Accessibility Skip to Global Navigation Skip to Local Navigation Skip to Content Skip to Search Skip to Site Map Menu

Pathways to diagnosis of gestational diabetes in Dunedin

Abstract

Background

Gestational Diabetes Mellitus (GDM) is a significant and increasing health problem in New Zealand. Untreated GDM can have marked adverse effects on the health of both the mother and her child. Prompt diagnosis and aggressive management of GDM are key when minimising adverse effects such as pre-eclampsia, pre-mature or operative labour, and macrosomia. The primary tests used to diagnose GDM are the oral glucose tolerance test (OGTT) and glycated haemoglobin (HbA1) level. In 2014 the Ministry of Health (MOH) proposed a new management pathway for GDM based on these tests. This pathway contrasts with the pathways set out by the Dunedin Diabetes in Pregnancy Team (DIPT). The MOH pathway proposes that women with an HbA1c of 40-49mmol/mol should receive lifestyle advice and an OGTT at 24-28 weeks gestation. In contrast the DIPT proposes these women receive immediate referral to their service.

Aim

To audit the pathways by which women presented to the DIPT from 1 January 2010 to 31 December 2014.

Methods

Relevant data was extracted from the DIPT database and analysed using the statistical programme R. One-way analysis of variance was used to test for differences in the mean gestational age at referral between ethnicities. Linear regression was used to test for changes in the proportion of women who presented with a diagnostic OGTT from 2010 to 2014.

Results

328 women were included in this study. The mean age of women was 32.5 years and 65% were New Zealand European. Mean gestation at referral was 28.7 weeks. From 2010 to 2013, the proportion of Maori women managed by the service increased steadily, whilst the proportion of women of other ethnicities remained constant. Overall, 74% of the women referred to the DIPT team had a diagnostic OGTT. Only 4 women were referred to the DIPT with an HbA1c result. A total of 26% of women were referred to the DIPT with a non-diagnostic OGTT, and after stratification by ethnicity vast majority of these patients were found to be NZ European. Of women with a non-diagnostic OGTT, 31.8% had one or more positive risk factors for GDM. The reason for referral could not be determined for 26% women with a non-diagnostic OGTT.

Conclusions

Our audit revealed that the majority of women who were referred to the DIPT had a diagnostic OGTT at ≥25 week gestation, but this proportion has been decreasing each year. Women without a diagnostic OGTT were referred if they had one or more risk factors for GDM. Overall, compared to other ethnicities, women of Pacific ethnicity were less likely to be referred due to risk factors.

Authors of report

Georgia Griffin, Eunice Khoo, Stenar Kirs, Deepesh Mehta, Leah Pihama, Rebecca Roberts, Nikeeta Segran, Abigail Sia, Marc Wakeling, Caleb Watene

^ Top of Page

Clinical audit: The yield of head computed tomography scans performed at Dunedin Hospital

Abstract

Background

Computed tomography (CT) head scanning is a valuable and commonly used diagnostic tool; however it is also a costly and limited resource. It is currently unknown what proportion of CT head scans performed at Dunedin Hospital (DH) reveal findings that lead to change in clinical management and although guidelines about use of CT scanning exist, none are consistently applied across DH. This audit aimed to produce findings that could be used to assist with the development of guidelines around appropriate use of radiology resources.

Objectives

To determine the proportion of CT head scans performed in DH between the 1st January 2015 and 31 June 2015 that had new abnormal findings; stratified by urgency, age, and indication.

Methods

Data about the indications and findings of CT head scans performed at DH during a 6 month period was collected and analysed. The yield – the proportion of scans with a finding – was calculated for each indication and also for some combinations of indications. Yield was also stratified by urgency and age.

Results

The overall yield for CT head scans was 24.8%. Both overall, and for the sub-sets of indications, our audit found that yields that were higher than in most background literature. However, when indications were matched only with relevant clinical findings, yield in our audit was more similar to that in the literature.

Conclusions

This audit showed that the yield of CT head scans at DH was generally higher than documented in current literature. This could indicate that CT scans are already being ordered appropriately at DH, however standardised clinical guidelines could still be useful to implement. It is hoped the findings of this audit will assist with the development of such guidelines.

Authors of report

Devika Bartlett, Maila Begley, Anna Black, Vanessa Bowden, Sasha Cheng, Caleb Goh, Rowan Hamill, Hannah-Rose Hart, Kewin Lau, Emily MacNamara, Sally Studholme

^ Top of Page

The Foundation Standard – Friend or foe?

Abstract

Introduction

The process of standards and accreditation is an increasingly important part of the modern healthcare landscape. In New Zealand a new set of mandatory standards, known as the Foundation Standard, is set to be rolled out in all general practices nationwide by 2017. The purpose of introducing such standards and accreditation procedures is to promote quality improvement of patient-centred and standardised care, while also being able to assess the progress towards these with measurable criteria. Furthermore, successful accreditation aims to ensure an equivalent level of care across wide geographical areas, attempting to reduce the chance of the so-called postcode lottery.  Despite these well intentioned aims, concerns have been raised about the lack of evidence of the effectiveness of such standards, as well as the potential costs of implementation.

Authors of report

Briar Warin, Crystal Diong, Faezah Haji Mohd Amin, Dorcas Chan, Hayden Shin, Agatha Kim, Zoe Sole, Trenton Taylor, Su’ad Muse,
Amalina Rosly

^ Top of Page

Measuring the immeasurable: Evaluating the health promotion activities of Pacific Trust Otago

Abstract

Introduction

Health promotion as defined by the World Health Organization, ‘is the process of enabling people to increase control over, and to improve their health’. Inherent in this process is the acknowledgment that many factors contribute to health, and consequently health promotion ‘moves beyond a focus on individual behaviour, towards a wide range of social and environmental interventions’.

In New Zealand, health promotion is an important strategy in reducing inequalities in health. It is an unfortunate reality that Pacific peoples suffer disproportionately from negative health outcomes. In addition to this, Pacific peoples are also overrepresented in lower-decile suburbs and lower-paid jobs, which are the socioeconomic factors that have the greatest influence on health. Health promotion that is Pacific-specific and culturally appropriate is therefore crucial and contributes to eliminating the health inequalities that exist in our society.

Pacific Trust Otago (PTO) is the sole Pacific-specific health promotion provider in the Otago region, serving a diverse Pacific population of approximately 4000 people. PTO consists of a small team of dedicated staff that have run many health promotion initiatives since starting in 2003, and have developed a strong working relationship with the community.

The brief that the Trainee Intern Group received was that PTO had requested an evaluation of their health promotion services in order to guide how they could assess and improve their services in the future. It was proposed that this evaluation would include a review and assessment of the data that had been collected by the organisation over time.

This report will describe the Trainee Intern Group’s research methods, information gathered, conclusions and specific proposals for PTO for the future. 

Authors of report

Anna Charles-Jones, Eric Cho, Casey Dason, Harry Fellowes, Claire Han, Mark Huang, Rebecca Ly, Jono Paulin, Robert Pu

^ Top of Page

Timely cholecystectomy – how are we doing at Dunedin Hospital?

Abstract

Background

Gallstone related pathology is a common cause of morbidity and occasionally mortality in New Zealand. Following the publication of Cochrane reviews which showed that early cholecystectomy (within 24 hours of presentation with acute cholecystitis or other gallstone related disease) results in decreased post-operative complications when compared to delayed elective cholecystectomy, the best practice is now to do cholecystectomies within 24 hours of the initial presentation. Studies looking at whether this best practice is followed in other parts of New Zealand have revealed variable success, however no study to date has been conducted reviewing the practice in Dunedin Hospital.

Aim

The aim of this audit was to review current practice of cholecystectomy in Dunedin Hospital; whether early cholecystectomy was being carried out on patients presenting with acute gallstone pathology and in what proportion of patients the surgery was done within the 24 hour recommended time vs electively.

Method

Several databases were utilised to find the necessary information. Firstly, the Otago Surgical Audit Database was used to select the relevant patients who had had a cholecystectomy in the two-year time period beginning 1st January 2014 and ending on 31st December 2015. Secondly, the Dunedin Hospital Theatre database was used to gather the length and timing of cholecystectomy surgeries. Subsequently, the iSoft Clinical Database, which stores patient information, was used to verify the selected patients and whether they had had any previous biliary disease admissions, any subsequent readmissions, and any other procedures including magnetic resonance cholangiopancreatography (MRCP), intraoperative cholangiogram (IOC) and endoscopic retrograde cholangiopancreatography (ERCP).

In part two of the study, the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD- 10-AM), was used to identify all first presentations of gallstone related pathology discharged from Dunedin Hospital in the period of 1st January 2014 to 31st December 2015. Following this, the Australian Classification of Health Interventions (ACHI) was used to identify cholecystectomies performed within the same period at Dunedin Hospital. Subsequently, the codes gathered from the ICD-10-AM and ACHI were then sent to Clinical Records and Coding Department of the Southern District Health Board (SDHB) to identify the appropriate cases using the discharge database. The ICD-10-AM data were then matched to the ACHI data using patient NHIs. This then produced a set number of patient cases who had gallstone related pathology and received a cholecystectomy. Further to this, analysis was made as to when these patients received their cholecystectomies (on their first admission or subsequent admission, and whether they received it within the study period).

Results

432 patients were identified as undergoing cholecystectomy from 1st January 2014 to 31st December 2015. Of the 432, 26 patients were excluded due to their theatre data being unavailable or because they had a non-biliary disease. 406 patients were thus included in this study, of which 254 (62.6%) received a cholecystectomy on their index admission (first admission with acute gallstone pathology within the study period). A total 280 patients received acute surgery, while 126 received elective surgery. Of those patients who received acute surgery (n = 280), 185 (66.1%) received surgery within 24 hours of being booked for surgery. The median time from booking to surgery for all acute patients (n=280) was 19.9 hours.

There was no significant difference in length of surgery, post-operative stay, conversion rate from laparoscopic to open surgery, and the rate of readmission due to complications between patients who received surgery within 24 hours and those who had surgery after 24 hours.

A search of Dunedin Hospital discharge data found that 719 patients were discharged with a diagnosis of gallstone pathology from 1st January 2014 to 31st December 2015. Of these 294 (41%) received surgery on their first admission.

Conclusions

This study suggests that the rate of early cholecystectomy in Dunedin Hospital is similar to that of other large New Zealand hospitals. The time between booking to receiving surgery is within the Dunedin Hospital guidelines for the majority of cases.

Authors of report

Grace Alexander, Samia Noor Ghazali, Nadia Hassan, Briar Hunter, Eric Kim, Alex Munro-Selwood, Vimal Patel, Samuel Pau, Joshua Su’a

^ Top of Page

Preventing severe perineal tears during childbirth

Abstract

Introduction

Obstetric anal sphincter injuries (OASIS) during childbirth are a cause of significant maternal morbidity, and their incidence is increasing in developed countries including New Zealand. While there is a large body of literature on prevention strategies for OASIS, individual studies are variable in quality and there is a lack of consensus amongst guidelines for obstetricians and midwives regarding their use in practice. Nonetheless, structured interventional programmes have been trialled in several countries using pragmatic methods, and have led to significant reductions in rates of OASIS. OASIS are therefore preventable using a coordinated organisation-led approach, but the practices of midwifery and obstetric providers must first be evaluated at the local level.

Aims

i) To summarise the current evidence for the effect of perineal harm prevention strategies on incidence of OASIS; ii) To conduct a preliminary survey of midwives in the Southern District Health Board (SDHB) focusing on OASIS prevention; and iii) To compare results of the survey with the evidence from the literature review. These data will inform the development of an OASIS education framework and clinical guideline for practitioners in the SDHB.

Literature review

We performed an electronic database search for primary and secondary research on OASIS prevention. Warm compress, manual perineal support, and a combination of upright positioning, coached breathing, and control of birth speed have been shown to significantly reduce rates of OASIS. On the other hand routine episiotomy, compared to restricted use, is associated with an overall significant increase in OASIS. Other strategies have mixed or no effects on severe perineal harm.

Methods

We recruited and surveyed midwives in the SDHB regarding their OASIS prevention practices and beliefs using a mixed quantitative and qualitative survey, from the 8th to the 29th of July 2016.

Results

A total of 72 midwives took part in the survey (response rate ~35%). The techniques most often used were warm compress (72%), immersion in water (71%), and control of birth speed (62%). Techniques perceived to reduce perineal harm included warm compress (97%), control of birth speed (95%), continuous perineal support/hands on approach (85%), and immersion in water (79%). Strategies perceived to increase harm included second stage fundal pressure (84%), epidural anaesthesia (82%), and episiotomy (79%). Subgroup analysis showed some differences in beliefs and practices between lead maternity carers and core midwives, but no differences between years of experience strata. Qualitative analysis revealed three main themes: Skills, such as birthing positions and coaching techniques; partnership between the midwife and birthing woman; and adaptability to ensure that the birthing woman’s needs and situational requirements are met.

Conclusion

Based on our survey sample, most OASIS prevention practices and beliefs of midwives in the SDHB align with best practice. However, there is diversity in the frequency of use of some strategies, and some techniques such as immersion in water appear to be used regularly by most midwives despite the lack of an evidence-base, though in addition to perceived benefit this may reflect other factors such as the birthing woman’s preferences and comfort. A similar study with obstetric providers as the survey population is necessary to complete an evaluation of the context of OASIS occurrence in the SDHB, and facilitate the development of a regional OASIS quality improvement project.

Authors of report

^ Top of Page

Medical students’ learning at the bedside – the patient’s perspective

Abstract

Background

Internationally, several studies have been conducted to evaluate patients’ perception of medical students and their experiences having medical students involved in their care in various clinical settings. However, there is a lack of information about patients’ view on the interaction between teaching clinicians and medical students and how patients’ perceive these interactions impact their health care.

Aim

To undertake a quantitative and qualitative pilot research assignment to investigate the overall views of patients within the Southern District Health Board on the quality of medical student teaching and learning.

Methods

A cross-sectional study of patients within the Southern District Health Board was conducted via a questionnaire. This study was developed from a piloted questionnaire by the medical education group (our clients), and already had ethical approval from the university when joined the project. From this the 11 trainee intern who conducted this study developed the questionnaire further, as well as developing a delivery and analysis method. The questionnaire asked patients about the students and the teacher involved, looking at issues of professionalism and respect, the learning environment, appropriateness and comfort.
Qualitative data was also gathered. Patients were recruited for this study from both an inpatient and outpatient setting at Dunedin Public Hospital and a small number from Southland Hospital. Inpatients were recruited across multiple hospital wards and specialties, including paediatrics (only children aged 12 years and older). Outpatients were recruited from across the medical, surgical, and women’s health outpatient clinics. Data was collected and analysed using a program called epi info and then exported to Excel.

Results

The response rate was 48%. Eighty-nine patients that answered the questionnaire were included in the data analysis. Interestingly 11% of patients (n=9) were not asked for consent prior to student interaction. Patients were asked to grade the student on a number of aspects of their interactions. In all categories patients’ responses were overwhelmingly positive, with the vast majority of responses (62.5%) being either ‘excellent’ or ‘very good’. Very few responded with ‘fair’ or ‘poor’ to any of the questions. Patient teacher evaluation followed a similar pattern to the student evaluation. The results were again overwhelmingly positive with approximately 75% of responses in all categories being ‘very good’ or ‘excellent’.

Conclusion

Overall, patients’ experience in this study were positive. Due to our poor response rate, it is not possible to determine whether the findings were reflective of the actual patients’ experience with medical students at our institution. Further research with a good response rate is necessary to determine patients’ perception of and overall experience with medical students.

Authors of report

Lauren Barnett, Tait Bartlett, Rebekah Carey, Jacqui Gale, Stacey Goodson, Fly Ing-Aram, Jordan Karpik, Eric Lim, Thomas Paterson, Ben Wilkinson

^ Top of Page

The quality of medical student teaching and learning: Through the eyes of the patient

Abstract

Introduction

Bedside teaching is considered to be an essential source of practical learning for medical students. Despite the patient’s significant contribution to bedside teaching, the majority of the current literature focuses on clinician and student views on teaching and learning. Phase One of the study surveyed patients primarily in the inpatient setting. Phase Two now focuses on patients in outpatient clinic and primary care settings.

Aim

To undertake a quantitative and qualitative pilot research assignment to investigate the overall views of patients within the Southern District Health Board and GP practices in the South Island on the quality of medical student teaching and learning.

Methods

Phase Two of a cross-sectional study focusing on patient perspectives on medical student teaching and learning in a clinical setting was conducted using a questionnaire. A piloted questionnaire developed by the Medical Education Group was modified. Patients were recruited from an outpatient setting at Dunedin Public Hospital as well as a selected few General Practices across New Zealand from 17th October to 11th of November 2016. Data was collected and combined with Phase One of the present study prior to final analysis using Microsoft Excel.

Results

Overall students have a positive impact on Outpatient and GP appointments. 88% of patients had an excellent or good impression of interactions and 89% enjoyed helping students learn. Only one participant reported negative aspects of patient-student interaction. It was also found that 10% of patients were not asked for consent before interacting with students, compared with 11% in Phase One.

Conclusions

The overall patient experience with medical student teaching and learning was positive although there were some limitations to the study. Patients provided highly positive ratings to how they perceived their interaction with both the student and the teacher. Further studies with higher response rates and outreach to more healthcare settings are required to ascertain the true perceptions of patients of their experience in teaching situations.

Authors of report

Aidan Smith, Andrew Ashworth, Angela Chou, Blake Henley, Daniel Eaton, Keerthi Seeman, Morwan Bahi, Nathan Young, Taz Fujino, Vidya Yugaraja

^ Top of Page