A nationwide audit was conducted in all DHBs over the period of 1 July to 31 October 2013 of hand hygiene in regards to compliance with the WHO recommended five moments of hygiene. The internationally recognised and recommended ‘5 Moments of Hand Hygiene’ consist of:
- Before patient contact
- Before procedure
- After procedure of body fluid exposure risk
- After patient contact
- After contact with patient surroundings.
It was found that Southern DHB (SDHB) was below the national standard of 70% with these five moments of hand hygiene. Previous studies have shown that non-compliance with hand hygiene is multi-factorial and a multi-dimensional approach is required to increase compliance. The aim of our study was firstly to determine the common reasons for non-compliance and secondly to investigate how these commonalities could be addressed by infection control.
We conducted both qualitative and quantitative research.
- Part 1 (qualitative research): 10 in-depth interviews with key medical staff were undertaken. Each was recorded and transcribed for analysis of key themes and new ideas.
- Part 2 (quantitative research): A survey was sent to all registrars, house surgeons and trainee interns in Dunedin Public Hospital or Invercargill Hospital. The survey included questions around barriers to hand hygiene and suggestions for improvement.
Our quantitative research yielded no statistically significant results due to a poor response rate. Our qualitative results suggested that cognitive barriers were more significant than physical barriers to hand hygiene and having a leader or role model for hand hygiene was a common suggestion for improvement.
We suggest that a multidimensional approach is required for increasing hand hygiene compliance in the SDHB. From our research we generated 5 factors that we consider key for improving compliance; making hygiene the ‘easy option’, promoting good skin care, making study data more available, engaging senior staff to act as role models and creating a position of hand hygiene champion
Authors of report
Charlotte Smart, Chetan Patel, David Becker, Huw John, Lisa Wain, Stephanie Yung, Yoshitetsu Harimoto
Are we prescribing a syndrome? A study of General Practitioner beliefs, knowledge and practice regarding anticonvulsant use in women of childbearing age
The teratogenic potential of sodium valproate was first reported in the 1980s. Foetal exposure to sodium valproate is associated with an increased risk of congenital malformations and adverse neurodevelopmental outcomes. The aim of this study is to develop and distribute a questionnaire to general practitioners in order to find out their current beliefs, attitudes and practice regarding the use of sodium valproate in women of childbearing age and to see if these are aligned with the available guidelines.
We developed a questionnaire, which was guided by an extensive literature review and consultations with a number of specialists. The questionnaire was distributed to 152 GPs enrolled in the Southern Primary Health Organisation (PHO). Results from the survey underwent descriptive analysis.
Due to the low response rate (11.8%), we were unable to obtain statistically significant results. From the available results, we identified a low rate of prescription of sodium valproate in women of childbearing age, largely ≤ 10%. We also identified that GPs are aware of sodium valproate’s poor safety profile for the foetus. However, they expressed a high level of uncertainty regarding the appropriate alternatives to sodium valproate and their safety profiles. GPs indicated a need for specialist input in this area of management.
It needs to be considered whether GPs are the most appropriate practitioners to be targeted in order to improve this area of patient management.
Authors of report
Mohsin Chaudhry, Tina Chiang, Rosemary Claridge, Lakeishia Judd, Michael Knight, Flora Kwon, Shi Cheng Lim, Henry Naylor, Lucy Peterson, Anna Ruygrok.
The study was designed and undertaken at the request of the Pacific Trust Otago (PTO). The aim was to provide the trust with information about the Dunedin Pacific communities’ knowledge and uptake of the trusts health promotion services as well as any perceived barriers and improvements the community felt were important.
PTO is a community based trust contracted by the New Zealand Ministry of Health to provide health promotion services to the Pacific community of Dunedin. PTO works with the Pacific community providing access to physical exercise programmes and education about healthy eating as well as a range of other services targeted at youth and children. These services include sports tournaments, exercise classes, community workshops, cooking classes and nutritional information, pacific youth lifestyle camps, well child nurse and family garden competitions.
Pacific people make up one of the major ethnic groups of New Zealand totalling 7.4% of the population. Of the total Pacific people living in New Zealand, 0.95% currently reside within Otago. This equates to 2,826 people. As a whole New Zealand’s pacific population is growing and this pattern is reflected in the Otago region.
The pacific population is the youngest of all the major ethnic groups in New Zealand with 46.1% of the population younger than 20 years old (compared to 27.4% in the total New Zealand population) and a median population age of 22.1 years. The term Pacific people describes a diverse group of people who originate from a number of different nations including Samoa (48.7%), Cook Islands (20.9%), Tonga (20.4%), Niue (8.1%), Fiji (4.9%), Tokelau (2.4%) and others. Individuals may identify themselves with more than one Pacific ethnicity(2).
Two New Zealand Ministry of Heath surveys identify a number of health inequities for Pacific peoples after adjusting for differences in age and sex. The New Zealand Health Survey (NZHS) is completed annually and collects health data including health related behaviours, status, and access to health care. It looks at adults (≥15 years) and children (2-14 years) from all ethnicities and socioeconomic areas across New Zealand. The New Zealand Adult Nutrition Survey (NZANS) focuses solely on nutrition in adults (≥15 years) and was last completed in 2008/2009. It looks at important nutrition factors such as food and nutrient intake, factors affecting dietary intake, nutrition status and nutrition related health status.
Obesity is a problem affecting many New Zealanders and has been identified as an issue of concern for Pacific people. The NZHS found that 27% of Pacific children and 68% of Pacific adults were obese. This is significantly higher than any other ethnic group. Achieving and maintaining a healthy body mass is the product of balancing energy input (eating) and energy output (exercise). The NZHS and the NZANS have found that Pacific New Zealanders were less likely to be meeting the Ministry of Health Guidelines for healthy eating. Of particular concern was the consumption of high sugar carbonated drinks and high fat fast foods. In addition to the energy input problems the NZHS found that Pacific adults were 0.9 times less likely to undertake physical activity for ≥ 30 minutes ≥ 5 times per week compared to non-Pacific adults. The good news is that Pacific children were 1.19 times more likely to be physically active when getting to and from school when compared to non-Pacific children.
In 1996 the World Food Summit defined food security as “All people, at all times, having physical, social and economic access to sufficient safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life”. The idea behind food security is based upon three key concepts. Having the means to obtain food considered to be appropriate for a nutritious diet, having quantities of food available on a consistent basis that would be considered sufficient and basic knowledge of food nutrition and care in addition to adequate sanitation and water. The NZANS found that well over half of Pacific adults surveyed had moderate to low food security.
A potential consequence of obesity is type two diabetes mellitus. Currently one in eight Pacific adults has been diagnosed with diabetes making their risk of developing the condition 3.6 times greater than non-Pacific adults. With obesity and diabetes comes increased cardiovascular risk. Cholesterol and blood pressure are both important measures of cardiovascular risk. The New Zealand Heart Foundation have set a total cholesterol upper limit of 4 mmol/L. The current mean total cholesterol for Pacific males (4.97 mmol/L) and females (4.68 mmol/L) is above this recommendation. However, their HDL cholesterol sits above the recommended amount of 1 mmol/L. Pacific females have been found to have lower total cholesterol and HDL cholesterol compared to non-Pacific females. However, they have significantly higher total cholesterol to HDL cholesterol ratios. In addition to this Pacific adults are 1.2 times more likely to require medication to help control their cholesterol compared to non-Pacific adults.
The American Heart Association defines normal systolic blood pressure as <120 mmHg, pre-hypertension as 120-139 mmHg and hypertension as ≥140 mmHg. Based on this information and mean systolic blood pressures calculated for Pacific adults from the NZANS we find that the mean systolic blood pressure for Pacific females (117 mmHg) is normal but for males (127 mmHg) is pre-hypertensive. It has been found that Pacific adults are 1.3 times more likely to require medication to treat hypertension compared to non-Pacific adults.
A major barrier to accessing health care for New Zealand Pacific people is the monetary cost. Just over one in five Pacific adults felt they needed an appointment with their General Practitioner (GP) but were unable to attend due to cost (vs 14.5% of total population). The same issue arises with access to after-hours care with 10.3% compared to 7.1% of total population. The impact of cost is less of a problem for children needing to see the GP and likely a result of government subsidies for all New Zealand children less than 6 years of age. However, these subsidies do not extend to after-hours care meaning pacific children have difficulty accessing this care just as their parents do. The difficulties with cost also extend to filling prescriptions. At the beginning of 2013 the cost of subsidised medication in New Zealand was increased from three dollars per medication to five dollars per medication. Pacific adults were found to be 2.6 times more likely to be unable to access prescription medication due to cost and Pacific children were 3 times more likely.
These health inequities have led to the development of 'Ala Mo'ui: Pathways to Pacific Health and wellbeing 2010-2014. This Ministry of Health document is a collaborative effort and discusses the Government’s priority focus areas to improve Pacific health and wellbeing. The document has six priority outcomes including pacific workforce development, meeting the needs of pacific people, spending money on the best methods to achieve health, development of more services for Pacific people in the community and in primary care, supporting Pacific people to be healthy and achieving better broader health determinants. The plan also includes an expectation that interventions will be measured and reports about progress will be provided to the ministry of health.
Previous studies investigating the impact of health promotion on Pacific New Zealanders include the Obesity Prevention in the Community (OPIC) project. This project involved four countries, the New Zealand branch involved youth in Mangere, Auckland and focused on reducing the consumption of sugary carbonated drinks, it was delivered through schools. The researchers were unable to demonstrate a change to the body mass index of the participants. There have also been Church based health promotion programmes. While these showed initial positive outcomes the changes were not sustained in the long term.
Authors of report
Raymond Chan, Sam Cutfield, Joseph Gourlay-Gudex, Rachel Greenwood, Jina Han, Wan Yi Lim, Ethan Ling, Amanda McCorkindale, Maeve MacMurdo, Richard Storey, Clement Tan.
Various studies have evaluated aspects of physical health amongst the shearing and farming communities, but to date, there is no research which assesses mental health in the shearing workforce. Shearing is a highly physical, seasonal occupation, often associated with long distance travel, which has potential implications on mental health.
Our research aims to assess the mental well-being of the shearing workforce in Otago and Southland.
A cross-sectional study was conducted to assess the mental health amongst this population. Information was obtained using a questionnaire including a range of questions and the scoring tools AUDIT-C and HADS, completed via surveys either through phone-calls, online, post or visiting the shearing gangs in the shearing sheds.
In the predominantly Māori (65.9%) shearing workforce, higher rates (compared with the general NZ population) of illicit substance use (31.5% vs 16.6%) and risky drinking behaviour (85% vs 19%) were evident. HADS scores and period prevalence of suicidal ideation were comparable to the normative data. Comparing self-perception, those who positively identified as having had mental health issues in the past 12 months had higher proportions of formal diagnosis (19.0% vs 3.7%) and scoring outside the normal range on the HADS-A score (61.9% vs 8.3%).
Reassuringly, indicators of anxiety and depression are comparable with the general population. However, the shearing workforce in the Otago and Southland regions have higher rates of illicit substance use and alcohol misuse which are detrimental to health in the long term. Further research is required to assess the full extent of its impact but health promotion is nonetheless essential.
Authors of report
Tzu-Hung Chen, Christopher Haug, Jerry Hsu, Frances Stringfellow, Joel Tissingh, Yieng Ling Wong, Gavin Yeh
Early hospital readmission is increasingly recognised as a marker for poor inpatient care. As a sentinel event, these unplanned readmissions impact on patients' lives and represent extra costs to the health care system.
The Health Round Table is a non-profit organisation for health services in Australia and New Zealand which collects, analyses and publishes information comparing organisations in order to identify ways to improve health care practices at a managerial level. According to the Health Round Table Report analysis, there has been an apparent rise in the rate of acute readmissions within 28 days of discharge in Dunedin Hospital during the period of 1 July 2013 to 31 December 2013, in comparison to the same period a year earlier. The underlying factors that drove this increase have to date not been identified. Previous research has shown that many cases of readmissions are unavoidable due to unmodifiable factors. Hospital readmission can be reduced, however, by addressing issues such as premature discharge, inadequate post-discharge support and insufficient follow-up.
The presence of co-morbidities place patients at increased risk for readmission over and above that which could be attributed to the co-morbidity alone. Co-morbidities may well be exacerbated by the acute illness and the stress of the index admission, and may consequently lead to new acute illnesses that increase the risk of readmission. Previous studies have demonstrated that among patients with congestive heart failure as a co-morbidity, readmissions are common events, occurring in 20% to 50% of patients within 14 days to 6 months after discharge. Previous studies have also shown correlates of readmission including male sex, prior admissions, prior heart failure, diabetes, co-morbidity, lower systolic blood pressure, and lower serum sodium in addition to acute heart failure caused by myocardial infarction or severe hypertension.
Any post-operative complication as an inpatient increases the risk of readmission by 4.2 times (95% confidence interval (CI): 2.89–6.13). Changes made to chronic drug treatment in the hospital and after discharge may cause loss of disease control or adverse drug events, which represent a large proportion of all post-discharge adverse events. A study which involved 282 individuals aged 80 and older with 30-day readmissions showed that 66 (23.4%) had an adverse drug reaction that contributed to rehospitalisation.
As with many health outcomes, ethnicity also influences risk of readmission. A New Zealand study in 2013 found Māori had 16% higher odds of readmission or death when compared with NZ European patients (odds ratio (OR) = 1.16; 95% CI: 1.08–1.24). Age is another factor that has been shown to affect the rate of readmissions. Medical readmissions are common in older people (aged 80+) with 16.1% (95% CI: 15.8–6.3%) of admissions resulting in a readmission within 30 days of discharge.
It could be argued that length of stay could be a predictor of future early readmissions. One study found that longer length of stay was predictive of early readmission with readmitted patients having a median initial length of stay 1 day longer than the group not readmitted. This may simply be an indicator of the severity and complexity of the initial admission. Conversely, could reduced length of stay increase the risk of early readmission by prematurely discharging patients before they are sufficiently recovered? This is of particular interest given changes in the hospital policy to encourage shorter lengths of stay.
The aim of our study is firstly to assess if there has been a true overall increase in rates of readmission between the period of 1 July to 31 December of the years 2012 and 2013, and what specific departments these increases are limited to. We will then compare the prevalence of risk factors among the patients in 2012 and 2013. In addition, a pilot study will be designed to evaluate the underlying factors that might have contributed to the increase of hospital readmissions in 2013. As a pilot study, we aim to identify factors that may contribute to readmission rates in Dunedin Hospital. We hope that this study will provide a platform for further research which may be used to inform and guide health policy makers in making future decisions.
Helen Bernhardt, Jie Qi Choong, Oriagh Fox, Jon Ha, Aqilah Haji Abd Rashid, Victor Ji, Jennifer Miller, Thomas Oliver, Varisilia Rokocakau
Colorectal cancer is one of the most common cancers worldwide (1), and the second highest cause of cancer mortality in New Zealand (2). However, with improved early detection and treatment the number of survivors has risen significantly and is now said to be curable in two thirds of presentations (3). This rise in survivors has lead to interest in improving the quality of life post-treatment. The health-related quality of life (HRQoL) measure is now used in decisions regarding further treatment and in clinical trials (1). Our study focuses on the quality of life of colorectal cancer survivors, with needs assessment in the areas of Te Whare Tapa Whā - taha hinengaro (mental health), taha tinana (physical health), taha wairua (spiritual health), and taha whānau (family health).
Over the past decade, tremendous progress has been made in the early detection and effective treatment of many cancers, resulting in an ever growing population of cancer survivors. In New Zealand in 2010, colorectal cancer (CRC) was the most common cancer affecting both men and women (22), with a five year relative survival of 60.5% for males and 63.1% for females, increasing by 6.3% and 7.5%, respectively, from 1998 (23). It is by no means surprising that survivors of colorectal cancer now represent the third largest group of long-term cancer survivors in Western societies, following survivors of breast and prostate cancer (24) Cancer survivorship is still a relatively recent notion internationally, with the 2005 Institute of Medicine (IOM) report ‘ From Cancer Patient to Cancer Survivor: Lost in Transition’ being the earliest internationally recognised document published in the US that focuses on survivors of adult cancer during the phase of care that follows primary treatment (24). This comprehensive publication has had by far one of the most influential blueprints to date to guide survivorship program development globally (25). The post-treatment phase of bowel cancer survivorship, which is the period our study is interested in, is recognised as a distinct phase in the cancer continuum occurring at the end of primary treatment and encompassing the domains of psychosocial and supportive care, health promotion, surveillance and long-term monitoring, and early intervention for late and long-term effects.
Sonal Gosai, Nina Henderson, Shen Leong Oh, Angus Murray, Nicole Sycamore, Malihah Stephenson, James Van Rooyen, Jane Vermunt, Tae Young Yoon, Su Zhou
Academic Doping? A quantitative survey on the use of substances for improving academic performance at the University of Otago
The use of substances to aid study, particularly cognitive enhancers by students is a topic that has been increasingly main news headlines. Studies from Germany and Australia showed 1.3% and 3.2% lifetime prevalences of methylphenidate use respectively for the purpose of study. In the United States, this prevalence is as high as 7-9%. Efficacy and adverse health effects are not clear. “Academic doping” is poorly studied in New Zealand, and there is a dearth of awareness and policy around this ethically complex issue.
In our cross-sectional study, 1800 University of Otago students were sent an online survey. Lifetime use and current use of six drug classes: caffeine, alcohol, dietary supplements, prescription stimulants, other prescription substances, and illicit substances were studied. Participants were asked reasons for use and their attitudes and perceptions.
Preliminary response rate was 33% (n= 602). Lifetime prevalence of prescription stimulants was 3.8% (excluding those with a diagnosis of ADHD) and the most common stimulant was methylphenidate. This finding correlated with male gender, faculty of study and recreational drug use. The most common reasons for the use of prescription stimulants were to improve concentration, stay awake, improve memory and manage the pressure to succeed.
We found comparable prevalences to other studies for caffeine, dietary supplements and prescription stimulants. This study justifies further multi-centre research and qualitative studies. The authors recommend institutional and regulatory body efforts to address this issue.
Malcolm Gill, Chaey Leem, Cassandra Li, Frances Mein Smith, Anantha Narayanan, Ben Shepherd, Selene Ting, Karin Van Bart
Are current mental health services in the Southland catchment of Southern DHB configured to facilitate re-integration of clients into the workforce? If not, how should they be re-orientated? A qualitative study
Re-integration into the work stream is now recognised as a key outcome indicator in mental healthcare and the President elect of the World Psychiatric Association has suggested that it is this and, not symptom reduction that should be the primary focus. Several international studies have demonstrated this effect. The Southland Mental Health Team have proposed implementing a ‘Thinking Skills for Work Programme’ to help to achieve this.
To review if mental health services in in the Southland catchment of Southern DHB are configured to facilitate re-integration of clients into the work-force? If not, should they be so re-oriented? And if so, how?
Four researchers conducted one-to-one interviews with keyworkers, psychiatrists, support workers, psychologists and counsellors in the Invercargill, Wakatipu and Gore Community Mental Health Teams. Recordings and field notes were taken and key themes identified for analysis.
A total of 42 out of an eligible 50 participants were interviewed and four main themes were identified; current attitudes, actions/methods, service configuration and improvements. Three themes were broken into subcategories and these were discussed systematically using representative quotes from the focus groups.
Generally feelings from workers were positive about employment as being important for mental health client recovery however there was reluctance for it to be implemented as a primary outcome indicator due to the feeling that approaches should be individualised. There was some uncertainty within the team as to whose role it was to assist in employment and a feeling of there being a scarcity of information in relation to employment assistance. There was a belief that there was room for improvement within the service configuration and some suggestions for improvements were given. Seven recommendations were summarised; 1) A defined keyworker role which involves assisting employment; 2) Training keyworkers in assisting employment; 3) Guidelines and information booklet on available resources; 4) Specific employment chief within the Southland Community Mental Health Team; 5) Use ‘Thinking Skills for Work’ programme to identify the right clients; 6) Community education and stigma reduction; and 7) Lead the way for governmental changes.
Emma Clyma, Samuel Fussey, David Neynens, Anh Nguyen