Health services administration

To the Editor: The World Health Organization Surgical Safety Checklist (Checklist) has recently been editorialised by Merry and Barraclough.1 We are all keen to see perioperative mortality and morbidity reduced to a minimum, and one cannot disagree with the intent of the Checklist, which was tested in a pilot study2 involving almost 8000 patients in eight hospitals (in disparate developed and developing countries). The study showed a reduction in the death rate associated with surgery from 1.5% to 0.8% (or 15 per 1000 down to eight per 1000). Impressive indeed! My concerns are firstly with process. One hospital in Brisbane has already introduced the Checklist without the constructive engagement of those at the clinical coalface, contrary to what proponents of the Checklist advocate, and it is being used in a way which distracts personnel during the induction of anaesthesia. To those familiar with accident analysis, this is a good example of poor process implementation by a hospital administration and its managers. Secondly, I am concerned by the use of the study of Haynes and colleagues2 to underwrite the Checklist. Results of the study would be more meaningful if the reduction rates in mortality in the hospitals in the developed countries (Canada, United States, United Kingdom and New Zealand) were separated from those in the developing countries. Or would this have shown the developed countries’ reduction rate to be statistically non-significant? Are we to believe that use of the Checklist could save seven lives per 1000 procedures in Australia, or 15 000 to 21 000 lives across the three million procedures undertaken here annually? Total figures for perioperative mortality across all procedures in all operative categories remain a matter for conjecture. However, in looking at the high-risk group of cardiac surgical operations in Victorian public hospitals,3 we can see a published mortality rate of 10 per 1000 for coronary artery bypass or isolated valve surgery, only a little higher than that seen after the introduction of the Checklist across a broad surgical population. We should be careful to see that spin does not become embedded within medicine, even where it is associated with what is probably a good idea.

James P Bradley

In reply: Thank you for the opportunity to respond to Bradley’s letter. We agree that constructive engagement of clinicians is essential in adoption of the World Health Organization Surgical Safety Checklist (the Checklist) — that point is clearly made in our editorial.1 Bradley’s anecdotal comment about use of the Checklist causing distraction during the induction of anaesthesia is difficult to evaluate in the absence of more detail. Surely any competent anaesthetist committed to patient safety could liaise with other team members to find an acceptable time to fulfil the entirely reasonable expectation of ensuring that relevant safety checks have been done? Furthermore, the study of Haynes and colleagues2 provides considerable reassurance about the possibility of unintended harm from use of the Checklist. Justification for the Checklist does not depend on the above-mentioned study alone: the Checklist was developed by an extensive process of literature review and consultation. It reflects expert consensus, and its endorsement by the Australian and New Zealand College of Anaesthetists, the Royal Australasian College of Surgeons and many other organisations adds to this consensus. There is no suggestion that the Checklist will save any particular number of lives in any given country — rather, its use is likely to reduce the number of patients harmed during surgery, and this is surely worthwhile.

Alan F Merry · Bruce H Barraclough

To the Editor: The editorial by Runciman in the Journal was cogent and timely.1 The Garling report on acute care services in New South Wales public hospitals highlights areas where critical changes need to be made in order to improve patient safety.2 It is widely recognised that junior doctors play a vital role at the coalface in many key areas, including assessment and escalation of care for deteriorating patients and the handover of patient care, both in hospital between shifts and also from hospital to the community. In NSW, these processes are currently receiving much needed attention in order to ensure patient safety within hospital settings. As Runciman so rightly identifies, junior doctors also play a critical role in “transformational” cultural change. In public hospitals such as my own, it has been fascinating to observe the small ways in which a junior doctor can influence senior clinicians in fields such as compliance with hand hygiene protocols, and in querying transfusion requests which do not conform to National Health and Medical Research Council clinical guidelines. We need to continue to mentor junior doctors so their messages about change and improvement are well delivered and well received. With the move of junior doctor pre-vocational training into community settings (the Prevocational General Practice Placements Program) there are increasing opportunities for change on a larger scale. In the future, patients will not be the only agents who move from community to hospital settings and back again. Junior doctors will be employed across both settings and will be an important vector for change and improvement. We will also need to encourage supervision by senior doctors who engage with and understand the health system, not just the hospital system. Providing junior doctors with appropriate tools to drive change (eg, training in graded assertiveness and situational awareness), encouraging them to view their role in health system improvement at the whole-of-community level, and providing leadership across the system, give us every reason to believe that Runciman’s vision of transformational change is possible, and indeed likely.

Joanna R Sutherland

To the Editor: I read, with encouragement and hope, Runciman’s timely editorial concerning the pressing need for patient safety education to become an integral part of medical undergraduate curricula.1 I also support his plea for patient safety to now be treated as a full-blooded science. His description of medicine as “islands of excellence in a sea of mediocrity” is both apt and perhaps still somewhat generous. In many health care ranks (in common with the rest of the human race) there continues to be a reluctance at the personal level to admit the natural and ever-present human tendency to err.2 Consequently, opportunities continue to be lost to learn from analysis of these mistakes by reporting their mechanisms honestly in detail, either anonymously or openly in a trusting work environment. Sadly, the ongoing barriers of a blame culture (often accompanied by outcome bias), misplaced ego and lack of understanding of such fundamental issues as error cascades and latent errors work against these simple and powerful safety improvement steps. The preoccupation of sections of our medicolegal system with blaming and shaming usually innocent health care individuals for system failures is also a barrier to such reporting. While Runciman suggests a gradual awakening of appreciation of such system faults, lip service still abounds and basic human error concepts continue to be uncomprehended or overlooked, even by some of the more senior and influential members of our profession. This works against the education of junior doctors. As Runciman urges, the only way to deal with this now is to give the young, fertile medical undergraduate minds the opportunity to grasp these fundamental concepts at the beginning of their clinical lives. It is their patients who will benefit as well as their own peace of mind and, importantly, their own humility, throughout their years ahead. The repeated objection that undergraduate curricula are already overloaded is not acceptable. The science of patient safety is no longer an optional or minor subject for medicine. It should be woven intimately throughout the undergraduate curriculum.

John A H Williamson

To the Editor: The pace of improvement in the safety and quality of health care has been disappointing. However, the recent enthusiasm for medical education providing a new solution is troubling.1,2 The safety and quality movement has been regrettably dismissive of the need for creation of evidence.3 Indeed, it now seems that the focus on “dramatic” errors has been a distraction from the major volume of harm due to the poor care of patients with chronic disease.4 There is substantial literature on the development of professionalism, which attests to the difficulty of teaching medical students non-technical skills (or of selecting students with “appropriate” attitudes). There are three major reasons for this difficulty. The first is the problem of defining the desirable standard — whether of safety or professionalism.5,6 The second is the so called “hidden curriculum” — the ubiquity of error, unsafe practice and unprofessional behaviour that students are exposed to in clinical environments. Third, many of the safety and quality issues and skills just do not seem relevant to the students, despite the care that has been taken in the development of safety and quality curricula. To provide “experience that is arranged to be both motivating in the moment and consequential for capabilities in the long run”7 will require a new and more pragmatic approach to education. We need to select safety and quality issues that all doctors can influence by exercise of their personal knowledge and skills. This is the stuff of medical education. Errors in clinical reasoning8 form an excellent teaching topic, but many safety problems are simply too hard for medical students (neither do we expect medical students to learn the details of intensive care or casemix funding). Provision of appropriate experiential learning requires links to the people who understand and manage governance and safety in the clinical workplace. Rather than a stand-alone communication syllabus, the medical students in Queensland, for example, should receive the same teaching about clinical handover as the junior (and senior) medical staff of Queensland Health. Handover is then perceived as a highly relevant skill. If competencies in safety for medical stu-dents are to be required they must be linked to both fuller competencies for graduate training and the introduction of safer workplace practices. Without these parallel and more important activities, the proposed reform in medical education is likely to be disappointing in its impact.

Christine M Jorm

Objective: To evaluate the impact of psychiatric inpatient bed closures, accompanied by a training program aimed at enhancing team effectiveness and incorporating data-driven practices, in a mental health service.Design and setting: Retrospective comparison of the changes in services within three consecutive financial years: baseline period — before bed reduction (2006–07); observation period — after bed reduction (2007–08); and intervention period — second year after bed reduction (2008–09). The study was conducted at Cramond Clinic, Queen Elizabeth Hospital, Adelaide.Main outcome measures: Length of stay, 28-day readmission rates, discharges, bed occupancy rates, emergency department (ED) presentations, ED waiting time, seclusions, locality of treatment, and follow-up in the community within 7 days.Results: Reduced bed numbers were associated with reduced length of stay, fewer referrals from the community and subsequently shorter waiting times in the ED, without significant change in readmission rates. A higher proportion of patients was treated in the local catchment area, with improved community follow-up and a significant reduction in inpatient seclusions.Conclusion: Our findings should reassure clinicians concerned about psychiatric bed numbers that service redesign with planned bed reductions will not necessarily affect clinical care, provided data literacy and team training programs are in place to ensure smooth transition of patients across ED, inpatient and community services.

Tarun J Bastiampillai MB BS, BMedSc, FRANZCP · Niranjan P Bidargaddi BE(CompSc), PhD · Rohan S Dhillon MB BS, FRANZCP, MClinSc · Geoffrey D Schrader FRANZCP, PhD · Jörg E Strobel MD, FRANZCP · Philip J Galley RMN, DipCPC, BA(Hons)

Investment in information and communication technology (ICT) in the health sector can bring important benefits. To date, the focus has been on automating clinical work practices such as ordering tests and prescriptions, which significantly improves efficiency and safety. Uptake of ICT has been slow and the results less favourable than anticipated for various reasons, including poor integration of systems into complex clinical work processes, limited training, and the intermittent nature of ICT funding. As a result, many health care organisations have been operating hybrid paper and computer systems that introduce new patient risks, staff frustration, and outcomes below expectation. The focus must shift from automation of clinical work to innovation; from evolutionary application of ICT to revolutionary uses. Health professionals must embrace ICT as a “disruptive technology” that will produce significant changes in their roles and responsibilities and lead to real health reform with new, innovative models of health care delivery. As other industries have shown, substitution and role changes are areas in which ICT can lead to the greatest gains.

Johanna I Westbrook PhD, FACMI, FACHI · Jeffrey Braithwaite MBA, PhD, FCHSM

Objective assessment of the health of the population is the key to policy and planning Accurate, timely information about a population’s health, health risks and use of health services and medicines is essential for planning and evaluating health policies and care. Health surveys based on representative probability samples of the population are designed to provide this by collecting data on health behaviours, health determinants such as socioeconomic disadvantage and obesity, prevalence of diseases, need for health care and whether this has been provided, functional capacity, and nutritional status.1 Such surveys can be classified as health interview surveys or health measurement surveys. The former are based on interviews or self-administered questionnaires and rely on a participant’s subjective assessment, while the latter include the addition of anthropometric, physiological and clinical measurements and tests (such as lung volume spirometry) and/or the collection of blood and other biological samples.2 Thus, the health measurement survey generally provides more objective data than the health interview survey; for example, on the prevalence of various diseases and risk factors, where self-reported information is known to be quite inaccurate (sometimes due to the fact that the disease has not yet been diagnosed).1 The recent announcement of a national Australian population health survey program using objective measures3 is therefore a welcome initiative for the community, health practitioners and policymakers alike. National health measurement survey programs have been conducted regularly in other countries for many years. The longest such series is in the United States, where the first national survey was carried out in 1959 — now known as the National Health and Nutrition Examination Survey (NHANES), it celebrated its 50th anniversary in 2009.4-6 European examples include the Finnish surveys from the 1970s, German and Norwegian surveys from the 1980s, and English and Scottish surveys from the 1990s.1 These survey programs have provided their countries with rich and unique national data sources for monitoring important health issues and formulating public health policies. In the US, for example, federal agencies and other public health organisations use data from NHANES to assess nutritional status and its relationship to health promotion and disease prevention.4,5 Survey findings also serve as the basis for national standard physical measurements like height, weight and blood pressure. Health science researchers use information from the survey to develop public health policy, programs and services, and expand the health knowledge of the nation.4 As a result, numerous advances in public health and nutrition have directly benefited US citizens’ health from the use of survey data to: document blood lead levels before and after the removal of lead from gasoline, paint and other household agents; quantify second-hand smoke exposure and evaluate the impact of policies to reduce or eliminate this exposure; identify low levels of folate in the population and the subsequent increase in these levels after folic acid fortification of foods; document the increase in obesity and diabetes in the population, including undiagnosed diabetes; and underpin the 1977 and 2000 paediatric growth charts.6 In Australia, there has been investment in collecting health information and concomitant biomedical and other measures in the past, but those studies, conducted through the 1980s and up to the mid 1990s, are no longer current, leaving significant gaps in our knowledge of the health of the population.7 More recent health measurement survey proposals have not proceeded, or have failed to deliver reliable national disease and risk factor prevalence estimates because of problems with study design, sampling and response rates.7-9 Now, the Australian Bureau of Statistics (ABS) is including a health measurement survey as an ongoing element of its Australian Health Survey program.3 This is certainly good news for health researchers, community planners, health practitioners and policymakers, and for the Australian public as a whole. The new survey program offers opportunities to provide an improved information base for national health policy development, health program planning and health research in ways that have not previously been possible. The Australian Health Survey program will have four components: National Health Survey, an existing household interview survey; National Aboriginal and Torres Strait Islander Health Survey, an existing household interview survey; National Nutrition and Physical Activity Survey, a new household interview survey; and National Health Measures Survey, a new health measurement survey.10 Planning is being undertaken by the Australian Government Department of Health and Ageing, in partnership with the ABS and the National Heart Foundation of Australia. Beginning in 2011, a representative sample of 50 000 Australians will be asked to complete the Australian Health Survey, representing “the most comprehensive health survey ever undertaken by the ABS”.3 Participants will also be asked to provide voluntary blood and urine samples to allow testing for nutritional status and early indicators of disease, such as high blood cholesterol or glucose levels.10 The investment in this national health survey program, with its inclusion of objective measures, will provide a firm foundation for health policy development in the 21st century, with undeniable benefits for individuals and the Australian community as a whole.

Diana M S Hetzel MB BS · John D Glover BEc, BA

Objective: To determine the cost-effectiveness of routine administration, irrespective of blood pressure (BP), of a fixed-dose combination of perindopril and indapamide to patients with type 2 diabetes mellitus.Design, setting and participants: Prospective cost-effectiveness analysis within the Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation (ADVANCE) trial, an international, multicentre, randomised controlled trial of 11 140 participants with type 2 diabetes randomly allocated to receive perindopril plus indapamide (4 mg–1.25 mg/day) or placebo.Main outcome measures: Health-related quality-of-life measured by the EuroQol-5D, resource utilisation, and cost-effectiveness (cost per death averted at 4.3 years’ average follow-up, and estimated cost per life-year gained, by extrapolation).Results: The mean health-related quality-of-life score of survivors was 0.80 (on a 0–1 scale [death to full health]), with no difference between treatment groups. Active treatment reduced hospital admissions for coronary heart disease and coronary revascularisation by 5%. For the Australian participants, perindopril–indapamide cost A$1368 per patient during the trial period, but reduced total hospitalisation costs by A$410 and other medication costs (mainly other BP-lowering drugs) by A$332. The absolute reduction in all-cause mortality for the active treatment group was 1.1%, giving a cost per life saved of A$49 200. Lifetime extrapolation gave an estimated cost per life-year saved of A$10 040 (discounted at 5% per year).Conclusion: The combination of perindopril and indapamide in patients with type 2 diabetes appears to be cost-effective.Trial registration: United States National Library of Medicine NCT00145925.

Paul P Glasziou MB BS, PhD · Philip M Clarke MEc, PhD · Jan Alexander · Mohana Rajmokan MSc · Elaine Beller BSc, MAppStat · Mark Woodward PhD · John Chalmers MD, PhD, FRACP · Neil Poulter MSc, FRCP · Anushka A Patel FRACP, PhD

Objective: To describe the diagnostic pathways experienced by a large, representative group of Australian women with ovarian cancer, and to document the time between first presentation to a medical professional and clinical diagnosis.Design, setting and participants: 1463 women with epithelial ovarian cancer from an Australia-wide population-based study (2002–2005) completed a telephone interview in which they described the events that led to the diagnosis of their cancer.Main outcome measures: Number and type of doctors consulted, investigations performed, referral patterns and the time from first presentation to diagnosis.Results: Of the 1463 women, 145 had their cancer diagnosed incidentally and were excluded from analysis. Most of the remaining 1318 women (1222, 93%) presented first to their general practitioner. As a result of their first medical consultation, 75 women (6%) were given a diagnosis, and 484 (37%) were referred to a gynaecologist, gynaecological oncologist or oncologist for further assessment. Overall, 85% of women visited three or fewer doctors before their cancer was diagnosed; 66% of cancers were diagnosed within 1 month of the initial presentation, and 80% were diagnosed within 3 months. For 12% of women, the diagnostic process took longer than 6 months; this was more likely for women residing in remote Australia, those with lower incomes, and those presenting with abdominal pain or bowel symptoms, or with more than one symptom.Conclusions: Despite anecdotal suggestions to the contrary, most women with ovarian cancer in Australia are investigated and diagnosed promptly. The diagnostic process is more protracted for a minority of women, and the factors we found to be associated with diagnostic delay warrant further investigation.

Susan J Jordan MB BS, FRACGP, PhD · Jane E Francis MA, MPH · Anne E Nelson PhD · Helen M Zorbas MB BS, FASBP · Karen A Luxford BSc(Hons), PhD · Penelope M Webb MA, DPhil

Objective: To assess the attitudes of health care professionals engaged in open disclosure (OD) to the legal risks and protections that surround this activity.Design and participants: National cross-sectional survey of 51 experienced OD practitioners conducted in mid 2009.Main outcome measures: Perceived barriers to OD; awareness of and attitudes towards medicolegal protections; recommendations for reform.Results: The vast majority of participants rated fears about the medicolegal risks (45/51) and inadequate education and training in OD skills (43/51) as major or moderate barriers to OD. A majority (30/51) of participants viewed qualified privilege laws as having limited or no effect on health professionals’ willingness to conduct OD, whereas opinion was divided about the effect of apology laws (state laws protecting expressions of regret from subsequent use in legal proceedings). In four states and territories (Western Australia, South Australia, Tasmania and the Northern Territory), a majority of participants were unaware that their own jurisdiction had apology laws that applied to OD. The most frequent recommendations for legal reform to improve OD were strengthening existing protections (23), improving education and awareness of applicable laws (11), fundamental reform of the medical negligence system (8), and better alignment of the activities of certain legal actors (eg, coroners) with OD practice (6).Conclusions: Concerns about both the medicolegal implications of OD and the skills needed to conduct it effectively are prevalent among health professionals at the leading edge of the OD movement in Australia. The ability of current laws to protect against use of this information in legal proceedings is perceived as inadequate.

David M Studdert LLB, ScD, MPH · Donella Piper LLB, PhD, LLM · Rick Iedema PhD

Enhancing patient care. A practical guide to improving quality and safety in hospitals. Alan Wolff, Sally Taylor. Sydney: MJA Books, 2009 (234 pp). ISBN 9780977578665. Wimmera Hospital, in Horsham, western Victoria, has a well deserved reputation for promoting quality and safety. Here, Alan Wolff, Wimmera’s medical director, and Sally Taylor, its clinical risk manager, outline the steps they followed in developing a rigorous quality management process at the hospital. This is indeed, as claimed, a practical guide and is recommended for all those interested in clinical governance. The Wimmera model appropriately distinguishes between safety and quality, and outlines steps to promote quality and assure safety. In terms of how the book might have been strengthened, I think a chapter outlining what a board safety and quality committee might do would have been useful. Further, the book has its provenance in a regional hospital and there is a question in my mind about whether all the elements of the Wimmera model are scalable. The book also de-emphasises the role of routine data for tracking safety in hospitals. Although hospitals can track their own trends over time using routine data, this sort of monitoring is much more powerful when it involves comparison with other like facilities. The model’s approach to management of adverse events focuses too much on the visible, the “event”, and tends to de-emphasise the myriad small things (eg, the incidence of pneumonia) which might together contribute to a poorer experience of hospitalisation. The book could also have been strengthened by incorporating guidance on how to structure investigations, when they are called for. The Queensland approach “pyramid model” of looking at data, casemix, resources, processes of care and professional issues is a valuable one.1 The book rightly identifies the health professional involved in an adverse event as the “second victim”. The medical director might also be seen as the “third victim”. The role of the medical director is a hard one, especially in a small hospital. It means holding to account local colleagues, often people with whom one has worked for many years. It is an isolated role and one deserving of more support. The authors are to be commended for making this hard journey an easier one.

Stephen J Duckett

We need those not directly in the firing line to appreciate the evidence on overcrowding Resolving access block and emergency department (ED) overcrowding is finally front and centre of the political agenda. Governments have heeded calls for action and responded by announcing a national access target to improve timely treatment in Australian EDs. After the target is implemented, “anyone presenting to a public hospital emergency department will be admitted, referred for treatment or discharged within four hours of presentation, where it is clinically appropriate to do so”.1 In the United Kingdom, a similar 4-hour target has been in place since 2004, and, despite a recent policy announcement concerning its abolition from April 2011, timeliness of care and avoidance of delay once a patient is ready to move to a ward “will always remain an important element of any balanced approach to quality”.2 Reducing the number of hospital beds and increasing occupancy above 85% in the name of operational efficiency have clearly had a negative effect, as the demand for hospital beds in Australia exceeds supply.3 The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.3 In this issue of the Journal, several articles discuss hospital occupancy. Keegan articulates the evidence for using hospital bed occupancy as an operational quality measure and target.4 As hospital bed occupancy rises above 85%, adverse effects include increased rates of hospital-acquired infections, staff health deterioration and escalating hospital inefficiency. Keegan advocates a shift to using patient outcome measures, rather than current process measures to judge health system function. This evidence presents a counterpoint to a discussion started by Bain and colleagues earlier in the year, which suggested that the 85% target occupancy figure is “a candidate for myth status” and is “both simplistic and likely to lead to flawed policy”.5 Jones points out that occupancy and hospital size are linked, and therefore broadens the debate to include hospital size.6 He explains clearly what we all know intuitively: hospital planners have been delivering hospitals that are too small. When planning new hospitals, future bed requirements would be more realistically estimated by using readily available figures for occupied bed-days and examining trends over time, compared with just using admission numbers and length of stay. This would take into account factors influencing volatility of demand for beds. Trends in occupied bed-days show that English hospitals needed as many beds in 2007 as in 1998, despite a large reduction in available beds. The situation is the same in Australia and Canada, yet there is a pervading belief among planners that increasing efficiencies will account for any shortfalls. Jones discusses factors apart from demography that affect demand, including clinical practice changes, environmental cycles, and the increasing need for end-of-life care. He concludes, “can we please have a true evidence-based debate . . .?”, as patients and clinical staff deserve to benefit from the tools required to deliver effective and efficient health care. It is very pleasing to see the debate continue; the rapid growth in the published literature on access block and ED overcrowding since 2007 demonstrates increased focus on this issue.3 But further than this, we need those not directly in the firing line to appreciate the evidence on access block and ED and hospital overcrowding, so that we see the end of policy setting without attention to relevant system capacity issues. For instance, the Australian Commission on Safety and Quality in Health Care has identified reduction of hospital-acquired infection as a priority;7 however, interventions are focused only at the individual staff and patient level, without mention of the system issue of overcrowding. Similarly, while EDs are the most commonly complained about sites of care in New South Wales, and a third of these complaints relate to access to care,8 the NSW public health system’s incident management system does not include access block and ED overcrowding as reportable incidents. Failure to acknowledge the causes and consequences of high hospital bed occupancy is seen in well publicised health system responses to incidents that have occurred in overcrowded EDs. The solutions proposed in response to these incidents so far have not included fixing the underlying reason for the patient being stuck in the waiting room — lack of hospital capacity.9,10 Transparent performance reporting and new national standards are part of planned health reforms in Australia, but there are problems with the accuracy of current performance data,11 and, as Keegan points out, development of meaningful outcome measures of patient care is required.4 In the meantime, the verdict is in on access block, high bed occupancy and ED overcrowding — they are bad for patients, staff and the system itself. It is time hospital capacity was also on the patient-safety policy agenda.

Sally M McCarthy MB BS, MBA, FACEM

The importance to patient safety of clinician-led mortality auditing needs system-wide recognition In April 2010, the Council of Australian Governments (COAG) agreed on health and hospitals reform, with the establishment of the National Health and Hospitals Network. The aims of the network include “helping patients receive more seamless care across sectors of the health system” and “improving the quality of care” with “high-performance standards”.1 As a key component of the reforms and a funding condition, health facilities will be required to regularly report performance data to the federal government. Data will be based on national performance indicators that are already agreed to by COAG and address “access to services, quality of service delivery, financial responsibility, patient outcomes and/or patient experience”.2 Disappointingly, the COAG reforms appear to neglect clinical patient outcome data that are reported for the purpose of monitoring and improving patient safety, not least of which are mortality data. In Australia, pooled data on anaesthesia-related and surgery-related perioperative mortality are routinely analysed by the Australian and New Zealand College of Anaesthetists Mortality Working Group and the Royal Australasian College of Surgeons’ Australia and New Zealand Audit of Surgical Mortality, respectively.3 The practice of anaesthesia is highly regarded for its patient-safety record, and mortality reporting is considered an important tool in monitoring safety by informing standards of care with respect to equipment, techniques and classification of patients’ fitness.4 This year will see the first national public reports on surgical mortality in Australia, with early reports from Western Australia supporting the argument that clinician participation and leadership in mortality audits produce changes and improvements in patient care. Data from WA show that the proportion of deaths associated with deficiencies of care has fallen, and 73% of participating surgeons have changed their practice in at least one way.5 Clinician-led mortality reporting can contribute meaningfully to health reform but, sadly, there are few other instances of peer review of treatment-associated mortality and centralised public reporting in Australian health systems. Closer examination reveals that even the national anaesthesia dataset is incomplete because several states do not participate in mortality audits.3 Cooper and Gaba, in an appraisal of international anaesthesia-related mortality reporting, explain the limitations of, and possible reluctance to participate in, mortality reporting, which they claim is “plagued by confounding variation in definitions, relatively small sample sizes from selected institutions, and the lack of large population studies”.4 The Special Committee Investigating Deaths Under Anaesthesia (SCIDUA) in New South Wales — the longest-serving committee of its sort in Australia — is an excellent model of clinician-led mortality reporting.6 Appointed by the NSW Minister for Health and administered by the Clinical Excellence Commission (CEC), SCIDUA reviews all deaths occurring within 24 hours of anaesthesia or sedation. Data analyses by SCIDUA, which this year is celebrating its 50th anniversary, have substantially contributed to mortality reporting internationally.3,7,8 The Australia and New Zealand Audit of Surgical Mortality developed from the SCIDUA model via the NSW Special Committee Investigating Deaths Associated With Surgery (established in 1993, the latter is now the Collaborating Hospitals Audit of Surgical Mortality, and it too is administered by the CEC). SCIDUA’s terms of reference provide solutions to several of the limitations described by Cooper and Gaba4 and are useful starting points for other groups establishing mortality registers.6 Important starting points include a clearly defined preoperative period and phrasing of degrees of contribution to death. SCIDUA’s registry includes both expected and unexpected deaths, enabling identification of unanticipated emerging threats to safety, such as those associated with new drugs and procedures. Patients are classified according to their risk of death from comorbidities. This classification allows data about expected and unexpected deaths to be analysed separately, an essential requirement for trend analysis when concomitant increases in patient and surgical complexity could confound mortality rates. All sources of data obtained by SCIDUA are protected by qualified privilege under section 23 of the Health Administration Act 1982 (NSW). Of historical interest, SCIDUA was responsible for this section of the Act, which ensures qualified privilege to peer-review committees across all clinical disciplines within NSW. Recent changes to the NSW Public Health Act 1991 and Public Health (General) Regulation 2002 have led to a modified procedure for reporting deaths occurring within 24 hours of anaesthesia or sedation (now classified as a Category 1 scheduled medical condition). However, the new procedure retains not only mandatory notification of perioperative death but protection by privilege of anaesthetists who voluntarily submit information and analyses. These provisions encourage frank and comprehensive reporting, evidenced by the breadth of information available for analysis.3 Lessons in maintaining patient safety generated through SCIDUA are communicated widely. SCIDUA sends a confidential report outlining its conclusions about the circumstances contributing to death to the notifying anaesthetist. Pooled de-identified data are incorporated into the Australian and New Zealand College of Anaesthetists’ national triennial mortality report.3 The health care community is alerted to perceived safety risks through an annual report provided to the NSW Minister for Health and through periodic reports published in national and international journals.9,10 All deaths in all health facilities should be subject to clinical scrutiny. De-identified and pooled data should be systematically analysed for the purpose of continually monitoring patient safety as therapies change. The models provided by SCIDUA and, more recently, the Australia and New Zealand Audit of Surgical Mortality are there to be applied by all health care providers. Food for thought!

Leonie M Watterson MB BS, FANZCA, MClinED · Ross B Holland MB BS, FANZCA, FHKCA · Jan M Davies MSc, MD, FRCPC · Clifford F Hughes AO, MB BS, FRACS

Objective: To investigate the potential contribution of international medical students at Australian universities to the Australian medical workforce.Design, setting and participants: A prospective survey in 2006–2007 of 619 international medical students in their final 2 years of undergraduate- and graduate-entry medical courses across eight Australian universities, followed by a 2009 survey of 88 international medical graduates of the University of Melbourne (most of whom were respondents of the earlier survey), assessing the correlation between students’ intended place of internship and their actual place of internship.Main outcome measures: The survey respondents’ preferred internship location; the proportion of respondents who intended to remain in practice in Australia long term; and correlation between respondents’ intended internship locations and actual placements in their first postgraduate year.Results: Of the 619 international medical students surveyed in 2006, 358 (58%) responded. Most planned to undertake Australian internships and seek permanent-resident status, although a third were undecided about their long-term plans. Nationality was a highly significant variable. Most preferred city rather than regional or rural training locations and expressed interest in migrating to Australia. The 2009 survey of the University of Melbourne’s 2008 medical graduates showed a high correlation between students’ plans in their last two years of study and outcomes in their first postgraduate year, with 73% accepting Victorian internships for 2009.Conclusion: International medical students studying at Australian universities represent a substantial and highly acceptable medical workforce resource for Australia. Their requirement for internships needs to be considered in, and should influence, infrastructure planning.

Lesleyanne Hawthorne PhD, MA, BA(Hons) · Jan Hamilton MA, BA, GradDip Multicultural Education

Health professionals worry that information about adverse events conveyed to patients in open disclosure (OD) may be used against them in medicolegal proceedings. Whether and how strongly state and federal laws in Australia protect against such uses is unclear. Our analysis concludes that existing laws do not prohibit the sharing of most types of information on adverse events with patients. However, none of these laws was enacted with OD in mind and, in general, the protections they provide are quite weak. If policymakers want OD to become a routine part of medical practice, law reform may be needed in the form of stronger protections directed specifically at the contents of OD communications.

David M Studdert LLB, ScD, MPH · Mark W Richardson LLB, MSc

Objective: To assess the outcomes of appendicectomy in an acute care surgery (ACS) model compared with a traditional on-call (Trad) model.Design: Retrospective historical control study comparing appendicectomy outcomes in the Trad period (April 2004 to March 2005) with outcomes in the ACS period (April 2006 to March 2007).Setting: The Prince of Wales Public Hospital, a metropolitan tertiary referral centre in Sydney.Patients: All adult patients undergoing appendicectomy during 1-year periods before and after the introduction of the ACS model.Intervention: The introduction of an ACS model for managing all emergency general surgical presentations.Main outcome measure: Complication rate.Results: A total of 402 appendicectomies were performed, 176 during the Trad period and 226 during the ACS period. There was no perioperative mortality. The complication rate was lower in the ACS period than the Trad period (9.3% v 17.0%; P = 0.02). After the intervention, there was no significant change in the time from presentation to arrival in theatre or in length of stay, but the proportion of operations performed at night (24:00–08:00) was reduced from 26.1% to 15.0% (P = 0.006). The proportion of negative appendicectomies was reduced from 22.7% to 17.3%, but the change was not statistically significant (P = 0.08). There was no difference in perforation rate before and after the intervention (13.6% v 13.3%; P = 0.86).Conclusion: The ACS model provides a safe surgical environment for patients and is associated with a reduced complication rate. Under the ACS model, there was an increase in the number of patients treated conservatively overnight, but this did not lead to an overall increase in perforation rate or length of stay.

Robert C Gandy MB ChB, MRCS · Phillip G Truskett MB BS, FRACS · Shing W Wong MB BS, MS, FRACS · Sanchia Smith MB BS · Michael H Bennett MB BS, MD, FANZCA · Andrew D Parasyn MB BS, FRACS

Timely access to safe hospital care remains a major concern. Target bed-occupancy rates have been proposed as a measure of the ability of a hospital to function safely and effectively. High bed-occupancy rates have been shown to be associated with greater risks of hospital-associated infection and access block and to have a negative impact on staff health. Clinical observational data have suggested that bed occupancies above 85% could adversely affect safe, effective hospital function. Using this figure, at least initially, would be of value in the planning and operational management of public hospital beds in Australia. There is an urgent need to develop meaningful outcome measures of patient care that could replace the process measures currently in use.

Andrew D Keegan MB BS, FRACP, PhD

Current methods used to calculate the required size of hospitals are underestimating the true capacity needed for operational efficiency. Trends in occupied bed-days (rather than admissions and length of stay) give better estimates of future bed requirements. Hospital occupancy rates depend on volatility in demand, not efficiency. Larger bed pools and hospitals can operate at higher average occupancy. Cost efficiency should be focusing on staffing based on the patients in the beds and not on the available beds. Hospitals require supporting climatalogical forecasts to allow for seasonal and other climate-related changes in admissions, if flexible staff deployment is to become a reality.

Rodney P Jones BSc(Hons), PhD, ACMA

There is considerable public, political and professional debate about the need for additional hospital beds in Australia. However, there is no clarity in regard to the definition, meaning and significance of hospital bed counts. Relative to population, there has been a total decline in bed availability in Australia over the past 15 years of 14.6% (22.9% for public hospital beds). This decline is partly offset by reductions in length of stay and changes to models of care; however, the net effect is increased bed occupancy which has in turn resulted in system-wide congestion. Future bed capability needs to be better planned to meet growing demands while at the same time continuing trends for more efficient use. Future planning should be based in part on weighted bed capability matched to need.

Andrew Wilson MB BS(Hons), PhD · Gerard J FitzGerald MD, FACEM, FRACMA · Susan Mahon BN, MBA, AFCHSE

In reply: I thank Mountain and colleagues from the Australasian College for Emergency Medicine for their letter.1 Despite their interpretation of our article,2 I think we share many points of agreement. Having worked extensively as a clinician, I agree that patient harm is occurring because of insufficient capacity to treat, and that patients will benefit from more capacity to treat. I also agree that this is an important issue and that approaches to dealing with it should not be subverted. Most importantly, I would also agree that the number of available hospital beds is critical — the unanswered questions are about how many beds, and where they should be provided. I also thank the authors for their acknowledgement that “clinical modelling” is a fundamental driver for their position. Our industry would do well to take its direction in the use of queuing theory from internationally recognised experts in the area, rather than from within the ranks of my fellow doctors. In response to Mountain et al’s call for an 85% bed-occupancy limit as a solution, my call is for more detail about the practicalities of how we would implement this limit, which could start with the provision of clear answers to the following questions: How would compliance with the 85% occupancy limit be monitored? What are the practical measures that bed managers, nurse unit managers, executives and others could use to ensure that compliance occurs? If patient throughput in acute inpatient areas increased, what downstream effects could we expect? How would the application of resources in fixing “access block” compare with the application of the same resources in fixing “exit block”? (And an obvious sub-question: what is the relationship between the two phenomena?) Has a consensus been reached with all specialist groups as to which clinical units in hospitals should have access to extra beds when they become available? Or is it intended that an 85% limit would be applied across the board, irrespective of the differences between patient care needs, lengths of stay, rates of arrival and staffing mixes in different wards? How and when would the effectiveness of such an initiative be assessed? Perhaps another occupancy figure would appear even more efficacious through the lessons learned. I believe these are reasonable questions that ought to be answered by anyone calling for this change. I repeat my group’s call for more, and more informed, investment in health system capacity given this huge problem and the solution being proffered.

Christopher A Bain

WWyeth Australia has been a valued partner with the Medical Journal of Australia since 1995 in recognising and rewarding the best of original research published each year in the Journal. The 2009 MJA/Wyeth Award was presented at the Australian Medical Association (AMA) National Conference in Sydney on 28 May 2010. The Journal’s Content Review Committee has awarded the prize for 2009 to Tanya Bubner and her colleagues from the University of Adelaide and Flinders University for their research paper, “Effectiveness of point-of-care testing for therapeutic control of chronic conditions: results from the PoCT in General Practice Trial”, published in the 1 June 2009 issue of the Journal. Point-of-care testing (PoCT) provides the treating general practitioner with immediate test results and has the potential to improve monitoring of chronic conditions, therapeutic control and clinical efficiency, and to enhance clinical decision making within the time frame of the consultation. PoCT not only provides an alternative method of pathology testing, but also allows a different style of patient management compared with traditional pathology laboratory testing. Demand for PoCT in general practice is increasing; however, there is little evidence about its benefits, particularly these related to clinical outcomes. Bubner and colleagues assessed the safety, clinical effectiveness and cost-effectiveness of and satisfaction with PoCT in general practice. In a large, multicentre, cluster randomised controlled trial, they found that PoCT was equivalent to pathology laboratory testing for a variety of pathology tests in chronic diseases. The researchers found that for the proportion of patients with results in the target range, PoCT was equivalent to pathology laboratory testing for measuring glycated haemoglobin, urine albumin, albumin–creatinine ratio, total cholesterol and triglyceride levels, but not for high-density lipoprotein cholesterol level and international normalised ratio. The research by Bubner and colleagues provides important evidence for the introduction of PoCT into general practice. The award was presented by Ms Yvonne Bowyer, Deputy Managing Director, Wyeth Australia; I thank her on behalf of the AMA and the Australasian Medical Publishing Company, the publisher of the MJA, for Wyeth’s continuing commitment to promoting excellence in Australian clinical research through the prestigious MJA/Wyeth Award. Martin Van Der Weyden, Jane Harrison, Ruth Armstrong, Justin Beilby, Yvonne Bowyer, Tanya Bubner, Andrew Pesce

When consummate Aboriginal and Torres Strait Islander storyteller Jane Harrison took the stand to receive the 2010 Dr Ross Ingram Memorial Essay Prize in late May, it was an opportunity to reflect on the growing involvement of Aboriginal and Torres Strait Islander people with the MJA — as authors, contributors and reviewers — since the competition’s inception 5 years ago. Jane’s winning essay, Healing our communities, healing ourselves, in which she explores the particular challenges faced by Aboriginal and Torres Strait Islander people who work to improve Indigenous health while facing difficulties in their own lives, was published in the 17 May 2010 issue of the Journal. Jane is a descendant of the Muruwari people of New South Wales, from the area around Bourke and Brewarrina. Currently the Aboriginal Child Rearing Stories Project Officer at the Secretariat of National Aboriginal and Islander Child Care, she spent 6 years researching and writing the award-winning play, Stolen, which has brought the stories of Australia’s stolen generations to thousands of people in Australia and overseas since its release in 1998. Her other work includes the play, Rainbow’s end, and an episode of the popular SBS series, The circuit. In receiving her prize, Jane challenged those present to take their interest in Indigenous health and welfare beyond abstract gestures and endeavours to the personal level, by having real conversations and forging real relationships with Aboriginal people. Entries for next year’s Dr Ross Ingram Memorial Essay Competition are currently open. For full details see http://www.mja.com.au/public/information/RossIngramCompetition.html. Martin Van Der Weyden, Jane Harrison, Ruth Armstrong, Justin Beilby, Yvonne Bowyer, Tanya Bubner, Andrew Pesce

Increasing numbers of patients are presenting for unscheduled medical admission to hospitals worldwide, prompting clinical redesign of “front-door” emergency medical services. In the United Kingdom, there has been considerable investment in the establishment of acute medical units (AMUs) and the training of acute medicine physicians. Some centres in Australia have established similar medical assessment units. While these initiatives have undoubtedly met with some success, the evidence base for their overall benefit remains elusive. We describe key aspects of the recent establishment of acute medical services in Britain and discuss the relevance of these experiences to Australia. Successful models of care in acute medicine have often been shared with other centres. The adaptation of existing models of care to meet local demands is superior to simply adopting an existing model. Once the desired clinical functionality of a service is determined, informed decisions can be made on staffing requirements, skill mix, and the structure of any new clinical unit. The functionality of the acute medical service, rather than simply the physicality of an AMU, should drive service design.

Paul F Jenkins MA, MB, FRCP · Lorna L Barton MB BS, MRCP · Gregor B S McNeill MB ChB, MRCP

Academic teaching hospitals and their networks can best serve patients and other stakeholders by achieving critical mass and scope of clinical services, teaching and research. Successful hospital reconfigurations are associated with a convincing case and majority clinician buy-in. The inscrutable political decision to relocate services away from a major teaching hospital campus and into a merged Queensland Children’s Hospital was determined without broad stakeholder consultation or a transparent and accountable business case. This compromised process poses a significant and enduring risk to patient care and Queensland’s paediatric, perinatal, adolescent and obstetric academic teaching hospital services. As the proposed major stakeholder in Australia’s public hospitals and medical workforce training, the federal government should review this decision using an effective methodology incorporating relevant criteria. National guidelines are needed to ensure best practice in the future planning and auditing of major health care projects. The medical profession is responsible for ensuring that health care policy complies with reliable evidence and good practice.

Christopher K Davis MB ChB, MBA, FRACP · Harry Smith MB BS, MD, FRCPA