Long-Term Food Insecurity, Hunger and Risky Food Acquisition Practices: A Cross-Sectional Study of Food Charity Recipients in an Australian Capital City.

Inadequate social protection, stagnant wages, unemployment, and homelessness are associated with Australian household food insecurity. Little is known about the recipients of food charity and whether their needs are being met. This cross-sectional study of 101 food charity recipients in Perth, Western Australia, measured food security, weight status, sociodemographic characteristics and food acquisition practices. Seventy-nine percent were male, aged 21-79 years, 90% were unemployed, 87% received social assistance payments, and 38% were homeless. Ninety-one percent were food insecure, 80% with hunger, and 56% had gone a day or more without eating in the previous week. Fifty-seven percent had used food charity for ≥1 year, and, of those, 7.5 years was the mode. Charitable services were the main food source in the previous week, however 76% used multiple sources. Begging for money for food (36%), begging for food (32%), stealing food or beverages (34%), and taking food from bins (28%) was commonplace. The omnipresence and chronicity of food insecurity, reliance on social security payments, and risky food acquisition suggest that both the social protection and charitable food systems are failing. Urgent reforms are needed to address the determinants of food insecurity (e.g., increased social assistance payments, employment and housing support) and the adequacy, appropriateness and effectiveness of food charity.

Male sexual assault: Physical injury and vulnerability in 103 presentations.

OBJECTIVES: To i) describe the demographic and assault characteristics of males alleging recent sexual assault, ii) determine the severity and frequency of general body injury and the frequency of anal and genital injury, iii) identify vulnerability factors and assault characteristics associated with injury. DESIGN: Cross-sectional study. SETTING: Sexual Assault Resource Centre (SARC), Western Australia. PARTICIPANTS: Total of 103 post-pubertal males attending SARC from Jan-2009 to Dec-2016. METHODS: Men underwent a standardised medical examination and data collection by forensically trained doctors following consent for general body and/or ano-genital examination. Men were considered vulnerable if at least one of the following factors was present: current mental illness; intellectual or physical disability; alcohol intoxication; previous sexual victimization; living in prison or homeless (no fixed address), aged < 18 years. Statistical analysis was performed by Fisher exact test. An algorithm was used to classify general body injuries as mild, moderate or severe. RESULTS: At least one vulnerability factor was present in 88.3% of the 103 men. More than one factor was present in 54.4%. General body injury was observed in 58.0% (40/69) of men consenting to general body examination; 46.4%, 10.1% and 1.4% were classified as having respectively, mild, moderate and severe injuries. Three assault characteristics were associated with general body injury: the use of blunt force (p = 0.002), multiple assailants (p = 0.049) and deprivation of liberty (p = 0.040). Genital injury and anal injury was observed in, respectively, 6.5% (5/77) and 14.3% (11/77) of men consenting to ano-genital examination. Of the 49 men examined following completed penetrative anal assault, 18.4% (9/49) had anal injuries. In these 49 men, those assaulted by strangers were more likely to have an anal injury compared to non-stranger assaults (p = 0.019). No demographic, clinical or vulnerability characteristics of the sexually assaulted men were associated with general body, genital and/or anal injury. CONCLUSION: Although general body injuries were more frequent than genital and anal injuries, most of the body injuries were mild in severity. While the majority of men in our study presented with one or more vulnerabilities only assault characteristics (not vulnerabilities) were associated with injury.

Capturing sexual assault data: An information system designed by forensic clinicians and healthcare researchers.

BACKGROUND: The Sexual Assault Resource Center (SARC) in Perth, Western Australia provides free 24-hour medical, forensic, and counseling services to persons aged over 13 years following sexual assault. OBJECTIVE: The aim of this research was to design a data management system that maintains accurate quality information on all sexual assault cases referred to SARC, facilitating audit and peer-reviewed research. METHODS: The work to develop SARC Medical Services Clinical Information System (SARC-MSCIS) took place during 2007-2009 as a collaboration between SARC and Curtin University, Perth, Western Australia. Patient demographics, assault details, including injury documentation, and counseling sessions were identified as core data sections. A user authentication system was set up for data security. Data quality checks were incorporated to ensure high-quality data. RESULTS: An SARC-MSCIS was developed containing three core data sections having 427 data elements to capture patient's data. Development of the SARC-MSCIS has resulted in comprehensive capacity to support sexual assault research. Four additional projects are underway to explore both the public health and criminal justice considerations in responding to sexual violence. The data showed that 1,933 sexual assault episodes had occurred among 1881 patients between January 1, 2009 and December 31, 2015. Sexual assault patients knew the assailant as a friend, carer, acquaintance, relative, partner, or ex-partner in 70% of cases, with 16% assailants being a stranger to the patient. CONCLUSION: This project has resulted in the development of a high-quality data management system to maintain information for medical and forensic services offered by SARC. This system has also proven to be a reliable resource enabling research in the area of sexual violence.

Sexual assault and general body injuries: A detailed cross-sectional Australian study of 1163 women.

OBJECTIVES: To describe the frequency and severity of general body injury in women alleging recent sexual assault and then identify demographic and assault characteristics associated with injury severity. DESIGN: Cross-sectional study. SETTING: Sexual Assault Resource Centre (SARC), Western Australia. PARTICIPANTS: Total of 1163 women attending SARC from Jan-2009 to Mar-2015. METHODS: Women underwent a standardised medical examination and data collection by forensically trained doctors. Multivariate ordinal logistic regression analyses were performed. An algorithm was used to classify general body injuries as mild, moderate or severe. RESULTS: General body injury was observed in 71% of women; 52%, 17% and 2% were classified as having respectively, mild, moderate and severe injuries. Moderate or severe injury was observed in 30.4% of women assaulted by intimate partners, 16.4% of women assaulted by strangers and 14.9% of women assaulted by friends/acquaintances. In regression analysis, an interaction between mental illness and assailant type existed after adjusting for age, intellectual disability, time-to-examination, number of assailants and location. Mental illness was an independent predictor for lower injury severity (adjusted odds ratio=0.5, 95% CI 0.3, 0.9) in women assaulted by strangers and higher injury severity in women assaulted by a friend/acquaintance (adjusted odds ratio=2.4, 95% CI 1.6, 3.6). While women assaulted by intimate partners had more frequent moderate-to-severe injuries than other women their current mental illness status was not associated with risk of injury severity. CONCLUSION: This study highlights the increased injury severity in women assaulted by intimate partners. The risk of moderate/severe injury for women with mental illness assaulted by their acquaintances was unexpected and requires further investigation.

Genital and anal injuries: A cross-sectional Australian study of 1266 women alleging recent sexual assault.

OBJECTIVES: To describe the frequency of genital and anal injury and associated demographic and assault characteristics in women alleging sexual assault. DESIGN: Cross-sectional study. SETTING: Sexual Assault Resource Centre (SARC), Western Australia. PARTICIPANTS: Total of 1266 women attending SARC from Jan-2009 to Mar-2015. METHODS: Women underwent a standardised data collection procedure by forensically trained doctors. Multivariate logistic regression analyses were performed. MAIN OUTCOME MEASURES: (1) Frequency of genital and anal injuries by type of sexual assault. (2) Identification of independent factors associated with genital and anal injuries following, respectively, completed vaginal and anal penetration. RESULTS: Genital injury was observed in 24.5% of all women with reported completed vaginal penetration; in a subset with no prior sexual intercourse 52.1% had genital injury. Genital injury was more likely with no prior sexual intercourse (adjusted odds ratio [adj. OR] 4.4, 95% confidence interval [95%CI] 2.4-8.0), multiple types of penetrants (adj. OR 1.5, 95%CI 1.0-2.1), if general body injury present and less likely with sedative use and delayed examination. Anal injury, observed in 27.0% of reported completed anal penetrations, was more likely with multiple types of penetrants (adjusted OR 5.0, 95%CI 1.2-21.0), if general body injury present and less likely with delayed examination. CONCLUSION: This study separately quantifies the frequency of both genital and anal injuries in sexually assaulted women. Genital injuries were absent in a large proportion of women regardless of prior vaginal intercourse status. It is anticipated that findings will better inform the community, police and medico-legal evidence to the criminal justice system.

Non-fatal strangulation in sexual assault: A study of clinical and assault characteristics highlighting the role of intimate partner violence.

OBJECTIVE: To describe the prevalence, risk factors, signs and symptoms of non-fatal strangulation (NFS) in women referred to a Sexual Assault Resource Centre (SARC) following recent sexual assault. METHODS: A cross-sectional study using data routinely collected at time of forensic examination of women (age ≥ 13 years) referred to the Western Australian SARC between Jan-2009 and Mar-2015 alleging a recent sexual assault. Data on demographics, assault characteristics and forensic findings were available. RESULTS: A total of 1064 women were included in the study; 79 (7.4%) alleged NFS during the sexual assault. The prevalence of NFS varied significantly by age-group and assailant type. Of women aged 30-39 years 15.1% gave a history of NFS compared to less than 8.2% in all other age groups. Of women assaulted by an intimate partner, 22.5% gave a history of NFS compared to less than 6% of women assaulted by other assailant types. Of all sexual assaults with NFS, intimate partners were the assailant in 58.2% of cases, whereas in sexual assault cases without NFS, intimate partners were the assailant in 15.9% of cases. Odds of NFS were 8.4 times higher in women sexually assaulted by an intimate partner compared to women assaulted by an acquaintance/friend and 4.9 times higher compared to women assaulted by a stranger. When considering both age and assailant type the highest proportion of NFS (33.9%) was in women aged 30-39 years sexually assaulted by an intimate partner. Other factors associated with NFS during sexual assault included deprivation of liberty, verbal threats, being assaulted in the woman's home and use of additional blunt force. External physical signs of NFS were absent in 49.4% of all NFS sexual assault cases. CONCLUSIONS: This study identifies and quantifies NFS risk factors in female sexual assault and highlights the strong association with intimate partner sexual assault. Greater awareness of NFS in sexual assault should lead to improvement in medical screening, forensic management and safety risk assessment by sexual assault and domestic violence services, emergency departments and police.

A pragmatic approach to embedding patient blood management in a tertiary hospital.

BACKGROUND: We describe the implementation and impact of a patient blood management program (PBMP) in an Australian teaching hospital. STUDY DESIGN AND METHODS: A PBMP was introduced at a single tertiary care hospital in 2009 as a pilot for the Western Australian Health Department statewide PBMP. The first 3 years of interventions aimed to make effective use of preoperative clinics, manage perioperative anemia, improve perioperative hemostasis, reduce blood sample volumes, and implement restrictive transfusion triggers and a single-unit transfusion policy. RESULTS: Between 2008 and 2011, admissions to Fremantle Hospital and Health Services increased by 22%. Using 2008 as a reference year, the mean number of red blood cell (RBC) units per admission declined 26% by 2011. Use of fresh-frozen plasma and platelets showed 38 and 16% declines, respectively. Cryoprecipitate increased 7% over the 4-year period. For elective admissions between 2008 and 2011, the leading decline in RBC transfusion rate was seen in cardiothoracic surgery (27.5% to 12.8%). The proportion of single RBC unit use increased from 13% to 28% (p < 0.001), and the proportion of double units decreased from 48% to 37% (p < 0.001). CONCLUSION: This is the first tertiary hospital in Australia to establish a multidisciplinary multimodal PBMP. Interventions across disciplines resulted in decreased use of RBC units especially in orthopedic and cardiothoracic surgery. Continuing education and feedback to specialties will maintain the program, improve patient outcomes, and decrease the transfusion rate.

The hospital mortality project: a tool for using administrative data for continuous clinical quality assurance.

The increasing demand for greater clinical accountability requires development of convenient tools to measure healthcare safety and quality, which are able to provide information contemporaneously. The purpose of this paper is to describe the development of the Hospital Mortality Project, a quality assurance initiative designed to encourage and facilitate clinical accountability for hospital mortality by all clinical departments and clinicians. The project was carried out in two stages. Part 1: After registration of in-hospital patient deaths ( May 1, 2004 to December 31, 2007), the consultant in charge of patient care was notified and requested to assign the death to a predefined category. This categorisation leads to further investigation as appropriate. Part 2: Hospital administrative data from April 1, 1997 to December 31, 2007 were used to assess a defined index, the Hospital Mortality Index (HMI), which was the expressed in the form of an Attribute Control Chart (p-CHART ) and then used as a performance indicator for hospital departments and clinicians. Summary data are reported to the clinical departments and to the hospital executive via the Quality Improvement Committee on quarterly basis. The clinical review was complete for 2,990 of 3,132 (95%) inpatient deaths till December 31, 2007, while a further 142 (5%) deaths are still in the process of being reviewed as of April 7, 2008. The median age of all the cases was 78 years (IQR 67-86) of which 1,657 (53%) were male. The Poisson regression analysis showed that since 1997 departments with a minimum of 100 deaths in total showed no clinically significant change in HMI over time. The Hospital Mortality Project provides a simple and efficient tool to analyse data for clinical managers to facilitate accountability.

Providers and consumers support the Western Australian Audit of Surgical Mortality.

BACKGROUND: The Western Australian Audit of Surgical Mortality (WAASM) was established in June 2001 to independently peer-review all surgical deaths in Western Australia. The objectives of this study were (i) to evaluate whether participation in the WAASM has influenced clinical and hospital practice; and (ii) to ascertain the support and relevance of the WAASM to surgeons, hospitals and consumers. METHODS: Three qualitative questionnaires were designed to evaluate the response of surgeons, hospital administrators and consumers to the WAASM. The outcomes measured included audit participation, value and use of feedback provided, changes to clinical and hospital practice and the future role of the WAASM. RESULTS: The key findings were that 138 (73%) of 190 surgeons participating in the WAASM had changed their clinical practice in at least one way, 44 (24%) were aware of changes in hospital practice and 21 (11%) were aware of changes in a colleague's practice. Particular areas where changes in surgical practice had occurred included attention to deep vein thrombosis prophylaxis (81, 44%), increased constructive discussion among peers (78, 42%) and quality of documentation in case notes (68, 37%). All groups supported the continuation of the WAASM. Hospital executives and consumers recommended that the WAASM be included in accreditation. CONCLUSION: Surgeons, hospitals and consumers supported the concept of independent peer review of surgical care. They confirmed the ability of audit to influence and change surgical and hospital practice. It strengthens the intention of the Royal Australasian College of Surgeons to extend the WAASM project throughout Australia and New Zealand.

The Western Australian Audit of Surgical Mortality: advancing surgical accountability.

OBJECTIVE: To describe the peer review process of the Western Australian Audit of Surgical Mortality (WAASM), selected outcomes and recommendations. STUDY DESIGN: Prospective audit using peer review of all cases of patients who died while under the care of a Western Australian surgeon between 1 January 2002 and 30 June 2004. Audit reviews were current to 30 September 2004. PARTICIPANTS AND SETTING: 194 of 202 surgeons participated after a patient died under their care. MAIN OUTCOME MEASURES: Surgeon participation, deficiencies of care, deep vein thrombosis (DVT) prophylaxis, futile surgery, postmortem reviews, proportion of operations performed by consultant surgeons. RESULTS: The audit process was complete for 896 of 1647 reported deaths (54%), while a further 503 (31%) were still under review at 30 September 2004. Twenty deaths associated with terminal care were excluded from analysis. Median patient age was 80 years, and 799 of the 876 patients who died (91%) had significant comorbidities that increased the risk of death. Deficiencies of care were reported in 179/876 (20%). In 45/876 deaths (5%) the deficiency of care was assessed to have caused the death, and 15 deaths were considered preventable. The risk of a deficiency of care was 1.9 times higher in elective admissions than emergency admissions. Autopsy was undertaken in 83/768 (11%) deaths with complete data. Changes in practice were noted in some areas targeted by WAASM, such as improved DVT prophylaxis. A problem with fluid management was recorded. CONCLUSION: Most patients who died were elderly, had complex comorbidities and were treated appropriately. The WAASM has helped to change surgical practice and emphasises the importance of ongoing systematic audit. The participation of surgeons demonstrates their commitment to accountability and supports the intention of the Royal Australasian College of Surgeons to extend the process throughout Australia and New Zealand.