARY ANGIOGRAPHY FROM THE NURSING PERSPECTIVE.......................................................................................................................................23

IMPACT OF A HOSPITAL-BASED INTERVENTION ON THE OUTCOME OF MINIMAL TRAUMA FRACTURES..........................................................................................................................................24

‘SINK OR SWIM’ - THE BREASTFEEDING EXPERIENCES OF WOMEN WHO GAVE BIRTH AT PENINSULA HEALTH ............................................................................................................................25

Table of Contents

EVALUATION OF RESPONSE TO PRE-OPERATIVE CHEMOTHERAPY FOR LOCALLY ADVANCED BREAST CANCER: A COMPARISON OF CONVENTIONAL METHODS WITH PET SCAN AND BIOLOGICAL MARKERS........................................................................................................................26

ACUTE PAIN SERVICE HYSTERECTOMY ANALGESIA AUDIT 2004 .................................................27

PERCEPTIONS AND KNOWLEDGE OF CM WITHIN HOSPITALS – IS PATIENT SAFETY COMPROMISED? ..................................................................................................................................28

COMMUNITY CARE UNIT EVALUATION – IS DEINSTITUTIONALISATION WORKING IN OUR COMMUNITY?........................................................................................................................................29

PSYCHIATRIC SERVICES – MENTAL HEALTH RESEARCH ON THE PENINSULA...........................30

THE TRIANGLE OF CARE: A MODEL IN PRACTICE ...........................................................................31

LINKING THE PARTS: ARTICULATING THE ROLE OF CONSULTANT PALLIATIVE CARE NURSES IN ACUTE HOSPITALS ..........................................................................................................................32

PALLIATIVE CARE WORK, BETWEEN DEATH AND DISCHARGE .....................................................33

COMMUNITY-ACQUIRED PNEUMONIA: TOWARDS IMPROVING OUTCOME NATIONALLY, CAPTION PROJECT AND THE PENINSULA HEALTH EXPERIENCE .................................................34

REFERRED SKIN CANCERS: HOW MANY MORE ARE PRESENT? ..................................................35

MULTIDISCIPLINARY TEAM APPROACH TO CASE MANAGEMENT IN A COMMUNITY CARE UNIT................................................................................................................................................................36

DEVELOPMENT AND USE OF A MULTI-SENSORY ENVIRONMENT IN A DESIGNATED ROOM IN AN AGED ACUTE PSYCHIATRIC INPATIENT FACILITY .....................................................................37

Table of Contents

ABSTRACTS - ALLIED HEALTH RESEARCH PRIZE AND NURSING RESEARCH PRIZE

PROGRAM - ALLIED HEALTH AND NURSING RESEARCH PRIZES 2005 .........................................38

RAD ASSESSES PATIENT IN THE ED FOR DIRECT TRANSFERS TO THE SUB-ACUTE SETTING 39

DEVELOPING AND IMPLEMENTING A COMPREHENSIVE DIABETES MELLITUS SERVICE ACROSS AN 8 SITE, 355 BED, REHABILITATION, AGED AND PALLIATIVE CARE SERVICE..........40

THE DEVELOPMENT OF A FALLS RISK ASSESSMENT TOOL FOR AGED SUB-ACUTE AND RESIDENTIAL CARE FACILITIES .........................................................................................................41

MODIFIED DIET / FLUIDS ALERT SYSTEM .........................................................................................42

THE EXPERIENCE OF PATIENTS RECEIVING HOME BASED PALLIATIVE CARE DECIDING TO GO TO A HOSPITAL EMERGENCY DEPARTMENT ...................................................................................43

PARKINSON'S DISEASE - FROM RESEARCH TO PRACTICE - THE EVIDENCE ..............................44

PARTICIPATION IN THE NARI RESEARCH PROJECT “EVALUATION OF A MINIMUM DATA SET FOR VICTORIAN FALLS CLINICS.........................................................................................................45

RESIDENTIAL OUTREACH. AN INNOVATIVE RESPONSE TO EMERGENCY DEMAND FROM RESIDENTIAL AGED CARE FACILITIES ..............................................................................................46

PALLIATIVE CARE WORK, BETWEEN DEATH AND DISCHARGE .....................................................47

PREDICTING DISCHARGE DESTINATION...........................................................................................48

PAIN MANAGEMENT PROJECT IN THE PALLIATIVE CARE UNIT .....................................................49

INTRODUCTION OF AN EVIDENCE BASED HIP PROTECTOR PROGRAM INTO A PSYCHO-GERIATRIC UNIT ...................................................................................................................................50

WHAT ARE THE LIVED EXPERIENCES OF PALLIATIVE CARE OCCUPATIONAL THERAPISTS WHILST FACILITATING DYING AT HOME?..........................................................................................51

RADIAL VERSUS FEMORAL ARTERY ACCESS CORONARY ANGIOGRAPHY FROM THE NURSING PERSPECTIVE.......................................................................................................................................52

Table of Contents

ABSTRACTS - REGISTRAR RESEARCH PRIZE

PROGRAM – PENINSULA HEALTH REGISTRAR RESEARCH PRIZE 2005.......................................53

REFERRED SKIN CANCERS: HOW MANY MORE ARE PRESENT? ..................................................54

KIRSHNER WIRING OF FRACTURED ZYGOMA: A MINIMAL APPROACH ........................................55

ACCURACY OF SELF-REPORTED HEIGHT AND WEIGHT IN ELECTIVE SURGERY PATIENTS.....56

OPTIMISING PREDICTABILITY OF PRE-OPERATIVE CHEMOTHERAPY RESPONSE FOR LOCALLY ADVANCED BREAST CANCER: COMPARISON OF PET SCAN WITH CONVENTIONAL METHODS, AND ROLE OF BIOLOGICAL MARKERS ..............................................................................................57

THE DIAGNOSIS AND TREATMENT OF THYROID CANCER .............................................................59

OUTCOMES FOLLOWING INSULIN-DEXTROSE INFUSION IN DIABETIC PATIENTS WITH ACUTE MYOCARDIAL INFARCTION (IDIPAMI STUDY)....................................................................................60

OVARIAN VEIN REFLUX AND VARICOSE VEINS. IS THERE A RELATIONSHIP?............................61

THE DEFINITION AND MANAGEMENT OF OLIGURIA ........................................................................62

TOTAL THYROIDECTOMY FOR THE TREATMENT OF GRAVES’ DISEASE .....................................63

THE RESPONSE TO INTERVENTIONAL TREATMENT OF SYMPTOMATIC ADRENAL METASTASIS................................................................................................................................................................64

“IRONHEARTS”: BIOCHEMICAL AND FUNCTIONAL ABNORMALITIES OF LEFT AND RIGHT VENTRICULAR FUNCTION FOLLOWING ULTRA-ENDURANCE EXERCISE .....................................65

THE RELATIVE MOTION BETWEEN THE SCAPHOID AND THE LUNATE.........................................66

SPONSORSHIP

SPONSORSHIP......................................................................................................................................68

Abstracts – POSTER DISPLAY 6 of 68

EVALUATING THE EFFECTIVENESS OF DIETETIC INTERVENTION IN A CHEMOTHERAPY DAY UNIT

Lisa Schneider, Fiona Turnbull Introduction: Fifty to 90% of cancer sufferers experience weight loss as a result of their disease or its treatment (1). Approximately 40% of patients lose more than one tenth of their total body weight, which is associated with increased risk of morbidity and mortality (2). Up to half the numbers of deaths from cancer are related to malnutrition rather than cancer itself (3). Nutrition screening, counselling and monitoring is important in maintaining the nutritional status of oncology patients. The Nutrition and Dietetics department at Peninsula Health received funding in February 2004 to extend their services to the Chemotherapy Day Unit. The objective of this study is to evaluate the effectiveness of the newly established Dietetic service in the Chemotherapy Day Unit in reducing nutrition related cancer and chemotherapy side effects and maintaining or improving quality of life. Study Design: An evaluation questionnaire was designed comprising seven closed-ended questions assessing anthropometry, appetite, adverse nutritional side effects, quality of life, and energy levels during treatment. It was self-administered, and took less than five minutes to complete. Fifty consecutive patients commencing chemotherapy were asked to participate in the evaluation by completing the questionnaire. Patients with prior dietetic input for cancer or chemotherapy were excluded. Data was collected at baseline, one month and three months. Patients received individual dietetic treatment during this time. Results: Of the fifty patients initially interviewed, 42 agreed to participate by filling in the questionnaire. Four patients ceased treatment before the first review (one month) and three patients passed away. Therefore, data was collected on 35 patients. No significant changes in weight (P=0.789), BMI (P=0.845), appetite (P=0.281) or symptoms (P=0.434) were observed over the three month time period. Significant improvements in quality of life (from one to three months, P=0.039) and improvements in ability to participate in social activities over the three months (P=0.012) were demonstrated. Conclusion: Dietetic intervention in the chemotherapy day unit can prevent cancer induced weight loss and can lead to an increased quality of life and ability for patients to participate in social and recreational activities.


KARINGAL HUB HEALTH WALKS - EXERCISE IN A SUPPORTED ENVIRONMENT

Catherine McConnell1, Karen Bull2, Joe Radcliffe3 1 Frankston Community Health Service, Peninsula Health, Frankston 2 Falls Prevention Service, Peninsula Health, Mt Eliza 3 Mornington Peninsula Division of General Practice. Frankston

Introduction: Participation in physical activity and exercise has many health benefits for older people including a reduced risk of falls. Local health services and general practitioners formed a collaborative partnership with a local shopping centre five years ago to develop an indoor walk program within the local shopping centre. Methods: The program is delivered collaboratively by three local health agencies and has a structure to address barriers to participation. Warm up and cool down exercises include strength, flexibility and balance, known to be of particular benefit to the target group. The Vicfit leaders are fully funded by the shopping centre allowing the walks to be delivered free of charge. The walks are coordinated by a steering committee and are strongly supported by a coordinated team of volunteers. Results: Since commencing five years ago, the Karingal Hub Health Walks continues to attract 70-90 walkers each walk day, three days per week. Many participants report improved balance and wellbeing including reduced isolation. The majority of walkers are over the age of 60, many with chronic or age-related conditions. Discussion and Conclusions: Delivering exercise programs within a shopping centre provides a supported environment for older people with chronic and/or age-related conditions to continue exercise that may otherwise be discontinued. Health Services and the fitness industry, working in partnership, provides opportunities for sustainability and skill sharing, to meet the needs of the target group.


IMPROVING THE QUALITY OF DVT THROMBOPROPHYLAXIS IN MEDICAL PATIENTS AT FRANKSTON HOSPITAL

Guy Wilkes

Frankston Hospital, Peninsula Health, Victoria, Australia Aim: To improve the quality of DVT thromboprophylaxis in medical patients via the development and implementation of a health service wide policy. Method: In March 2005, an audit was conducted to evaluate (1) the extent of DVT thromboprophylaxis amongst medical patients and (2) the appropriateness of agents and doses used at Frankston Hospital. A new protocol was developed and approved by the Drugs and Therapeutics Committee. In conjunction with the Director of Clinical Practice Improvement, the “Don’t be a clot” campaign was launched. Education sessions were presented to doctors and pharmacists. Doctors who did comply with the protocol were identified in drug chart reviews and visited by the project pharmacist for academic detailing. A repeat audit was conducted in June 2005 and the results compared. Results: The initial audit found that of the160 medical patients, 62 patients had an indication for thromboprophylaxis. However, only 35 (57%) of these patients received treatment. The audit after the campaign demonstrated that out of the 44 patients that had an indication for thromboprophylaxis, 31 (71%) had received treatment representing a 25% improvement. Post-campaign, all patients received the correct dose and the percentage of patients receiving the preferred agent increased from 27% to 58%. Conclusion: The development and implementation of a health service wide policy for DVT thromboprophylaxis in medical patients can significantly improve the quality of prescribing. Further education sessions are planned and adherence to the protocol will be monitored on an ongoing basis.


THE DEVELOPMENT OF A FALLS RISK ASSESSMENT TOOL FOR AGED SUB-ACUTE AND RESIDENTIAL CARE FACILITIES

Caroline Stapleton, Peter Hough, Karen Bull, Ken Greenwood and Keith Hill Peninsula Health Rehabilitation, Aged and Palliative Care Service Mornington Peninsula, Melbourne Victoria, Australia

The aim was to investigate predictive validity of a Falls Risk Assessment Tool (FRAT) designed for nurses in non-acute aged care facilities.

Nine items were included: ambulation, cognition, continence, medical conditions, medications, psychological status, recent falls, sensory input and transfers. The validity of the FRAT for predicting faller versus non-faller group membership was examined over four months for 291 residents/patients.

Eighty-nine subjects fell in this period; single=39; 2-3=29; 4or>4=21, non-fallers=202. Comparing non-fallers with fallers a highly significant discriminant function resulted, x2 (4, n=291) =89.89, p <.0001. Four items entered the equation, with correlations between the four predictors and the discriminant function indicating that recent fall was the best predictor (.82), followed by psychological status (.55), medications (.46) and cognition (.41). A composite variable calculated from individual's scores on these four predictors correctly classified 80.4% of individuals, with a specificity of 90.1% and a sensitivity of 58.4%, using a cut-off score of 14.

Four items, easily obtained within two minutes by nurses from admissions procedures, can be used to predict those who are at most risk of falling. Patients scoring highly on these four items of the FRAT need maximum fall alert care. Staff cannot rely solely on this tool, but can expect most fallers to be identified.


SELF MANAGING CHRONIC HEART FAILURE Griet Hofer, Fiona Turner and Nicole Romney Peninsula Health - Peninsula Complex Care Program Peninsula Health has implemented an innovative model of care for clients with chronic health conditions. The Peninsula Complex Care Program covers a number of clinical streams including chronic heart failure. The chronic heart failure model of care was established in late 2002 following successful funding through the Department of Human Services Hospital Admission Risk Program funding stream. Access to the program is maximized through case finding by the staff, in addition to well established referral processes from Frankston Hospital ward staff, community based general practitioners and cardiologists, as well as transfer of clients from other metropolitan hospitals. . This multidisciplinary team (including nursing, pharmacy, psychology and nutrition) provide comprehensive education, telephone support and case management according to current best practice. There is also the opportunity for clients to participate in the chronic heart failure rehabilitation program. Extending over ten weeks this program reinforces the self management strategies for chronic heart failure, provides an individually tailored graded exercise program and facilitates group support. During the first two years, two hundred clients were referred to the project and an additional ninety-eight were identified through case finding. The project’s proactive management of clients has resulted in decreased length of stay, decreased frequency of emergency department presentations and decreased inpatient separations to Frankston Hospital (at six and twelve months post project intervention). In addition, the state average length of stay for chronic heart failure has increased over the term of the project (from 5.02 to 5.5), however Peninsula Health/ Frankston Hospital length of stay has steadily decreased from 5.39 to 3.54 days. This poster will provide a persuasive graphical illustration of the key successes of this progressive program.


ARGININE SUPPLEMENTATION ACCELERATES WOUND HEALING (COMPARATIVE CASE STUDY). ARGININE’S ROLE IN PRESSURE ULCER HEALING AND REDUCED LENGTH OF STAY

Raisa Shaikh, Kathy Wheatland, Fiona Butler Background: Pressure ulcers affect a significant number of people in hospitals. An economic analysis of the impact of pressure ulcer care in a 252-bed geriatric unit in Glasgow reported that 41% of the patients suffered from some pressure damage. The incidence data was reported to show that 45% of these pressure ulcers were potentially preventable. A study of 3,012 patients from 165 wards in eleven hospitals in Germany estimated the prevalence of pressure ulcers in patients with a mean age of 65 years at between 24% and 39% in 2001. Schoonhoven 2002 revealed a weekly incidence of patients with stage II pressure ulcers of 6.2% (95% confidence interval 5.2% to 7.2%) in two large Dutch hospitals. Studies in the elderly on skin wound strength, have concluded that arginine supplementations improves not only nutritional status but also hydroxyproline content and wound tensile strength Our aim was to monitor the cost savings to the hospital due to the provision of an Arginine based nutritional supplement which led to decrease in Length of Stay (LOS) in Hospital. Method: This study was done by comparing two retrospective case studies with similar Stage 4 pressure ulcers developed within the hospital irrespective of age or sex with different nutritional support but similar nursing care. This study utilised a basic comparison of various factors such as patient’s age, admission diagnosis, co-morbidities, weight, dietary intake, various biochemical parameters (such as Albumin, Total Protein, Haemoglobin levels, and lymphocytes) and various nutritional interventions. The daily cost of their dressing and specialist wound nurse’s time was also taken into consideration. Main Outcome measures: 1. Provision of an Arginine rich nutritional supplement to improve wound healing

and subsequently decreasing length of stay 2. Period of wound breakdown from stage 1 to stage 4. Study Results: The patient (Mrs. Y) with the arginine enriched nutritional supplement had her pressure ulcer healing at a faster rate compared to Mrs. X. The cost saving to the hospital on Mrs. Y was to the amount of $ 46,750.02 (This is not inclusive of nutritional interventions i.e. TPN / Enteral formula / Enteral Equipment / Dietitian’s Time) Conclusion: Immediate intervention and ongoing monitoring by a Dietitian and provision of the Arginine rich nutritional supplement has proven to accelerate wound healing & patient discharge. Decreased length of stay directly provides a considerable cost saving of $46,750.02 to the hospital.


A DIABETES WEBSITE TARGETED TO LOCAL HEALTH PROFESSIONALS AND INDIVIDUALS

Irwin Helen-Peninsula Health - Rehabilitation, Aged and Palliative Care Service Colson Jill, Charlton,Carla, Murphy Rosalie; Avery, Christine; Ball, Kylie; Cole, Sue; Distefano, Debbie; McKeeman Fiona; Hassan, Fadwa; Cameron. Brooke; Lynch, Shona, Hornblower Bernard - Peninsula Diabetes Professional - Special Interest Group Diabetes self-management education is recognised as an integral part of management of diabetes. The individual with diabetes may be presented with or have access to various and numerous forms of information. Whilst it is advisable and desirable for this information to be provided by a qualified Diabetes Educator this is not always possible for the patient and often people in the community may not know how to access local Diabetes Education Services. A Special Interest Group (SIG) of diabetes educators and allied health staff decided to consolidate, validate and present uniform diabetes information in a form which would enable the individual to access this in their own time and place of choice .It was decided that a community diabetes information website could provide this most effectively. People within this regional area have access to a multiple range of private hospitals, public hospitals, community centres and aged and rehabilitation services. These services all have Diabetes Educators employed who are members of this SIG. The website provides information about the SIG activities as well as diabetes fact sheets, other helpful links to diabetes information, local diabetes news and activities, diabetes research and local diabetes support and education contacts. The diabetes fact sheets follow 1ADEA, 2ADS and 3DA recommendations for diabetes management and all have uniform format and are signified with the specific SIG logo and references. The website has been promoted to the community via local diabetes education services. It has also been widely advertised through the regional Division of General Practice and their diabetes educator. A handy ‘Bookmark’ clearly indicating how to access the website has been produced and will be widely distributed during Diabetes week 2005.

The impact evaluation of the website will be conducted in 3 months, 6 months and 1 year after the distribution of the ‘Bookmark’. Audit and review of the handouts will occur yearly to ensure that ongoing best practice education and self-management information is provided. 1Australian Diabetes Educators Association 2 Australian Diabetes Society 3 Diabetes Australia


ECHOCARDIOGRAPHY ENHANCES MANAGEMENT OF CRITICALLY ILL PATIENTS

Dr. Subhash Arora Consultant Intensivist, Frankston Hospital, Frankston, VIC 3199 ICU patients require rapid diagnosis and interventions to reduce morbidity and mortality. Trans-Thoracic & Trans-Oesophageal Echocardiography (TTE/TOE) enables assessment of normal & pathological, cardiac & intra-thoracic vascular anatomy & function. We evaluated the impact of establishing a TTE/TOE programme on the diagnostic & interventional management of patients in a tertiary ICU. Two pre-trained ICU medical staff performed TTE/TOE examinations, supervised by Specialist Anesthetists & Physicians in Nuclear Medicine / Diagnostic Ultrasound over 11 months (01/07/2004 to 31/05/2005). Prospectively recorded data included: patient demographics; TTE / TOE findings; and ICU & other interventions undertaken. 250 examinations: TTE: 212 (84.8%) for Cardio-vascular instability / hypotension & TOE: 38 (15.2%) for suspected intra-cardiac valvular / sepsis etiology) were performed. Informed consent was obtained from the next of kin for all patients with TOE examinations. TTE evaluations confirmed / excluded the clinical diagnosis in 85.8%, and resulted in minor change in ICU interventions in 8.5%, major change in ICU interventions in 3.8%, and surgical intervention in 1.9% of examinations. TOE evaluations confirmed / excluded the clinical diagnosis in 42.1%, and resulted in minor change in ICU Interventions in 21.1%, major change in ICU interventions in 28.9% and surgical intervention in 7.9% of examinations. All TTE / TOE examinations were technically successfully completed with clinically useful information, without complications. In conclusion, echocardiography (TTE & TOE) in ICU enhances diagnostic & interventional management of critically ill patients. Echocardiography in ICU is a clinically feasible & justifiable service, requires organizational restructure with equipment, & mandates appropriate training & supervision of ICU trainees & specialists. It must provide audit & quality assurance reports, & encourage research initiatives to evaluate current & new ICU interventions.


CASE STUDY: PREGNANT AND PUMPING…

Kylie Ball, Sue Cole Diabetes Education Department, Frankston Hospital, Melbourne, Victoria, Australia. Introduction: This paper outlines the case of a patient successfully managed using an insulin pump during her pregnancy despite her not being the “typical” pump candidate. TM was a 24 year old woman with Type 1 Diabetes Mellitus who presented at 5 weeks gestation to a Diabetes Complications Screening Clinic. The pregnancy was unplanned and she had a history of poor control and motivation to care for her diabetes. At the clinic an extensive assessment took place and education was reviewed. At 6 weeks, her HbA1c was 10.8% and she was experiencing frequent nocturnal hypoglycaemia. Concerns for the pregnancy outcome were discussed. Method: The use of a continuous subcutaneous insulin infusion (CSII) was raised. A diabetes educator provided an overview of the use of pumps to TM and assessed her motivation, knowledge base and commitment to intensive therapy. At 14 weeks gestation CSII was commenced. TM was admitted to a general medical ward for two nights for initial stabilisation and underwent extensive education by the diabetes educator and dietitian. Upon discharge, TM was given daily phone calls initially by the diabetes educator and then followed up in the Gestational Diabetes Clinic weekly with an endocrinologist and a diabetes educator. Results: No adverse problems occurred during the pregnancy in regard to the utilisation of the loan pump. The patient remained motivated to maintain requirements of intensive therapy. The patients HbAIC improved to be 6% at 19 weeks gestation. It was maintained at 6.3% and 7.1% at 26 and 34 weeks gestation respectively. No further nocturnal hypoglycaemia was noted. TM delivered a healthy baby at 37 weeks. Conclusion: This case study demonstrates that with intensive education and ongoing support, the successful initiation of CSII during the second trimester of an unplanned pregnancy is achievable.


REALISING POTENTIAL: IMPROVING ACCESS BY UTILISING PARENTS KNOWLEDGE OF THEIR CHILDREN’S COMMUNICATION DIFFICULTIES

Lisa Giuliano, Kate Warwick and Hannah Halloran Speech Pathology, Rehabilitation, Aged & Palliative Care & Allied Health, Peninsula Health Waiting lists across health and disability early intervention services in a regional area of Victoria peaked at 14-24 months in mid-2004. Speech Pathology waiting lists had reached 14 months. The Peninsula Health Speech Pathology Department provides single discipline outpatient services to children prior to school entry. Information provided by parents during intake to this service was not providing sufficient detail to determine primary area of difficulty, or service eligibility. Hence, some clients were unnecessarily waiting for speech pathology assessment for up to 14 months prior to being transferred to another early intervention service waiting list. Current literature suggests parental report of expressive language and speech difficulties is accurate and correlates well with professional judgement. Reports of receptive language difficulties are less accurate. Intake processes were reviewed and improved to utilise parents’ skills and knowledge to their full potential. This paper will present data on local parents’ skills in identifying early communication difficulties. It will also detail how a department reduced waiting lists and improved access for children by increasing parents’ involvement in the intake process.


WORKING IN PARTNERSHIP TO IMPROVE MEDICATION SAFETY: PHARMACY DEPARTMENT AT PENINSULA HEALTH

Rebecca Pang Pharmacy Department, Frankston Hospital, Peninsula Health, Victoria, Australia Aim: To describe the range of medication safety activities that the Pharmacy Department at Peninsula Health have undertaken in partnership with other health professionals. Methods: In the last two years, the pharmacy department has conducted a number of joint initiatives involving medical and nursing staff, clinical informatics, public relations and consumers to promote medication safety. “Bee Alert” reduced the number of prescribing errors related to drug allergies. “Think pinK+” focussed on discontinuing use of concentrated potassium ampoules. “Be Aware” and “Don’t Be a Clot” tackled the issues of appropriate reversal of warfarin over-anticoagulation and DVT prophylaxis in medical patients respectively. Participation in the medication safety collaborative has also produced tangible benefits. Pharmacy technicians and nurses have instituted bedside drawer checks to ensure correct medications are used. Results: Outcomes include (1) 50% improvement in reduction of allergy-related prescribing error, (2) increase use of pre-mixed bags and oral potassium and improvement in storage conditions, (3) 70% improvement in eliminating drug selection errors in bedside drawers, (4) 92% compliance with the warfarin over-anticoagulation guidelines, (5) 25% increase in DVT prophylaxis in medical patients and (6) a reduction in potential or actual harm caused by an inaccurate Electronic Discharge Summary by 67%. Conclusion: Pharmacy department has successfully made medication safety a priority for all health professionals at Peninsula Health. Tangible outcomes have been achieved in many areas.


THE “BE AWARE” CAMPAIGN: PROMOTING THE THERAPEUTIC GUIDELINES FOR WARFARIN OVER-ANTICOAGULATION

Pang R, Morawetz L

Pharmacy Department, Frankston Hospital, Peninsula Health, Victoria, Australia Aim: To assess the effectiveness of the “Be Aware” promotional campaign in increasing compliance to the warfarin anticoagulation guidelines at Peninsula Health. Methods: In September 2004, a retrospective audit of the treatment of patients with an INR over five indicated that 53% of patients were treated according to Red Cross guidelines. After the guidelines were approved by the Drugs and Therapeutics Committee, the “Be Aware” campaign was launched in October 2004 to encourage its use. The posters and guidelines were placed in various locations as well as on the intranet advertised by a bat (the mascot for the campaign) flying around the screen. ID-badge size guidelines were also given to all doctors. Education sessions were conducted for doctors and nursing staff. Three further audits were done to determine the compliance rates in November 2004, March 2005 and May 2005. All 10mg vitamin K ampoules on ward imprests were replaced with 2mg ampoules in order to prevent patients inadvertently receiving large doses of Vitamin K for warfarin reversal. Results: The “Be Aware” campaign resulted in more than 30% improvement on adherence of the new guideline by November 2004. Improvement in the compliance rate was further demonstrated by the March and May audits which showed 92% compliance. Conclusion: The “Be Aware” campaign has been very successful in promoting the use of the warfarin over-anticoagulation guidelines. The campaign resulted in a 120% improvement when comparing the audit results in September 2004 and May 2005.


THE EFFECT OF GROUP STRENGTHENING EXERCISE ON STANDING BALANCE IN THE FRAIL ELDERLY- A PILOT STUDY.

Narelle Watson

Physiotherapist, Frankston Hospital Objective: Evidence has shown that strength training can result in improvements in balance, however, further research is required to ascertain the optimal dimensions of a strengthening program for improving balance. The purpose of this study was to determine the effectiveness of a strengthening exercise program for improving standing balance in the frail elderly. Design: Twelve frail community dwelling men and women aged over 65 years participated in the intervention. The intervention was a supervised strengthening exercise class two times a week over a period of 6 weeks. Strengthening intensity was 70-75% of one repetition maximum for all major muscle groups of the lower limbs. Study outcome measures were static balance measures on a computerised posturography platform, 10 metre walk times and single-leg stance times. Results: Subjects were found to experience a significantly fewer number of falls during testing on the computerised posturography platform post intervention (p=0.017). While not reaching significance, all other outcome variables changed in the desired direction following the strengthening intervention. Conclusion: Strengthening exercise may have beneficial effects on improving static balance and gait velocity in the community dwelling frail elderly. A significant reduction in the number of falls experienced by subjects during computerised posturography testing was evident post strengthening intervention. Such a result suggests that strengthening exercise plays a role in reducing the likelihood of falls in community dwelling frail older adults.


WAITING TIMES FOR ELECTIVE SURGERY: THE PERSPECTIVES OF MEDICAL PRACTITIONERS, LAY PEOPLE AND PATIENTS

Andrea Curtis, Rory Wolfe, Colin Russell, John Hart, Barry Elliot, Anthony Costello, Douglas Travis, Ross Snow and John McNeil Objective: To compare perceptions of maximum appropriate waiting times (Max wts) for joint replacement and prostatectomy across patients, medical practitioners, and lay people. Methods: Information about perceived Max wts for hip or knee replacement and prostatectomy was collected during the course of two studies performed to develop prioritisation tools for surgery. 80 people referred for hip or knee replacement and 48 men requiring prostatectomy for benign prostatic hypertrophy were recruited when placed on waiting lists for surgery. Subjects were interviewed about the physical and psychosocial impact of their condition. This information was presented in their own words in individual patient case-vignettes divided into clinical, social and psychological domains. Vignettes were collated into a booklet set for each study, with booklets containing 8 vignettes. Separate assessor panels comprising laypeople, general medical practitioners and either urologists or orthopaedic surgeons reviewed the booklet sets for the appropriate study. On enrolment an estimation of Max wt for surgery for each patient was provided by the patient themselves and the enrolling orthopaedic surgeon or urologist. Each member of the assessor panel also provided a Max wt for each patient after reviewing the patient vignette. Results: In both the orthopaedic and urology studies Max wts assigned to patients by enrolling surgeons and by the patients themselves ranged from 0 to 52 weeks. In both studies the median Max wt assigned by orthopaedic surgeons and urologists (13 weeks) was significantly different to that assigned by the patients themselves (prostatectomy patients = 3 weeks, p-value<0.0001; orthopaedic patients = 4 weeks, p-value<0.0001). Generally, most patients preferred shorter waiting times than those assigned by their enrolling surgeons. Within each study median Max wts were similar across all groups of assessors. Median Max wts for assessor groups were also similar to those for the enrolling orthopaedic surgeons and urologists. However there was significant variation between individual assessors within assessor groups. Conclusion: Patients waiting for joint replacement or prostatectomy would prefer surgery sooner than thought appropriate by their doctors. While the range of Max wts was similar between groups of assessors, there was considerable variation between individual assessors within each of the assessor groups. This indicates general group agreement on the upper limits of waiting times for surgery, but individual differences in judging appropriate waiting times for each patient.


MYOCLONUS DOES NOT ALWAYS PREDICT POOR NEURO-RECOVERY AFTER CARDIO PULMONARY RESUSCITATION

Ramesh Nagappan*, John Bothaa, Ian Carneya, Ernest Butlera, Timothy Dayb

Box Hill Hospital*, Frankston Hospitala, Monash Medical Centreb

Melbourne, Victoria, Australia Despite advances in pre-hospital medicine and technological strides to increase the efficiency of cardiac resuscitation, the rate of neurological recovery is still very low. Return of spontaneous circulation (ROSC) leads to good neurological function only in 5 – 10 % of those who suffer cardiac arrest. Witnessed ventricular fibrillation with a short time to ROSC and treated by induced hypothermia has the best chance of good outcome. After 72 hours of desedation (a) absent brain-stem reflexes or (b) absent motor response to painful stimulus or (c) bilaterally absent Somato-sensory evoked potentials are associated with poor neurological outcome or vegetative state. The long-term impact of induced hypothermia on the rate of neuro-recovery. and on survival benefit, remains to be known. Clinical and Electroencephalographic (EEG) myoclonus have long been associated with an invariably gloomy outcome. Myoclonus often triggers a change in strategy toward withdrawal of therapy. A 72-year-old male suffered cardiac arrest from ventricular fibrillation and a prolonged resuscitation. He manifested clinical and EEG features of classic myoclonus and returned to good neurological function. Six months later he again suffered a cardiac arrest and required prolonged resuscitation to restore circulation. His management included 24-hour hypothermia to 33 degrees Celsius. Yet again he manifested clinical and EEG features of classic myoclonus during a prolonged ICU stay. He enjoyed an excellent neuro-recovery. After circulatory resuscitation from cardiac arrest, myoclonus does not always signify hopeless neurological recovery. Whilst managing post-resuscitative encephalopathy, ICU clinicians should be cautious of effecting strategic changes to therapy based solely on myoclonus.


OXFORD MINIATURE VAPORISER FOR HALOTHANE IN MECHANICALLY VENTILATED ASTHMATICS

Ramesh Nagappan*, Sanjiv Vija, John Bothaa, Ian Carneya, John Coplanda Box Hill Hospital*, Frankston Hospitala, Melbourne, Victoria, Australia Critically ill asthmatics that require mechanical ventilation may benefit from Halothane. Whilst Halothane’s role may be established, various methods of administration of halothane have been tried. We used a simple in-line vaporiser, as part of the inspiratory limb of a Servo – 300 (Siemens) mechanical ventilator. We employed this device in 3 patients for a total duration of 120 hours without adverse effects. The Oxford Miniature Vaporiser (OMV) is a small and portable thermally buffered vaporiser used to speed the induction of anaesthesia. Draw over anaesthesia is simple in concept and entails drawing a carrier gas over a volatile liquid thus entraining its vapour to the gaseous carrier. Draw over systems operate at less than, or at ambient pressure, and flow through the system is intermittent, varying with different phases of inspiration, and ceasing in expiration. A one-way valve prevents reverse flow in the circuit. This is different to plenum anaesthesia in which a carrier gas is pushed through the vaporiser at a constant rate. In draw over systems the carrier gas is drawn through the vaporiser either by the patient’s own respiratory efforts or by a self-inflating bag or manual bellows with a one-way valve placed downstream from the vaporiser. We used the OMV as part of a regular positive pressure ventilatory circuit. The OMV was specially calibrated for Halothane and was robust and reliable. Halothane delivery was controlled and in steady fashion; a simple wall-suction unit scavenged the exhaled Halothane. We recommend OMV for regular ICU use.


PENINSULA HEALTH INTENSIVE CARE UNIT (ICU) SURVEILLANCE FOR CENTRAL VENOUS CATHETER (CVC) RELATED BACTERAEMIA RATE

Bernadette Lane, Manager Infection Prevention Unit, Peninsula Health

Dr John Botha, Director ICU, Frankston Hospital On July 1st 2005, Intensive Care Unit (ICU) surveillance was commenced with the view to benchmark our Central Venous Catheter (CVC) related bacteraemia rate against the Victorian Nosocomial Infection Site Surveillance (VICNISS) aggregate data. During July and August it was noted that nine patients had CVC related bacteraemia, and seven of these were caused from Methicillin Resistant Staphylococcus aureus (MRSA). On the 8th August, the first of a number of multidisciplinary meetings took place to discuss the problem and what actions were required. A number of changes were implemented within the ICU including a review of the insertion, care and access to central lines, a campaign to heighten awareness on hand hygiene, a review of the type of catheter used and contact precautions implemented for patients colonised/infected with MRSA. The outcome was that CVC related bacteraemia decreased substantially. Due to so many changes being made in such a short time frame, it is impossible to determine what singular recommendation had the most impact in reducing the bacteraemia rate.


RADIAL VERSUS FEMORAL ARTERY ACCESS CORONARY ANGIOGRAPHY FROM THE NURSING PERSPECTIVE

B Williamson, G Szto, J Bladen, R Templin, W Dyble, S Evans-Murphy, D Flenley. H Williams, S Best. Peninsula Health: Frankston Hospital, Frankston, Victoria. Introduction: At Frankston hospital one Cardiologist has been using the radial approach (RAD) in most patients undergoing outpatient coronary angiograms. The admitting nurse determines suitability after ensuring a normal Allen’s test. We sought to determine 1) patient satisfaction, 2) procedural costs, 3) vascular complications, 4) X-ray screening time compared to femoral (FEM) approach angiography. Method: A questionnaire was developed for pain and comfort during, post-procedure and after returning home. Procedural costs were calculated using current pricing. X –ray screening time was taken from the Cathcor database. Questionnaires were sent to the last 98 patients treated by Cardiologist 1, using the femoral approach, and to the last 96 patients treated by Cardiologist 1, using the radial approach. 50 questionnaires were returned from both groups. Results: The radial approach was used in 139 patients over 3 years. Pain during procedure was more severe in RAD (n=21, 42%), compared to FEM (n=14, 28%). Post procedure amongst the RAD was more comfortable 44% (n=27), compared with 54% (n=22). After discharge more RAD patients received medical consultation 14% (n=7), compared with 10% (n=5). Of 21 patients who experienced both procedures, slightly more (54% n=11), would prefer a radial approach. Procedural costs for an uncomplicated procedure were $8.50 higher in the RAD. The RAD group was eligible for discharge 3 hours earlier. X-ray screening time was higher in the RAD (4.5 minutes vs. 5.7 minutes). Conclusion: Coronary angiography from the radial artery is comparable to femoral in relation to patient comfort, X-ray screening time and procedural cost. It has a distinct advantage in allowing earlier discharge. This allows significant savings in nursing time. At this institution this has allowed freeing up of space in our angiography unit, with the result that more patients can be treated daily.


IMPACT OF A HOSPITAL-BASED INTERVENTION ON THE OUTCOME OF MINIMAL TRAUMA FRACTURES

S.Elkassaby, K. Quick, C.P. Gilfillan

Endocrinology, Frankston Hospital Women who sustain a low trauma fracture are at significantly increased risk of subsequent fracture, and suffer increased morbidity and mortality. A number of medical therapies have now been proven in randomized controlled trials to reduce the incidence of minimal trauma fracture in selected high-risk women. Despite this, most minimal trauma fracture patients are discharged from hospital without the initiation of effective medical therapy to prevent recurrent fractures. Public healthcare institutions have an obligation to act to close this “care gap”. This study is a prospective randomised evaluation of the efficacy of a hospital-based intervention delivered to patients admitted with a minimal-trauma fracture at our instituition. Patients with a diagnosis of a fragility fracture were randomised to two groups: An intervention group and a conventional treatment group. The intervention consisted of: clinical review, DEXA scan, basic biochemistry, a letter of recommendation to the LMO, provision of educational materials and if appropriate initiation of Calcium and vitamin D, a bisphosphonate or raloxifene, The conventional group had no specific intervention and were managed by orthopaedic and rehabilitation specialists. Both patients who received the intervention, and those who did not were followed up and will continue to be followed-up at one and two-year marks to determine the proportion of patients who are initiated and remain on effective anti-fracture therapy (primary outcome). At this stage, baseline data for this study is available: 112 patients have been enrolled: 56 in intervention group, 56 in standard-care group. 11 patients have completed the biochemistry, DEXA and clinic review. Of these: Biochemistry – one male with mild testosterone deficiency; no renal impairment; no calcium, parathyroid hormone or thyroid function abnormalities. All had 25(OH) Vitamin D3 < 100. Average level was 30-40. Lowest 25(OH) Vitamin D3 29 Skeletal risk score – three patients with a score between 2 and 5 with the remainder <1. 6patients are post menopausal; 3 with a past history of fracture (year 1960, 1967, 2000). DEXA bone scan: One patient with osteoporotic range T scores. 2 patients with T< -1.5 ( at Femoral Neck T score (- 1.66 and -2.02) Lumbar spine ( - 1.7 and - 1.83) All except 2 patients had a T score < -1 at both femoral neck and lumbar spine. Treatment initiated: Vitamin D initiated on 2 patients These data will be updated prior to presentation to present a more complete overview of our baseline population.


‘SINK OR SWIM’ - THE BREASTFEEDING EXPERIENCES OF WOMEN WHO GAVE BIRTH AT PENINSULA HEALTH Carole Gilmour, Midwifery Educator, Nurse Education Christine Moore, Lactation Consultant, Women’s Services The World Health Organisation (WHO) recommend infants be exclusively breastfed until 6 months of age (WHO, 2002). The scientific support for this is well documented and there is also much evidence that relates to reasons why babies do not successfully breastfeed. Despite the efforts of health professionals in providing appropriate care, breastfeeding rates in Australia do not meet WHO recommendations. There have been several initiatives commenced in Peninsula Health in an effort to improve breastfeeding rates. The Infant Feeding Support Service (IFSS) commenced at Frankston Hospital in July 1999 in order to provide ongoing information, support and encouragement to mothers who had chosen to breastfeed. The IFSS Clinic was initially just an outpatient service but since August 2003 there has also been a Day Stay Clinic two days a week. The midwives are provided with regular education related to all aspects of breastfeeding and must also complete a breastfeeding education package that is based on the WHO ‘Ten Steps to Successful Breastfeeding’ (WHO, 1998). This poster will depict the findings of a Breastfeeding survey conducted at Frankston Hospital in 2004-5. The aims of the survey were twofold. Firstly to assess the proportion of women who having been breastfeeding on discharge were still breastfeeding at six months. Secondly to identify problems that the women encountered, the information and support received and the support services that they utilized. This secondary aim was to enable the hospital to review the education for women, midwives and doctors to assist in planning strategies aimed at increasing breastfeeding rates. A self report survey was mailed out to 482 women, identified in our birth records as breastfeeding on discharge, six months after they gave birth. There were 220 responses (47%). Data was coded and entered into a statistical computer program for analysis, using descriptive statistics. Information from the open ended questions and extra comments was reviewed for recurring themes. Of 220 women, 121 (55%) were still breastfeeding at 6 months. The mean age of babies when breastfeeding ceased was 13.3 (SD 8.3) weeks. Despite WHO guidelines supporting exclusive breastfeeding up to six months, only 47 (18.5%) of our sample did not introduce solids until six months or later. Only 15 (6.9%) of the mothers reported no problems. Initial findings suggest that very few women sail through without any problems. In addition the women who persevere with breastfeeding do so for a few reasons: firstly they are very motivated to provide the best food for their babies; secondly they have been provided with sufficient support, be that health professionals, family, or friends, and finally they have been provided with the correct information necessary for successful breastfeeding in this modern environment. It is therefore seen that all the services provided at Peninsula Health remain important for successful breastfeeding. This survey has provided some direction for the midwives of Peninsula Health to review their services and explore different ways of providing the education and support that new mothers need.


EVALUATION OF RESPONSE TO PRE-OPERATIVE CHEMOTHERAPY FOR LOCALLY ADVANCED BREAST CANCER: A COMPARISON OF CONVENTIONAL METHODS WITH PET SCAN AND BIOLOGICAL MARKERS.

Beardsley, E., Hart, S., Midolo, P., Schneider-Kolsky, M., Stuckey, J., Baldey, A., Susil, B., Thomson, J., Ganju, V. Monash Medical Centre, Moorabbin, Victoria Frankston Hospital, Frankston, Victoria MIA Australia Background: The pathological response remains the best predictor of outcome in women treated with pre-operative chemotherapy for locally advanced breast cancer. Women undergoing pre-operative chemotherapy are assessed with biopsy, mammogram, ultrasound, positron emission tomography (PET), and biological markers on tissue and blood pre, during and after chemotherapy. Methods: 25 patients enrolled after screening to exclude distant metastases and inflammatory breast cancer. Patients are randomized to receive FEC100 x4 or Docetaxel x4 , then crossed over following the interim assessment. 13 patients have completed all 8 cycles of chemotherapy, 11 have undergone surgery. Results: All patients had positive PET scans pre-treatment. Standardized uptake value (SUV) median 6.48 with range 1.76 – 14.9. All patients have responded to chemotherapy. Of the 11 patients completing surgery, 3 pts had a complete pathological response, and 3 patients had minimal microscopic residual disease with negative nodes.

After 1st 4 cycles of chemotherapy Clinical

N = 14 Mammogram N = 14

Ultrasound N = 14

PET N = 14

Complete Response

3 (21%)

2 (14%)

2 (14%)

4 (29%)

Major/Partial Response

5 (36%)*

2 (14%)*

3 (22%)*

2 (14%)**

Others (SD, PD)

6 (43%)

10 (70%)

9 (64%)

8 (57%)

* - > 50% reduction in largest diameter ** - >50% reduction in SUV

Path Response Post 8 cycles (n =11)

PET post 4 cycles Complete 27% Major 27% Minor 45% CR/MR 3 1 3 SD 0 1 2 PD 0 1 0 Conclusions: PET is a promising tool in predicting response to neoadjuvant chemotherapy


ACUTE PAIN SERVICE HYSTERECTOMY ANALGESIA AUDIT 2004

Dr Helen Kolawole

Department of Anaesthesia, Peninsula Health, Melbourne. The rationale for this audit was to elucidate real world postoperative pain management and describe the experience of a group of postoperative patients. All 15 patients at Frankston Hospital undergoing hysterectomy and requiring PCA analgesia in February to April 2004 were audited prospectively. Following this, the records of the 29 hysterectomy patients for this time period were reviewed retrospectively to obtain information on : intra-operative, PACU, postoperative, and discharge analgesia as well as anti-emetic orders and administration. The audit showed that multimodal analgesia was administered intra-operatively and postoperatively in the majority of patients. PCA analgesia was rated as excellent. There was a high rate of PONV which warrants further review since this symptom is regarded by patients as a greater concern than postoperative pain1.


PERCEPTIONS AND KNOWLEDGE OF CM WITHIN HOSPITALS – IS PATIENT SAFETY COMPROMISED?

*Lesley A. Braun, #Gary W. Braun *PhD candidate RMIT University # Director of Clinical Practice Improvement, Frankston Hospital Background: There is a culture of continual improvement in patient safety within the hospital setting. One important aspect of this relates to medication safety. Several studies have identified use of complementary medicines (CMs) by hospital patients. Some of these are known or suspected to cause adverse reactions and interact with conventional treatment whereas others are considered effective treatments and supported by evidence. This study was undertaken to investigate what information hospital doctors and pharmacists obtain about their patients’ use of CMs, how they manage this information, their attitudes and knowledge about CMs and behaviours and confidence in dealing with CM-related issues. Materials and Methods: An anonymous, self-administered survey was offered to 158 medical, surgical and pharmacy staff at Frankston Hospital with 127 participating (response 80.4%). Results: Few respondents were found to routinely ask patients about CM use (28%) with many forgetting to ask (43.9%), thinking its not relevant (37.8%) or feeling they had insufficient knowledge to be able to ask patients (33.7%). Most (81.4%) did not feel confident that they had sufficient knowledge to be able to identify if CMs could adversely affect patient care, 67.5% felt CMs can be dangerous and patient use needs to be monitored and 48.4% thought more hospital based research was required. Pharmacists had significantly more knowledge about the evidence base and safety issues relating to CMs than hospital doctors (knowledge score 38.6% vs 14.1%) however this was still poor and 57.6% of all respondents were interested in receiving future training. Conclusion: It is important for hospital doctors and pharmacists to ask patients about CM use and to know how to interpret patient’s responses however most do not currently have sufficient knowledge or confidence to deal with CM-related issues. Further education and standardised guidelines are vital to ensure ongoing patient safety and promote evidence based patient care.


COMMUNITY CARE UNIT EVALUATION – IS DEINSTITUTIONALISATION WORKING IN OUR COMMUNITY?

Linda Byrne

Psychiatric Services, Frankston Hospital As part of a broader policy of deinstitutionalization, the Frankston Community Care Unit (CCU) opened in 1996 as residential accommodation for patients that were previously inpatients in long-term psychiatric hospital settings. The CCU is a 20 bed cluster housing development in a residential setting, staffed on a 24 hour basis by a multidisciplinary team. The CCU was established with the twin goals of clinical care and rehabilitation of the residents. A one-year follow-up study (Farhall et. al., 1999) found that while there were little change in symptoms or disability levels, residents reported improved levels of quality of life relating to their living environment. Relatives and carers also preferred the CCU setting for their relatives over hospitalisation. This study aims to examine retrospective data on CCU residents relating to length of stay, diagnosis and readmissions to acute care units to determine changes in admission patterns over time. We also aim to follow-up all residents admitted to the Frankston CCU since its opening in 1996 to determine current residency status and quality of life variables. We also plan to undertake a prospective arm to the study, following new residents over the course of 12. In addition to examining variables relating to demographic information, quality of life and diagnosis variables of the residents, we also will be assessing the perceptions of staff and the relatives/carers of the current and former residents about their views regarding the care of the residents. Our national policy and government reform processes have driven the move to non-institutional forms of care. However, recent evaluation of our mental health system (Groom, Hickie & Davenport, 2003) has shown that there has been widespread failure in implementation. This proposed study aims to examine the impact of this policy on some of the most vulnerable members of the local community.


PSYCHIATRIC SERVICES – MENTAL HEALTH RESEARCH ON THE PENINSULA

Linda Byrne

Psychiatric Services, Frankston Hospital Psychiatric Services is committed to taking a leading role in research on the Peninsula. We are currently undertaking a number of Pharmaceutical Trials aimed at improving the quality of life for people with mental illness. These trials are aimed at improving the symptoms of such serious illnesses as schizophrenia and bipolar disorder. In addition to Pharmaceutical trials, Psychiatric Services are developing a number of projects scheduled to commence in 2006. These include; research aimed at reducing the impact of delirium post-operatively in elderly patients following hip surgery and a project evaluating the Community Care Unit (CCU) and the outcomes for both current and past residents.


THE TRIANGLE OF CARE: A MODEL IN PRACTICE

Helen Wearne RN, RM, B Nursing, M Nursing (Palliative Care) MRCNA

Raelene Rees RN, B Nursing, Grad Cert Acute Care (Perioperative), Grad Dip Palliative Care Nursing, M Nursing, Grad Cert Health Professional Education.

Michelle Clancy, RN, Dip. Community Nursing, Grad Dip Management, Grad Cert, Palliative Care. The “Triangle of Care”, is the model developed in 1996 as part of DHS document “The Way Forward”, the strategic plan for development of Palliative Care Services in Victoria. The aim of the model is to support the provision of integrated care and effortless movement of clients across all three settings, being community palliative services, palliative care inpatient unit and acute hospital consultancy services.

This presentation intends to explore the challenges faced in the establishment and ongoing management of this integration of services within the Frankston/ Mornington Peninsula region. The community services are provided by Peninsula Hospice Service and Royal District Nursing Service and the inpatient and consultancy services by Peninsula Health. These services form the ‘triangle of care.’

We will describe some of the challenges faced as these discrete services came together with the shared goal to provide integrated “seamless” patient centred care and how through collaboration and development of close professional relationships and interlinking of services the goal has been achieved.

The establishment of strong links between services and strengthening of these has enhanced each individual service and has assisted in clarifying the different roles of the services. The collaborative arrangements include shared staff, regular patient care team meetings, discharge planning and education initiatives.

The speakers will present the successful implementation of the model, which helps to provide optimal patient outcomes. The success is based on relationships that need to encompass professional respect and a desire to work together, which is something that the staff in our region now often ‘take for granted.’


LINKING THE PARTS: ARTICULATING THE ROLE OF CONSULTANT PALLIATIVE CARE NURSES IN ACUTE HOSPITALS

M.O’Connor AM

Monash University, Frankston The role of consultant palliative care nurses in acute hospitals has developed over the last ten years or so, as an integral part of palliative care service delivery. Despite this, there is little evidence or literature that describes what contributes to the success of this role. However, anecdotal reports indicate that the role has become pivotal to both staff and patient – in connecting services, in liaison and advocacy, both within the hospital and to other service that may be required at home. Based on a review of the literature, an exploration of a number of these roles has been conducted to articulate commonalities in the current role and ascertain the strength and limitations of the role, thus providing direction for further development. The primary aims of this study were: • To describe aspects of the role of consultant palliative care nurses in acute

hospitals; • To evaluate aspects of the role from the nurses themselves; • To utilise this information to write a position paper and to make recommendations

for best practice in the future development of this role. Twelve nurses in palliative care consultant nurse roles in acute hospitals were interviewed, using open-ended questions. Taking a phenomenological perspective which would enable an understanding of the role to emerge, data from the interviews were analysed using thematic analysis. This poster reports the results of this study and makes recommendations for further work that will assist in the more uniform development of the nurse consultant role.


PALLIATIVE CARE WORK, BETWEEN DEATH AND DISCHARGE

C Webster, L Peters

Monash University, Melbourne, Australia*

Melbourne, Australia** This paper discusses a small quality improvement study that was undertaken in a palliative care unit (PCU), to demonstrate reasons for the lengthy patient turnover time after the death of a patient. There is a dearth of literature describing the role of the nurse in providing care of the family and others after the patient has died. The aim of the study was to undertake a post-death survey from the nursing perspective, of activities and the time required to complete tasks associated with follow-up care to the deceased patient and his/her family unit. Details of the post-death episode for all patients who died in the PCU over two time periods were collected using a newly designed tool. Study findings demonstrate that most deaths in this Unit occur out of business hours. In addition, the study has highlighted the protracted nature of post-death care, because of a variety of factors. Nursing work after death is complicated by a lack of multi-disciplinary and ancillary support, particularly out of business hours. These factors prolong the time between patient death and removal of the deceased, thus delaying admission of new patients. This project has provided important information both from a quantitative viewpoint as well as giving some insight into the role of the nurse after death occurs.


COMMUNITY-ACQUIRED PNEUMONIA: TOWARDS IMPROVING OUTCOME NATIONALLY, CAPTION PROJECT AND THE PENINSULA HEALTH EXPERIENCE

Darsim Haji, Francis Caplygin, Leong Goh, Skip Lam and Sheena Broughton Introduction: There is evidence that knowledge of and adherence to the community-acquired pneumonia (CAP) guidelines within the Therapeutic Guidelines: Antibiotic is suboptimal in Australian Emergency Departments. The guidelines incorporate a severity assessment tool (Pneumonia Severity Index), classifying patients according to risk of 30-day mortality (Class I: low risk, Class V: high risk). The National Prescribing Service is funding the CAPTION project which is a multi-centre drug use evaluation (DUE) project. Purpose: 1. To describe the management of community-acquired pneumonia (CAP) at

Frankston Hospital Emergency Department and another 37 Australian hospital. 2. To compare management of CAP to published national guidelines 3. Evaluate academic detailing and other interventions in improving prescribing

practice, including diagnostic scoring and appropriate antibiotic selection in the management of CAP.

Methodology: A national minimum baseline dataset was agreed upon to assess the management of CAP in EDs. A retrospective review of 20 patients at Frankston Hospital conducted. Training for academic detailing which is training health professionals in the use of social marketing techniques was undertaken. All senior and junior medical staff Frankston Hospital were detailed. Other interventions such as point of prescribing prompts (ID badges, stickers and wall posters) and group education session were also used. Post-intervention data from 20 patients with CAP were collected and finalised. Results: Pre-intervention: 50% of Patients treated at Frankston Hospital were male, 70 % were more than 60 years old compared to 50% nationally.70% were admitted to a ward , 5% to ICU and 25 % transferred .The mortality was 5% compared to 4% nationally .The PSI was not documented in any of the 20 patients giving a 0% documentation with 4% nationally. Using the PSI 30% 0f patients were class I/II compared with 43% nationally, 20% class III, 25% class IV and 25% class V compared with 11% nationally. Overall concordance of antibiotic with current guidelines was 15% compared with 17 % nationally with highest concordance being for class I (25%) and class IV/V (20%). Post- intervention data showed an increase in documentation of the PSI score from 0% to 40% and concordance rate with the antibiotic guidelines from 15% to 35%.


REFERRED SKIN CANCERS: HOW MANY MORE ARE PRESENT?

P J Terrill, S M Fairbank

Department of Plastic and Reconstructive Surgery, Frankston Hospital The assessment and management of non-melanotic skin cancers referred by General Practitioners forms a large proportion of a Plastic Surgeons practice. It is also common for specialists to discover additional skin lesions in sites not indicated by the referring doctor within his or her initial correspondence. The importance of complete skin checks to identify hidden additional lesions have been emphasised in the literature pertaining to malignant melanoma, however, their presence has not been quantified in situations where non-melanotic skin cancers are the subject of the initial referral. The aim of this study was to assess and quantify these additional skin tumours, identified following a general skin examination performed by a metropolitan Plastic Surgeon following squamous cell (SCC) or basal cell (BCC) carcinoma referral. A retrospective study was performed after retrieving the medical records documenting the assessment of 40 male and 60 female consecutive new referrals with non-melanotic skin cancers. Mean age 70 years. Results indicate that additional lesions were found in 64% of patients referred. Forty-four percent of patients had one or more skin cancers at another body site. Twenty-two percent of patients had further BCC’s, 20% multiple skin cancers and 3% of patients having other types of tumours. Nineteen percent of patients were clinically diagnosed as having solar keratoses as well as the referring lesion. The most common site for additional lesions was the head and neck region (54%), followed by the back (32%) and upper and lower limbs (13% each). If the patient presented with a skin cancer on the back, there was a 100% incidence of the patient having a second tumour. If the initial tumour was on the leg, an 87% chance of a second tumour, and other sites 48% to 50%. These results indicate that when patients present with a non-melanotic skin tumour, a thorough general skin check is essential.


MULTIDISCIPLINARY TEAM APPROACH TO CASE MANAGEMENT IN A COMMUNITY CARE UNIT

Daryll Lukjanov, Registered Nurse Division 3, Community Care Unit, Psychiatry

Marina Ting Registered Nurse Division 2, Community Care Unit, Psychiatry Providing continuity of care for consumers who have a major mental illness has proven to be complex and difficult in relation to meeting the needs of consumers and their carers. In Victoria, mental health services called Community Care Units (CCU) have been developed to provide extended care to assist consumer rehabilitation and recovery. A case management model where individual clinicians provided care to allocated residents was implemented when the CCU opened 9 years ago. The major complaint from carers and consumers about this approach was lack of continuity of care and communication when the nominated case manager was not available. At Peninsula Health Psychiatric Service the CCU provides residential rehabilitation services to 20 residents in a community setting. The CCU implemented a system of care coordination utilising multidisciplinary staff divided into three teams. Each team is responsible for implementing individualised recovery programs for a group of residents. The model has been operational for three years. Recently an evaluation was conducted to assess the strengths and weaknesses of the model from a consumer, carer and nursing view point.


DEVELOPMENT AND USE OF A MULTI-SENSORY ENVIRONMENT IN A DESIGNATED ROOM IN AN AGED ACUTE PSYCHIATRIC INPATIENT FACILITY

Jakqui Barnfield, Psychiatric Nurse Educator, Psychiatry

Anna Ciotta, Neuropsychologist, Psychiatry The average rate of moderate to severe dementia amongst Australians is 1 in 15 for people aged 65 and over, 1 in 9 for those aged 80-84, and for those aged 85 and over, the incidence increases to 1 in 4. With the ageing of Australia’s population, we can therefore expect an increase in the number of people affected by dementia in the next few decades. A multi-sensory environment is modelled on Snoezelen therapy, developed in Holland in the 1980s. It was initially designed to feelings of leisure, enjoyment and relaxation in persons with learning disabilities, by enhancing sensations and emotions. This is achieved using a constructed environment utilising visual displays, tactile objects, auditory and olfactory stimuli. Recent studies have shown the therapeutic benefit for people with dementia, identifying notable changes in affect, reducing challenging behaviours, such as agitation, intrusiveness, wandering, restlessness and aggression, and increasing relaxation and well-being. The project involves the development and evaluation of such an environment, in an aged acute psychiatric inpatient facility. The multi-sensory environment will provide a stimulating environment that is non-threatening, relaxing and therapeutic. Evaluation will occur on the efficacy of the environment in regards to reducing challenging behaviours in dementia, such as wandering, agitation, restlessness, intrusiveness and aggression. The multi-sensory environment aims to improve the quality of interactions between patients and their family members, friends, carers and staff with an enhanced staff morale, which is expected to increase indirectly through a reduction in challenging behaviours, and better management of these behaviours when they do arise.

Abstracts – ALLIED HEALTH RESEARCH PRIZE AND NURSING RESEARCH PRIZE 38 of 68

PROGRAM - ALLIED HEALTH AND NURSING RESEARCH PRIZES 2005 To be held on Wednesday, 23rd November 2005 in the Academic Centre. Time Name PRESENTATION TITLE 12.45pm Belinda Berry

(Social Worker) RAD Assesses Patient in the ED for Direct Transfers to the Sub-Acute Setting

1.00pm Helen Irwin (Registered Nurse)

Developing and Implementing a Comprehensive Diabetes Mellitus Service Across RAPCS

1.15pm Peter Hough (Physiotherapist)

The Development of a Falls Risk Assessment Tool for Aged Sub-Acute and Residential Care Facilities

1.30pm Andrea Scully (Dietitian)

Modified Diet / Fluids Alert System

1.45pm Barbara-Anne Cass(Registered Nurse)

The Experience of Patients Receiving Home Based Palliative Care Deciding to go to a Hospital Emergency Department

2.00pm Mary Danoudis (Physiotherapist)

Parkinson's Disease - From Research to Practice - The Evidence

2.15pm Vicki Davies (Occupational Therapist)

Participation in the Nari Research Project "Evaluation of a Minimum Dataset for Victorian Falls Clinics"

2.30pm Afternoon Tea 3.00pm Jenny Chapman

(Social Worker) An Innovative Response to Emergency Demand from Residential Aged Care Facilities

3.15pm Cecilia Webster (Registered Nurse)

Palliative Care Work, Between Death and Discharge

3.30pm Haria Lambrou (Physiotherapist)

Predicting Discharge Destination

3.45pm Helen Wearne (Registered Nurse)

Pain Management Project in the Palliative Care Unit

4.00pm Diana Clayton (Registered Nurse)

Introduction of an Evidence Based Hip Protector Program into a Psycho-Geriatric Unit

4.15pm Deidre Burgess (Occupational Therapist)

What are the Lived Experiences of Palliative Care Occupational Therapists Whilst Facilitating Dying at Home?

4.30pm Betty Williamson (Registered Nurse)

Radial Versus Femoral Artery Access Coronary Angiography From The Nursing Perspective

4.45pm Review of Presentations 5.00pm Awarding of Prizes 5.15pm Refreshments


RAD ASSESSES PATIENT IN THE ED FOR DIRECT TRANSFERS TO THE SUB-ACUTE SETTING

Belinda Berry The Response Assessment and Discharge (RAD) Team is an inter-disciplinary team working in the Emergency Department of Frankston & Rosebud Hospitals to facilitate safe discharges from the Emergency Department (ED) where possible and to initiate discharge planning from the point of presentation for those patients requiring inpatient admission. The ever increasing demands placed on the ED have led the RAD team to continue expansion of service provision to best meet the needs of patient care, whilst aiming to alleviate the pressures on the health service. The area targeted was the elderly patient population presenting to ED with non critical medical complaints. This patient population can have their needs better met in the sub-acute facilities within the health service, however, in order to access these beds patients are admitted to the ward in the acute setting to wait for a geriatrician assessment. A proposal was supported by the Director of Aged Care Medicine for RAD assess patients in ED for direct transfer to the subacute setting. A six month review of the initiative has produced a positive impact on the average length of stay (LOS) for this client population. A summary of the results will be presented highlighting the potential impact the on the acute sector. The success of this initiative has led to an appointment of an assessment nurse to continue to facilitate direct transfers in ED.


DEVELOPING AND IMPLEMENTING A COMPREHENSIVE DIABETES MELLITUS SERVICE ACROSS AN 8 SITE, 355 BED, REHABILITATION, AGED AND PALLIATIVE CARE SERVICE

Helen Irwin * Helen Irwin **Joseph E Ibrahim **Christopher Gilfillan * Rehabilitation, Aged and Palliative Care Services, Peninsula Health, Mt. Eliza, Victoria, Australia. ** Department of Aged Care Medicine, Monash University, Victoria Australia *** Department Endocrinology and Diabetes, Peninsula Health, Frankston Hospital, Frankston, Vic. Australia. Systematic and comprehensive management of diabetes mellitus in the inpatient rehabilitation and aged care setting is complicated because of often multiple co-morbidities, frailty and complex psychosocial and discharge needs. An ADEA credentialed diabetes nurse educator (RN-CDE) met the challenge of developing and implementing a comprehensive diabetes management service across multiple sites in a widely dispersed regional rehabilitation, aged and palliative care service (including residential aged care) where no prior dedicated and structured diabetes education service existed. A structure for managing diabetes was initiated. The nursing and medical staff of the service, and endocrinologists located at the affiliated acute hospital were engaged. A risk assessment in the wards involved assessing requirements of all clinical areas, relating standards of practice and the nature of the services provided against the ADS¹ / ADEA² and Aged care standards³. Within 12 months the following tasks were completed; equipment review and replacement, establishment of an ongoing staff education program, weekly site visits by the CDE-RN, implementation of evidence based practice to develop an algorithm for hypoglycaemia management including 2 treatment kits on all wards. Diabetes resource nurses have been trained on each ward to help the RN-CDE to facilitate education of patients and ward staff. Comprehensive Diabetes Resource manuals were implemented on each ward. A weekly Diabetes consultative round occurs in 2 of the larger facilities and involves the endocrinologist, ward RMO, RN-CDE and diabetes resource nurse. The consultative round now reviews up to 96% of patients with diabetes Outcomes include reduced medication errors, improved adherence to testing HbA1c levels and a reduced rate of hypoglycaemia. ¹ ADS –Australian Diabetes Society ² ADEA -Australian Diabetes Educators Association ³ Commonwealth Aged Care Standards


THE DEVELOPMENT OF A FALLS RISK ASSESSMENT TOOL FOR AGED SUB-ACUTE AND RESIDENTIAL CARE FACILITIES

Peter Hough AUTHORS Caroline Stapleton, Peter Hough, Karen Bull, Ken Greenwood and Keith Hill INSTITUTION Peninsula Health Rehabilitation, Aged and Palliative Care Service Mornington Peninsula, Melbourne Victoria, Australia The aim was to investigate predictive validity of a Falls Risk Assessment Tool (FRAT) designed for nurses in non-acute aged care facilities. Nine items were included: ambulation, cognition, continence, medical conditions, medications, psychological status, recent falls, sensory input and transfers. The validity of the FRAT for predicting faller versus non-faller group membership was examined over four months for 291 residents/patients. Eighty-nine subjects fell in this period; single=39; 2-3=29; 4or>4=21, non-fallers=202. Comparing non-fallers with fallers a highly significant discriminant function resulted, x2 (4, n=291) =89.89, p <.0001. Four items entered the equation, with correlations between the four predictors and the discriminant function indicating that recent fall was the best predictor (.82), followed by psychological status (.55), medications (.46) and cognition (.41). A composite variable calculated from individual's scores on these four predictors correctly classified 80.4% of individuals, with a specificity of 90.1% and a sensitivity of 58.4%, using a cut-off score of 14. Four items, easily obtained within two minutes by nurses from admissions procedures, can be used to predict those who are at most risk of falling. Patients scoring highly on these four items of the FRAT need maximum fall alert care. Staff cannot rely solely on this tool, but can expect most fallers to be identified.


MODIFIED DIET / FLUIDS ALERT SYSTEM

Andrea Scully This multidisciplinary project was initiated and completed across Speech Pathology, Support Services, Nursing Staff and Dietitetics at Rosebud Rehabilitation Unit to reduce risk of patients receiving incorrect modified diet / fluids in the dining room. Its aim was that 100% of patients in the dining room would receive the correct diet / fluids as recommended by the Speech Pathologist and or Dietitian. The current alert system was identified as inadequate by the team. It was revised and expanded to further reduce the risks associated with the current system. Highly visual, environmental cues in the form of placemats were developed and an education program was provided to all staff involved in the preparation and provision of meals. Outcomes were evaluated immediately post introduction of the alert system and at six months post. Results showed small but significant improvement in reducing risk of patients’ receiving incorrect diets / fluids and positive feedback was received from staff involved in using the system. Future considerations for this project include further evaluation and dissemination of project results to colleagues to promote improved alert systems modified diets / fluids across a range of healthcare settings.


THE EXPERIENCE OF PATIENTS RECEIVING HOME BASED PALLIATIVE CARE DECIDING TO GO TO A HOSPITAL EMERGENCY DEPARTMENT

Barbara-Anne Cass Introduction: This study examined the experience of patients receiving palliative care in the community who, for one reason or another, were admitted to a hospital emergency department. Two participants met the ethics approved criteria and were interviewed. Aims: The purpose of this study was to gain an insight into the experiences of patients receiving palliative care in the community who presented at the emergency department of an outer suburban hospital. The aim of the researcher was that this project would improve practitioners understanding of knowing how it feels for a person receiving palliative care to be in the hospital emergency department. In addition, insights were sought to enhance the provision of care across a continuum of settings. Method: A qualitative research design with a phenomenological methodology was chosen for this study. The methods of van Manen (1997) were used to guide the process. Data was collected in the form of personal interviews with the two participants. Results and Conclusion: This research confirms that there is a legitimate need for emergency interventions in some cases. It is recognised that palliative care service provision needs to be available in various settings. While research to date indicates that the home is the preferred place to die, it is acknowledged that this requires a steadfast commitment by family carers. Difficulties arise when tasks such as complex symptom management are required. In the emergency department there is clear distinction between rescue and palliation and this dichotomy can lead to indistinct goals of care.


PARKINSON’S DISEASE – FROM RESEARCH TO PRACTICE – THE EVIDENCE

Mary Danoudis Presented by Mary Danoudis, coordinator of the Movement Disorders Program, Peninsula Health. There has been extensive research over the last 10 years looking at the underlying causes of the movement disorders seen with Parkinson’s disease. This research has given clinicians principles on which to base their interventions. There are only a small number of good research projects that have looked at the outcomes of various interventions for people with Parkinson’s disease. The results suggest that specific task training does result in improvement in function. Only a few of these studies have included strategy training in their interventions. These subjects either received their rehab in their homes or in clinics. The clinicians at the PH Movement Disorders Program (MDP) base their interventions on the 5 principles identified as improving movement in the research by Prof R Iansek and Prof Meg Morris. Patients are taught the various strategies that can improve mobility, balance, speech and swallow and activities of daily living. I will present the outcome measures for a group of patients who have attended the MDP for strategy training. These results clearly demonstrate that strategy training has improved their function and quality of life.


PARTICIPATION IN THE NARI RESEARCH PROJECT “EVALUATION OF A MINIMUM DATA SET FOR VICTORIAN FALLS CLINICS

Vicki Davies Introduction: Peninsula Health Falls Specialist Service was one of 14 Falls Clinics who participated in the NARI “Evaluation of a Minimum data Set for Victorian Falls Clinics” research project. Aims: To establish the effectiveness of specialist Falls assessment of community dwelling clients by reviewing:

• Number of falls and fall injuries sustained post assessment • Changes in standard outcome measures • Compliance with Falls clinician’s recommendations

Methods: During initial assessment data was collected on falls and fall injuries, demographic details and targeted outcome measures. This was transmitted electronically with key falls risk factors and clinician recommendations. At six month review data on falls and falls injuries, outcome measures and compliance with recommendations was collected and transmitted to NARI for analysis. Results: Analysis of Peninsula Health data demonstrated a 53% reduction in falling and 54.9% reduction in injurious falls following specialist falls assessment. This was comparable with, or better than, results from other Falls Clinics. Conclusions: Providing specialist Falls assessment can reduce the risk of falls and falls injury in community dwelling older people.


RESIDENTIAL OUTREACH. AN INNOVATIVE RESPONSE TO EMERGENCY DEMAND FROM RESIDENTIAL AGED CARE FACILITIES

Jenny Chapman The Residential Outreach Support Service (ROSS) is an interdisciplinary team established to improve outcomes for residents of Residential Care Facilities (RCFs) by reducing unnecessary presentations to the Emergency Department. ROSS operates in an environment of increasing complexity and changing needs of the aging RCF population. The generic but also multi-disciplinary skills within the ROSS Team, has provided an opportunity to integrate roles, review practice and provide an effective and responsive out-reach service. ROSS have utilised a number of methods to implement the broad and multi-layered goals of the program. Data has been analysed regarding the type of referral, intervention and impact throughout the first year of the program. Preliminary data indicates that ROSS has an effective role to play in Emergency Demand, though there is scope for development, particularly in relation to Falls Prevention and Education in the residential care sector. Results will be presented about the success/impact of the program both on residents of RCFs, RCF staff, GPs and Acute/Sub-Acute services. ROSS is a developing and constantly changing service, which responds to the needs of consumers and the health service. The ROSS Team provides a showcase for allied health innovation, whilst striving for the best outcome for consumers


PALLIATIVE CARE WORK, BETWEEN DEATH AND DISCHARGE

Cecilia Webster Dr Louise Peters (PhD) Research Officer, Palliative Care Nursing Faculty Medicine, Nursing & Health Sciences Monash University

Ms Cecilia Webster (RN) Associate Nurse Unit Manager Tattersall’s Palliative Care Unit Peninsula Health

This paper discusses a small quality improvement study that was undertaken in a palliative care unit (PCU), to demonstrate reasons for the lengthy patient turnover time after the death of a patient. There is a dearth of literature describing the role of the nurse in providing care of the family and others after the patient has died. The aim of the study was to undertake a post-death survey from the nursing perspective, of activities and the time required to complete tasks associated with follow-up care to the deceased patient and his/her family unit. Details of the post-death episode for all patients who died in the PCU over two time periods were collected using a newly designed tool. Study findings demonstrate that most deaths in this Unit occur out of business hours. In addition, the study has highlighted the protracted nature of post-death care, because of a variety of factors. Nursing work after death is complicated by a lack of multi-disciplinary and ancillary support, particularly out of business hours. These factors prolong the time between patient death and removal of the deceased, thus delaying admission of new patients. This project has provided important information both from a quantitative viewpoint as well as giving some insight into the role of the nurse after death occurs.


PREDICTING DISCHARGE DESTINATION

Haria Lambrou, Anna Meadows Imagine if a simple survey existed which could reliably assist in predicting discharge destinations for elective Total Hip Replacement (THR)/Total Knee Replacement (TKR) patients from the first point of contact at Pre-Admission Clinic (PAC). Aim: To develop a tool that could be used in PAC to predict discharge destination for patients following elective THR/TKR surgery. Method: Orthopaedic physiotherapists and occupational therapists at Frankston Hospital developed a discharge destination tool requiring a score for the following categories: Medical, Physical, Social and Self-efficacy. Patients were surveyed at PAC and the results were reviewed following their discharge from hospital. Results: 22 patients were surveyed in an initial trial, where the tool correctly predicted discharge destination in 75% of patients. A subsequent trial was performed following minor adjustments to the tool, where 49 surveys were completed and 81% of the predictions were accurate. Strategies to increase this level of accuracy have also been proposed. Conclusion: This simple PAC tool can be useful in predicting discharge destination for elective THR/TKR patients. Additionally, if embraced by the team, various benefits have been hypothesised including: reduced length of stay; less customer complaints regarding the discharge process experience, as well as assisting with future clinical pathway developments.


PAIN MANAGEMENT PROJECT IN THE PALLIATIVE CARE UNIT

Helen Wearne

Frankston Palliative Care Unit Most literature on Pain Management highlights the need for regular impeccable pain assessment and reassessment as a requirement for good pain management. In the Frankston Palliative Care Unit (PCU), a tool, a process and ongoing education has been successful in embedding this in every day nursing practice. The tool provides a documentation approach that allows review of pain severity, site and pain interventions over time, and helps guide changes in pain management that improve patients outcomes in relation to that symptom. The process requires at least four hourly pain assessment for all patients, whether the patient identifies pain as an issue or not, and more frequent assessment for those patients whose pain is poorly controlled which entails reassessment 1 hour following any intervention. All nurses in the Unit have received education in pain management both as part of their orientation and on an ongoing basis as part of the PCU’s in-service education program. As a result of this, 92% of patients have demonstrable regular ongoing pain assessment, 86% of patients admitted to the PCU with pain as a problem have a 50% reduction in their pain score following admission to the PCU.


INTRODUCTION OF AN EVIDENCE BASED HIP PROTECTOR PROGRAM INTO A PSYCHO-GERIATRIC UNIT

Diana Clayton Authors: Diana Clayton, Clinical Nurse Consultant, Falls Prevention Service Jakinta Bowra RN Div 2, Carinya Residential Care Unit In Carinya there are a significant number of residents who are at high risk of falling, due to cognitive impairment. It was decided, based on the evidence found in research, to introduce the prescription of soft hip protectors into this unit. Hip protectors have been shown, through numerous trials, to reduce the incidence of hip fractures in the high falls risk population, both community dwelling and in residential aged care facilities. In conjunction with this implementation, a hip protector policy was developed for the whole of the Rehabilitation, Aged and Palliative Care Service (RAPCS) by the Falls Prevention Service, in conjunction with the Physiotherapy Department of RAPCS. During the time the hip protector program has been running issues have been identified involving staff reluctance to use the hip protectors and laundering of the hip protector pants. Even with these issues the results have been satisfying. Between July 2004 and April 2005, 22 residents were prescribed hip protectors with 20 of these going on to fall. There have been a total of 121 falls reported with only one fracture sustained. The resident sustained a fractured acetabulum, which could not have been prevented by hip protectors.


WHAT ARE THE LIVED EXPERIENCES OF PALLIATIVE CARE OCCUPATIONAL THERAPISTS WHILST FACILITATING DYING AT HOME?

Deidre Burgess Aim: To explore the lived experience of palliative care occupational therapists whilst assisting palliative patients to return home. Research Question: What are the lived experiences of palliative care occupational therapists whilst facilitating dying at home? Method: A phenomenological study was conducted whereby purposeful sampling identified occupational therapists with palliative care experience. Semi structured interviews were recorded and transcribed verbatim. Techniques employed to aid credibility of this research included triangulation of data, checks of the researcher’s assumptions by participants and bracketing. Results: Inductive analysis of data revealed that clinicians experienced home assessments along an emotion-experience continuum. Core values of care and connection were identified and underpinned therapeutic relationships. External factors such as interactions with the patient, family and team impacted significantly on how the participants experienced work satisfaction. Internal factors including personal beliefs, core values and ability to employ coping strategies were brought to light. Those able to accommodate client centered care were able to adapt to fundamental differences between home visits for palliative patients and traditional rehabilitation patients Conclusions: Clinicians’ abilities and comfort around to engaging with dying clients was shown to develop over time. Focus of therapeutic relationships moved from the patient to family as patients’ neared death. Practice was reframed over time and clinicians drew increasing satisfaction from emotional connection with those they supported. Respect for patients’ autonomy was actively supported, sometimes irrespective of risks. There is evidence to support the practice of ongoing debriefing in the workplace for clinicians in this field.


RADIAL VERSUS FEMORAL ARTERY ACCESS CORONARY ANGIOGRAPHY FROM THE NURSING PERSPECTIVE.

Betty Williamson B Williamson*, G Szto, J Bladen, R Templin, W Dyble, S Evans-Murphy, D Flenley. H Williams, S Best. Peninsula Health: Frankston Hospital, Frankston, Victoria. Introduction: At Frankston hospital one Cardiologist has been using the radial approach (RAD) in most patients undergoing outpatient coronary angiograms. The admitting nurse determines suitability after ensuring a normal Allen’s test. We sought to determine 1) patient satisfaction, 2) procedural costs, 3) vascular complications, 4) X-ray screening time compared to femoral (FEM) approach angiography. Method: A questionnaire was developed for pain and comfort during, post-procedure and after returning home. Procedural costs were calculated using current pricing. X –ray screening time was taken from the Cathcor database. Questionnaires were sent to the last 98 patients treated by Cardiologist 1, using the femoral approach, and to the last 96 patients treated by Cardiologist 1, using the radial approach. 50 questionnaires were returned from both groups. Results: The radial approach was used in 139 patients over 3 years. Pain during procedure was more severe in RAD (n=21, 42%), compared to FEM (n=14, 28%). Post procedure amongst the RAD was more comfortable 44% (n=27), compared with 54% (n=22). After discharge more RAD patients received medical consultation 14% (n=7), compared with 10% (n=5). Of 21 patients who experienced both procedures, slightly more (54% n=11), would prefer a radial approach. Procedural costs for an uncomplicated procedure were $8.50 higher in the RAD. The RAD group was eligible for discharge 3 hours earlier. X-ray screening time was higher in the RAD (4.5 minutes vs. 5.7 minutes). Conclusion: Coronary angiography from the radial artery is comparable to femoral in relation to patient comfort, X-ray screening time and procedural cost. It has a distinct advantage in allowing earlier discharge. This allows significant savings in nursing time. At this institution this has allowed freeing up of space in our angiography unit, with the result that more patients can be treated daily.

Abstracts – REGISTRAR RESEARCH PRIZE & TYCO AWARD 53 of 68

PROGRAM – PENINSULA HEALTH REGISTRAR RESEARCH PRIZE 2005

To be held on Saturday, 26th November 2005 in the Academic Centre. 8.00 am Breakfast 8.30 am

Introduction by Chairman

Professor Jonathan Serpell

8.35am

Referred Skin Cancers: How Many More Are Present?

Dr Sian Fairbank Surgery (Plastic Surgery)

8.50 am

Kirshner Wiring of Fractured Zygoma: A Minimal Approach

Dr Derek Neoh Surgery (Plastic Surgery)

9.05 am

Accuracy of Self-Reported Height and Weight in Elective Surgery Patients

Dr Natalie Gattuso (Anaesthetics)

9.20 am

Optimising Predictability of Preoperative Chemotherapy Response for Locally Advanced Breast Cancer: Comparison of PET Scan with Conventional Methods, and Role of Biological Markers

Dr Emma Beardsley Medicine (Medical Oncology)

9.35 am

The Diagnosis and Treatment of Thyroid Cancer

Dr Sarah Martin Surgery (General Surgery)

9.50 am

Outcomes Following Insulin-Dextrose Infusion in Diabetic Patients with Acute Myocardial Infarction (IDIPAMI Study)

Dr Shirley Elkassaby Medicine (Endocrinology)

10.05 am

Ovarian Vein Reflux and Varicose Veins. Is there a Relationship?

Dr Joseph Gunn Surgery (Vascular Surgery)

10.20 am

The Definition and Management of Oliguria

Dr Narcelita Lim, presenting for Dr P Mudholkar Medicine (Intensive Care)

10.35 am

Total Thyroidectomy for the Treatment of Graves’ Disease

Dr Corinne Ooi Surgery (General Surgery)

10.50 am

The Response to Interventional Treatment of Symptomatic Adrenal Metastasis

Dr Cham Saranasuriya Surgery (General Surgery)

11.05 am

“Ironhearts”: Biochemical and Functional Abnormalities of Left and Right Ventricular Function Following Ultra-Endurance Exercise

Dr Andre La Gerche Medicine (Cardiology)

11.20 am

The Relative Motion Between the Scaphoid and the Lunate

Dr De Juan Ng Surgery (Orthopaedics)

11.35 am

Morning Tea

11.50 am

Presentation of Prize

Dr Sherene Devanesen Chief Executive


REFERRED SKIN CANCERS: HOW MANY MORE ARE PRESENT?

SM Fairbank, PJ Terrill

Department of Plastic and Reconstructive Surgery, Frankston Hospital The assessment and management of non-melanotic skin cancers referred by General Practitioners forms a large proportion of a Plastic Surgeons practice. It is also common for specialists to discover additional skin lesions in sites not indicated by the referring doctor within his or her initial correspondence. The importance of complete skin checks to identify hidden additional lesions has been emphasised in the literature pertaining to malignant melanoma, however, their presence has not been quantified in situations where non-melanotic skin cancers are the subject of the initial referral. The aim of this study was to assess and quantify these additional skin tumours, identified following a general skin examination performed by a metropolitan Plastic Surgeon following squamous cell (SCC) or basal cell (BCC) carcinoma referral and their epidemiological factors. A retrospective study was performed after retrieving the medical records documenting the assessment of 41 male and 59 female patients. Mean age was 70 years, range 39 to 91 years. Results indicate that additional lesions were found in 67% of patients referred. The most common site was the head and neck region (49%), followed by the trunk (24%) and multiple regions (10%). In 51% of patients, these other lesions were in the same region as the referring lesion. The additional lesions were BCC’s (31%), mixed types of skin cancers (28%), solar keratoses (31%) and SCC’s (3%), melanomas (3%) and other (3%). Epidemiologically, most patients had fair skin (84%), brown hair (58%) and green/hazel eyes (42%). Comparing those patients who had only the presenting lesion to those who had multiple lesions, both groups had indoor occupations (64%), tended to burn after 1 hour in the sun (71%) and 83% reported blistering sunburns. Those with multiple lesions had less ability to tan (24% vs 10%) and were more likely to have had a melanoma excised in the past (25% vs 10%) or a non-melanotic skin cancer (64% vs 52%). These results indicate that when patients present with a non-melanotic skin tumour, a thorough general skin check is essential, in particular in the region of the original tumour and especially where there has been a past history of skin tumours.


KIRSHNER WIRING OF FRACTURED ZYGOMA: A MINIMAL APPROACH

D Neoh

Department of Plastic and Reconstructive Surgery, Frankston Hospital Introduction: The zygoma is the second most common facial bone affected in craniofacial fractures. Most of these fractures can be treated by simple “closed” reduction techniques but when the fracture involved is unstable, treatment often requires open reduction and internal fixation by plates and screws. We describe a minimalist approach to the treatment of such fractures. Aim and Method: Fixation by K-wire has been described in the literature and we present our Australian experience using a novel technique with a single K-wire. We then retrospectively looked at our experience with the technique over the last 5 years in our centre identifying overall outcome and any complications. Results: We identified 50 patients in the retrospective study over a period of 5 years. Only a single case required re-operation with internal fixation with plates and screws. The remaining 49 cases had a satisfactory reduction and stabilisation of the zygoma with subsequent removal of the K-wire at 3 weeks. There were 2 cases of infection and a single case of molar infarction. Conclusion: K-wiring of fractured zygoma is a useful technique that is quick, inexpensive and suitable for a majority of low velocity unstable fractures of the zygoma.


ACCURACY OF SELF-REPORTED HEIGHT AND WEIGHT IN ELECTIVE SURGERY PATIENTS.

Natalie Gattuso

Anaesthetic Registrar, Frankston Hospital Introduction: Obesity has implications for anaesthesia and surgery, and therefore admission planning. At Peninsula Health, elective surgery patients self-report height and weight on a pre-admission survey, which is screened to determine whether the patient needs further assessment and the appropriate facility for surgery. Aims: Obtain information on the size of patients undergoing elective surgery at Frankston Hospital, and determine the accuracy of using self-reported height and weight to calculate body mass index (BMI). Methods: Data was collected from 444 patients over 15 years of age undergoing elective surgery. Patients self-reported height and weight, and true measurements were taken on the day of admission. Gender, age and ASA status were also recorded. Results: 36% of patients were obese (BMI > 30) and 17% morbidly obese (BMI > 35). Women had higher rates of obesity (40%) than men (30%). Self-reported BMI correlated very well with true BMI (r > 0.95). Conclusion: There is a high prevalence of obesity in the population of elective surgery patients at Frankston Hospital. BMI calculated from self-reported height and weight provided an accurate representation of true BMI, validating the use of the pre-admission survey for this purpose.


OPTIMISING PREDICTABILITY OF PRE-OPERATIVE CHEMOTHERAPY RESPONSE FOR LOCALLY ADVANCED BREAST CANCER: COMPARISON OF PET SCAN WITH CONVENTIONAL METHODS, AND ROLE OF BIOLOGICAL MARKERS

Beardsley, E., Thomson, J., Brown, B., Ganju, V. Medical Oncology, Frankston Hospital Introduction: The pathological response remains the best predictor of outcome in women treated with pre-operative chemotherapy. The ability to predict response based on radiological and biological methods would enable as to optimise individual patient treatment. Aims: - To identify markers that correlate and/or predict major tumour response to

chemotherapy and complete pathological response. - To assess for qualitative differences between taxane and non-taxane-based

chemotherapy responses with regards to alteration in biological markers. - To assess influence of drug sequence during treatment on the final pathological

response. Methods: Women undergoing pre-operative chemotherapy are assessed with biopsy, mammogram, ultrasound, positron emission tomography (PET) and biological markers on tissue and blood pre, during and after chemotherapy. 25 patients enrolled after screening to exclude distant metastases and inflammatory breast cancer. Patients are randomized to receive FEC100 x 4 or Docetaxel x 4, then crossed over following the interim assessment. 14 patients have completed all 8 cycles of chemotherapy, 11 have undergone surgery Results:

After 1st 4 cycles of chemotherapy Clinical

N = 14 Mammogram N = 14

Ultrasound N = 14

PET N = 14

Complete Response

3 (21%)

2 (14%)

2 (14%)

4 (29%)

Major/Partial Response

5 (36%)*

2 (14%)*

3 (22%)*

2 (14%)**

Others (SD, PD)

6 (43%)

10 (70%)

9 (64%)

8 (57%)

* - > 50% reduction in largest diameter ** - >50% reduction in SUV

Path Response Post 8 cycles (n =11)

PET post 4 cycles Complete 27% Major 27% Minor 45% CR/MR 3 1 3 SD 0 1 2 PD 0 1 0


Initial SUV PET vs Pathological response

Post 8 cycles Initial SUV* at PET CR MR Minor > median 3 1 3 < median 0 1 3 *Standardized uptake value Anthracycline vs Taxane Post surg path Initial chemo CR MR Minor FEC n=7 2 1 4 Docetax n=4 1 1 1 Conclusions: - PET scanning, post 4 cycle, appears most closely to predict pathological

response at definitive surgery. - Higher SUV’s at initial diagnosis suggest increased chemotherapy

responsiveness, with better pathological response. - Initial Chemotherapy (FEC vs Docetaxel) currently does not show superiority in

the final pathological response.


THE DIAGNOSIS AND TREATMENT OF THYROID CANCER

Sarah Martin, Jonathan Serpell

General Surgery, Frankston Hospital Background: Thyroid cancer is rare. The aims of this study were to examine the incidence, diagnosis and outcome of thyroid cancer in a localised geographic population; and to assess the role of synoptic cytology and frozen section in management. Method: All patients with thyroid cancer from 1991-2005 were reviewed, from a prospectively collected single surgeon, Endocrine Surgery Database. Results: From a total series of 1377 referrals and 789 operations 77, patients with thyroid cancer were identified. There were 50 Papillary (65%), 19 Follicular (25%), 7 Medullary (9%) and 1 Anaplastic (1%) cancers. Synoptic Cytology reporting correctly indicated surgery in 64/68 (94%) and intra-operative frozen section allowed 10 conversions to total thyroidectomy. Ninety-two percent of patients had a total thyroidectomy, 58% as a one stage operation. All patients with papillary or follicular thyroid cancer received postoperative radio-iodine (except small incidentally discovered papillary cancers). Two of the follicular cancers presented with bone metastases, and one has subsequently developed a bone metastasis. Of the 7 medullary cancers, 6 have required modified radical neck dissection. To date there has been no locoregional recurrence, but 2 of the patients with medullary cancer have died of metastatic disease. Therefore the current overall mortality from all types of thyroid cancer is 2/77 (2.6%), for medullary cancer 29%, but none in the papillary and follicular groups. Conclusions: Thyroid cancer is rare, but has an excellent prognosis when appropriately treated. Cytology is highly sensitive in detecting thyroid cancers, especially combined with synoptic reporting and frozen section allowing one stage total thyroidectomy.


OUTCOMES FOLLOWING INSULIN-DEXTROSE INFUSION IN DIABETIC PATIENTS WITH ACUTE MYOCARDIAL INFARCTION (IDIPAMI STUDY).

Shirley Elkassaby, Kaye Quick, Christopher Gilfillan

Endocrinology, Frankston Hospital During acute myocardial infarction ischaemic myocardium switches to fatty acid metabolism in the setting of hypoxia and intense adrenergic stimulus. Fatty acid promote apoptosis and are arrhythmogenic. Insulin dextrose infusion (IDI) improves glucose supply and lowers toxic fatty acid metabolites and improve the survival of the ischaemic penumbra. Recent studies in humans have given contradictory results with some studies showing a survival benefit following IDI but other studies failing to confirm such benefit. Controversy in the literature mandates that we look at our own practices carefully. Our practice over the past 5 years has been to use infusions in all diabetics admitted with AMI , and this has been carried out in approximately 50% of patients. This study compares outcomes of diabetic patients presenting with a myocardial infarction who received an IDI versus those who did not. We tested the following hypotheses: 1. That insulin infusions post-AMI result in no significant increase in adverse events 2. That implementation of an insulin infusion protocol improves in-hospital

glycaemic control 3. That insulin infusion results in smaller infarct size as reflected by peak CK 4. That patients receiving insulin infusions have better outcomes at 12 months with

regard to glycometabolic and cardiovascular outcomes, including mortality. In the first part of the study we performed a file audit where data was collected on the patient’s past heart disease and diabetes history, inpatient diabetes control and biochemical indices (CK, HbA1c, lipids) and any complications (hypoglycemia, volume overload, hypokalemia). The second part of the study consisted of a 12 -18 month follow-up by way of a phone call enquiring about ischemic heart disease and glycometabolic outcomes. If patients had not had a recent HbA1C and lipid blood test then a pathology request was sent for these tests to be done. So far 90 patient files have been audited. Outcomes to date are that: 1) insulin-dextrose infusions are safe and rarely cause serious adverse events and 2) that implementation of an insulin infusion protocol improves in-hospital glycaemic control. Data on outcomes at follow-up will be presented.


OVARIAN VEIN REFLUX AND VARICOSE VEINS. IS THERE A RELATIONSHIP? Dr Joseph Gunn Vascular Surgery, Frankston Hospital Background: Ovarian vein reflux is regarded as a major contributing factor to pelvic congestion syndrome and is sometimes implicated as a cause of pelvic pain. However the role of ovarian vein reflux in the formation of lower limb varicose veins has never been studied. Lower limb varicose veins are a common condition with many well established pre-disposing factors. The contribution of ovarian vein reflux to lower limb varicose veins has not previously been investigated. Aims: To establish the incidence of ovarian vein reflux in patients presenting for assessment of lower limb varicose veins. To investigate the contribution of ovarian vein reflux to a specific pattern of lower limb venous reflux. Patients and Methods: Fifty-two (52) consecutive female patients presenting for assessment of lower limb varicose veins underwent standardised ultrasound examination according to protocol. In addition, ultrasound examination of the internal iliac veins and ovarian veins was also performed. The patients symptoms and objective signs of venous reflux were recorded and all patients had their CEAP classification established. Results: Eighty-one (81) lower limb examinations were performed in 52 patients. Twenty-eight (34%) patients with varicose veins had associated ovarian vein reflux. Of these 20 (71%) showed a typical pattern of saphenofemoral incompetence with varicosities communicating with the great saphenous vein. In 5 (21%) cases, lower-limb varicose veins were in communication with the incompetent pelvic veins. All of the cases with pelvic-limb connection exhibited vulval varicosities. Summary and Conclusion: A significant number (34%) of women with lower limb varicose veins also experience ovarian vein reflux. In a small proportion of cases (6%) ovarian vein insufficiency will be a major contributing factor to lower limb varicosities. The presence of vulval varices is a sensitive marker of venous reflux from pelvis to limb. Ovarian vein reflux is an important factor in certain cases of lower limb varicose veins and should be investigated further.


THE DEFINITION AND MANAGEMENT OF OLIGURIA

P Mudholkar, J Botha, J Mulder, R Bellomo

(Presented by Dr N Lim )

Intensive Care Unit, Frankston Hospital Oliguria is a commonly encountered clinical problem in the critically ill. Unlike Acute Respiratory Distress Syndrome which has a well accepted definition, clinicians have varying perceptions as to what constitutes oliguria and acute renal failure. The assessment of intravascular volume in the oliguric patient is also difficult with different hemodynamic measurements available to establish volume status of a patient. There are numerous investigations available to establish the cause of oliguria, and requests for these vary in different clinical settings. Despite the lack of any firm clinical evidence to support the use of any particular agent in the treatment of oliguria, there is varying clinical practice in the prescription of diuretic and other agents. Using a standardised e mail questionnaire, data was obtained from 188 practising intensivists and nephrologists across 4 continents. These data confirmed that there was a wide variation in perceptions as to what constitutes acute renal failure. Furthermore the strategies deployed to investigate these patients lacked consistency. The management of such patients also differed with few clinicians appearing to heed data from available clinical trials.


TOTAL THYROIDECTOMY FOR THE TREATMENT OF GRAVES’ DISEASE

Corinne Ooi, Jonathan Serpell

General Surgery, Frankston Hospital Background: Total thyroidectomy is now the preferred surgical treatment of Graves’ Disease. The aim of this study was to assess the indications and outcomes of surgery for Graves’ Disease in a specialized Endocrine Surgery Unit. Methods:

Information was obtained from a single surgeon’s endocrine surgery database over the period 1991 to October 2005. Of a total of 1405 patients in the database, 32 patients with Graves’ Disease were treated surgically

Results:

The indications for surgery were: goitre size in 7 patients (21.9%), resistance to medical therapy in all patients; inability to have radio-iodine in 17 patients (53.1%) and concern about significant Graves’ ophthalmopathy in 17 patients (53.1%). 29 patients with Graves’ Disease underwent a total thyroidectomy. Three subtotal thyroidectomies were performed early in the series but the unit policy now is to perform a total thyroidectomy. Temporary symptomatic hypocalcaemia occurred in 7 patients (21.9%), temporary asymptomatic hypocalcaemia in 4 patients (12.5%) and permanent hypocalcaemia in 1 patient (3.1%). One patient had a post-operative haematoma requiring drainage. All patients were cured of Graves’ Disease and had no recurrent thyrotoxicosis or progression of their eye disease.

Conclusion:

Total thyroidectomy is a safe treatment for a select group of patients who require surgery for Graves’ Disease.


THE RESPONSE TO INTERVENTIONAL TREATMENT OF SYMPTOMATIC ADRENAL METASTASIS

Cham Saranasuriya

General Surgery, Frankston Hospital Purpose: This study examined the natural history of adrenal metastasis from different primary sites and the outcome of treatments. Methodology: Patients with known adrenal metastasis on medical imaging who attended PMCI between 1990—2000 were retrospectively reviewed. Results: A total of 217 patients were identified. The known primary sites were: 62% lung, 9% melanoma, 6% breast, 5% colorectal, 3% renal, 3% upper GI, 3 laryngeal and 1 thyroid. The average survivals following diagnosis of adrenal metastasis were: 7 months for breast cancer, 6 months for melanoma, 10 months for colorectal cancer, 5 months for lung cancer. 26% patients presented with symptomatic adrenal metastasis. 2 patients underwent adrenalectomy, with one complete response and one 30 months survival with good symptomatic relief; 6 underwent palliative chemotherapy with symptomatic relief in 5. Of 22 who underwent palliative radiotherapy, 36% reported relief while 32% had progressive disease. Conclusion: The majority of adrenal metastasis were asymptomatic and can be treated conservatively. Palliative radiotherapy and chemotherapy can provide symptomatic relief. Adrenalectomy confers survival benefit in a selected group.


“IRONHEARTS”: BIOCHEMICAL AND FUNCTIONAL ABNORMALITIES OF LEFT AND RIGHT VENTRICULAR FUNCTION FOLLOWING ULTRA-ENDURANCE EXERCISE

Dr Andre La Gerche

Cardiology, Frankston Hospital Introduction: There has been speculation that ultra-endurance exercise may cause myocardial damage - possibly resulting in cardiac arrhythmias and sudden cardiac death. Methods: We tested 27 athletes one week before, immediately after, and one week after competing in an ultra-endurance triathlon. Tests included cardiac troponin I (cTnI) and B-type natriuretic peptide (BNP) assays as well as comprehensive echocardiographic systolic and diastolic function assessment. Results: Twenty-six athletes completed the race. After the race, cTnI and BNP were significantly elevated. Right ventricular fractional area change (RVFAC) and annular displacement (RVAD) were significantly reduced post-race. Echocardiography revealed segmental wall motion abnormalities in 7 athletes and reduced ejection fraction (LVEF) in that group post-race. Findings normalised by 1 week following the event (see Table). Conclusion: The elevated biochemical markers and functional abnormalities of the left and right ventricles suggest that transient myocardial damage occurs following competition in ultra-endurance sporting events. This may predispose to subsequent cardiac complications. Table

Pre-race Post-race 1 week p valueSubjects with elevated cTnI (>0.15 mcg/L)/ total subjects 3/26 15/26 0/25 0.02

BNP ng/L 11.9 41.5 15.6 <0.001LVEF (%) 60.4 57.1 59.9 0.09 LVEF (%) in athletes with abnormal wall motion 56.5 45.9 57.5 0.001 Abnormal wall motion / total subjects 1/26 7/26 0/26 <0.05 RVFAC (%) 0.47 0.39 0.45 <0.001RVAD (mm) 21.7 19.1 24.1 <0.001


THE RELATIVE MOTION BETWEEN THE SCAPHOID AND THE LUNATE

Dr De Juan Ng, Dr Stephen Tham, Assoc Prof Peter Wells

Orthopaedics, Frankston Hospital Background: Scapholunate carpal instability is a significant wrist injury which results in degenerative arthritis if left uncorrected. The optimum treatment for scapholunate dissociation is anatomic restoration of the ligament provided there are no secondary degenerative changes. Current reconstructive procedures including ligamentous reconstruction, capsulodesis and limited wrist fusions have not resulted in long lasting solutions. Objectives: The purpose of this study is to determine the relative motion between the scaphoid and lunate carpal bones with normal wrist motion to improve our understanding of normal wrist kinematics. Methods: Human ethics approval was obtained from Southern Health. We CT scanned the normal wrist of 10 volunteers with the wrist secured in a splint and placed in thirteen predetermined angles in the flexion/extension and radial/ulnar planes. Using the program 3D-Doctor Version 3.5 by Able Software Corporation (School of Physics and Materials Engineering at Monash University), the CT scan images of the scaphoid and lunate were converted into three dimensional models. Four landmark points were selected on the scaphoid and lunate which enabled four independent displacement vectors (between pairs of landmarks) to be determined. In addition, for these two bones the position of the centroid (centre of mass, under the assumption of a uniform solid bone density) was also recorded as calculated by the program. The distance between the centroids was calculated for each wrist position. For each bone in the neutral position, the four independent displacement vectors were used in linear combination to define an orthogonal unit vector set in the x, y and z axes. This was repeated for all other wrist positions with the unit vectors being formed using the linear combination coefficients generated from the neutral position. The relative positions of the scaphoid and the lunate were then derived by comparing the centroid distances and the sets of unit vectors between the two bones. These two sets can best be compared by considering the movement to be a simple rotation – a ‘hinge’ angle about a ‘hinge’ axis. We calculated the hinge angle and hinge axis orientation of the bones in each position with respect to that of the neutral position. We expressed centroid distances as a percentage change from the distance with the wrist in neutral position. The reason for this is that the absolute distances between the centroids varied with the different sizes of patients.


Results: For both flexion/extension and radial/ulna deviation of the wrist, the relative motion between the scaphoid and the lunate is predominantly around the z-axis (parallel to the radius or supination/pronation movement). This rotation of 21.1° (SD 10.97) occurs with the wrist in 60° flexion, 23.3° (SD 10.81) in 60° extension, 10.1° (SD 5.81) in 30° radial deviation and 10.9° (SD 5.65) in 30° ulna deviation. The centroid distance increased by 9.1% (SD 8.12) with the wrist in 60° extension, decreased by 8.5% (SD 3.95) in 60° flexion and decreased by 1.7% (SD 3.02) and 5.5% (SD 2.84) in 30° radial and ulnar deviation respectively. Conclusion: 1) There is relative motion between the scaphoid and lunate during wrist

flexion/extension and radial/ulnar deviation. 2) This relative motion is not linear. 3) Relative motion between the scaphoid and lunate is mainly around the z-axis. 4) Distances between centroids alter with carpal motion.

SPONSORSHIP OF PENINSULA HEALTH RESEARCH WEEK 2005 68 of 68

PENINSULA HEALTH RESEARCH WEEK 2005

SPONSORSHIP

Peninsula Health and the Research Development Committee gratefully acknowledge

the generous sponsorship of

Peninsula Health Research Week 2005 by:

GlaxoSmithKline

Tyco Healthcare

AstraZeneca

Merck Sharp & Dohme

Novo Nordisk

Ansell Healthcare

Sanofi Aventis

abstract booklet 2005 - peninsula health · 2009. 10. 14. · arginine supplementation accelerates...

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