Impact of hospital-wide process redesign on clinical outcomes: a comparative study of internally versus externally led intervention.

INTRODUCTION In response to increasing demand for hospital beds, institution-wide clinical process redesign has been advocated for improving efficiency. METHODS This retrospective, before-after study involved five tertiary hospitals in Queensland, Australia and assessed effects of externally led redesign over 6 months within two hospitals, comprising ward-based innovations led by consultancy-led standardised processes, and internally led redesign over 25 months in one hospital which implemented medical assessment and planning unit, 23 h elective surgical ward and new bed management processes. The primary outcome measures were control chart changes in emergency department (ED) access block and overdue category 1 elective surgery waits over 3.5 years involving intervention hospitals and two control hospitals. RESULTS At one externally led redesign hospital, control charts indicated a decrease in ED access block outside control limits which coincided with the intervention, but this was not subsequently sustained. There were no special-cause variations seen in the other hospital. In contrast, at the internally led redesign hospital, there were two decreases in access block outside control limits during the intervention period, resulting in a decrease from a baseline average of 55% to a postintervention average of 22%. All hospitals showed declines in elective surgery waits with oscillations in data indicating the existence of special-cause factors other than redesign. CONCLUSION Internally led compared with externally led redesign led to superior and sustained improvements in ED access block as a result of major structural reforms that were driven by committed clinicians and managers and cut across departmental boundaries.

Survival from haematological malignancy in childhood, adolescence and young adulthood in Australia: is the age-related gap narrowing?

OBJECTIVES: To examine 5-year survival from haematological malignancies in children, adolescents and young adults in Australia and determine if there has been any improvement in survival for the older age groups compared with children (the age-related "survival gap"). DESIGN, SETTING AND PARTICIPANTS: Population-based study of all Australian children (aged 0-14 years), adolescents (15-19 years) and young adults (20-29 years) diagnosed with acute lymphoblastic leukaemia (ALL), acute myeloid leukaemia (AML), Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) between 1982 and 2004, with follow-up to 2006. MAIN OUTCOME MEASURES: 5-year survival from ALL, AML, HL and NHL analysed for four periods of diagnosis (1982-1989, 1990-1994, 1995-1999 and 2000-2004). RESULTS: During 1982-2004, 13 015 people aged < or = 29 years were diagnosed with primary leukaemia or lymphoma in Australia. For those with ALL, 5-year survival for adolescents improved from 40% (1982-1989) to 74% (2000-2004); the improvement for young adults was smaller (31% to 47%), and both these groups still had lower survival than children, whose 5-year survival improved from 74% to 88%. There was a larger narrowing of the gap for AML: for cases diagnosed in 2000-2004, 5-year survival was similar for young adults (63%), adolescents (74%) and children (69%). For lymphoma cases diagnosed in 2000-2004, 5-year survival in all age groups was greater than 95% for HL and greater than 81% for NHL, although children fared better than adolescents and young adults. CONCLUSIONS: These Australian population-based data confirm an improvement in survival from haematological malignancies across all three age groups, but an age-related survival gap remains for adolescents and young adults compared with children, especially for young adults with ALL. Greater participation of adolescents and young adults in clinical trials and more detailed data collection are needed to provide evidence about optimal treatment regimens in these age groups.

Trends in birth size and macrosomia in Queensland, Australia, from 1988 to 2005.

The objectives of this study were to explore temporal changes in birth measures in Queensland, Australia, and examine whether secular trends are similar to those in other countries. This study used data from the Queensland Perinatal Data Collection, including singleton livebirths (n = 831 375) from 1988 to 2005. Recorded birthweight (BW, g), birth length (BL, cm), gestational age (weeks), maternal age, ethnic origin and calculated ponderal index (PI, kg/m(3)) were used. Temporal trends were assessed over the intervals 1988-2005 for BW and 2001-2005 for BW, BL and PI. Mean BW increased during the 17-year interval by approximately 1.9 g/year at a relatively low rate compared with reports from other countries. The proportion of high BW infants (> or = 4000 g) rose by 0.8% per year. Stratification by Indigenous status indicated that the increase in mean BW and prevalence of high BW was confined to non-Indigenous newborns only. The secular increase in BW was further modified by gestational age, and maternal age. The increase in BW was larger in term infants (4.2 g/year) than in preterm infants (1.8 g/year), and larger in infants of younger mothers than in those of older mothers (5.0 g/year vs. 3.1 g/year). There were no trends in mean BL and mean PI at birth from 2001 to 2005. In Queensland, mean BW increased moderately in the last 17 years, as did the proportion of high BW infants. The trend in rising BW remained after controlling for other perinatal characteristics. Birth measures per se and related trends differed by Indigenous status and warrant further investigation.

Effect of smoking among Indigenous and non-Indigenous mothers on preterm birth and full-term low birthweight.

OBJECTIVE: To estimate the percentage of preterm (< 37 weeks) and full-term low-birthweight (37-41 weeks, < 2500 g) babies born to mothers who smoke, stratified by Indigenous status and statistically adjusted for the potential confounding effects of social and demographic factors, medical conditions and pregnancy complications. DESIGN, SETTING AND PARTICIPANTS: Population-based study of singleton babies born to mothers resident in Queensland who gave birth in Queensland from 1 July 2005 to 31 December 2006. MAIN OUTCOME MEASURES: Adjusted percentages of preterm birth and full-term low birthweight for babies born to Indigenous and non-Indigenous mothers. RESULTS: Of the 79 803 babies studied, 4228 (5.3%) were born to Indigenous mothers and 16 395 (20.5%) were born to mothers who smoked during pregnancy. The percentage of Indigenous mothers who smoked (54%) was almost triple that for non-Indigenous mothers (risk ratio, 2.90; 95% CI, 2.81-2.99). The adjusted outcomes for babies born to Indigenous non-smokers were similar to those for non-Indigenous non-smokers (preterm, 7.1% v 6.1%; full-term low birthweight, 1.6% v 1.1%). The adjusted percentages for smokers were high regardless of Indigenous status (preterm, Indigenous v non-Indigenous, 8.3% v 7.8%; full-term low birthweight, Indigenous v non-Indigenous, 5.3% v 3.7%). CONCLUSIONS: Antenatal smoking remains an important cause of poor health among both Indigenous and non-Indigenous newborn babies. Most pregnant smokers receive their antenatal care in the public sector. State and federal governments, who directly fund this sector, have a particular responsibility to ensure that interventions are offered to all pregnant smokers to help them quit smoking.

A Raman spectroscopic study of synthetic giniite.

The mineral giniite has been synthesised and characterised by XRD, SEM and Raman and infrared spectroscopy. SEM images of the olive-green giniite display a very unusual image of pseudo-spheres with roughened surfaces of around 1-10microm in size. The face to face contact of the spheres suggests that the spheres are colloidal and carry a surface charge. Raman spectroscopy proves the (PO4)3- units are reduced in symmetry and in all probability more than one type of phosphate unit is found in the structure. Raman bands at 77K are observed at 3380 and 3186cm-1 with an additional sharp band at 3100cm-1. The first two bands are assigned to water stretching vibrations and the latter to an OH stretching band. Intense Raman bands observed at 396, 346 and 234cm-1are attributed to the FeO stretching vibrations. The giniite phosphate units are characterised by two Raman bands at 1023 and 948cm-1 assigned to symmetric stretching mode of the (PO4)3- units. A complex band is observed at 460.5cm-1 with additional components at 486.8 and 445.7cm-1 attributed to the nu(2) bending modes suggesting a reduction of symmetry of the (PO4)3- units.

A Raman spectroscopic study of selected natural jarosites.

Raman spectroscopy has been used to characterise the jarosite group of minerals of formula Mn(Fe3+)6(SO4)4(OH)12 where M may be K, (NH4)+, Na, Ag or Pb and where n = 2 for monovalent cations and 1 for the divalent cations. Raman spectroscopy proved useful for mineral identification especially where closely related minerals crystallise out from solutions where paragenetic relationships exist between the minerals. The band position of the SO4(2-) symmetric stretching mode proved to be a function of the ionic radius of the cation. The bending modes show a slight dependence. The spectra of the natural samples can be complex. This complexity is attributed to the incorporation of low levels of other cations into the structure.

NIR spectroscopy of selected iron(II) and iron(III) sulphates.

A problem exists when closely related minerals are found in paragenetic relationships. The identification of such minerals cannot be undertaken by normal techniques such as X-ray diffraction. Vibrational spectroscopic techniques may be applicable especially when microtechniques or fibre-optic techniques are used. NIR spectroscopy is one technique, which can be used for the identification of these paragenetically related minerals and has been applied to the study of selected iron(II) and iron(III) sulphates. The near-IR spectral regions may be conveniently divided into four regions: (a) the high wavenumber region>7500 cm(-1), (b) the high wavenumber region between 6400 and 7400 cm(-1) attributed to the first overtone of the fundamental hydroxyl stretching mode, (c) the 5500-6300 cm(-1) region attributed to water combination modes of the hydroxyl fundamentals of water, and (d) the 4000-5500 cm(-1) region attributed to the combination of the stretching and deformation modes of the iron(II) and iron(III) sulphates. The minerals containing iron(II) show a strong, broad band with splitting, around 11,000-8000 cm(-1) attributed to (5)T(2g)-->(5)E(g) transition. This shows the ferrous ion has distorted octahedral coordination in some of these sulphate minerals. For each of these regions, the minerals show distinctive spectra, which enable their identification and characterisation. NIR spectroscopy is a less used technique, which has great application for the study of minerals, particularly minerals that have hydrogen in the structure either as hydroxyl units or as water bonded to the cation as is the case for iron(II) and iron(III) sulphates. The study of minerals on planets is topical and NIR spectroscopy provides a rapid technique for the distinction and identification of iron(II) and iron(III) sulphates minerals.

NIR spectroscopy of jarosites.

Near-infrared (NIR) spectroscopy has been used to analyse a suite of synthesised jarosites of formula Mn(Fe3+)6(SO4)4(OH)12 where M is K, Na, Ag, Pb, NH4+ and H3O+. Whilst the spectra of the jarosites show a common pattern, differences in the spectra are observed which enable the minerals to be distinguished. The NIR bands in the 6300-7000 cm-1 region are attributed to the first fundamental overtone of the infrared and Raman hydroxyl stretching vibrations. The NIR spectrum of the ammonium-jarosite shows additional bands at 6460 and 6143 cm-1, attributed to the first fundamental overtones of NH stretching vibrations. A set of bands are observed in the 4700-5500 cm-1 region which are assigned to combination bands of the hydroxyl stretching and deformation vibrations. The ammonium-jarosite shows additional bands at 4730 and 4621 cm-1, attributed to the combination of NH stretching and bending vibrations. NIR spectroscopy has the ability to distinguish between the jarosite minerals even when the formula of the minerals is closely related. The NIR spectroscopic technique has great potential as a mineral exploratory tool on planets and in particular Mars.