Development of a Rural Asthma Management Model, RAMM.

INTRODUCTION: The prevalence of asthma in Australia is increasing and places a significant cost burden on the community as well as reducing individuals' quality of life. In the late 1990s, asthma was the sixth National Health Priority in Australia and the prevalence of asthma in the Loddon Mallee region (LMR) of Victoria was approximately 1% higher than the State average. Four LMR local government areas had close to double the State average hospital admission ratios for asthma. AIM: The aim of this project was to develop a Regional Asthma Management Model (RAMM) and strategies for its implementation throughout the LMR, as a tool to implement a major health priority of both the Victorian State and Australian Commonwealth governments: to improve health outcomes for people with asthma. METHODS: A literature review was undertaken to identify best practice in asthma management for use as the basis of questions in workbooks designed to profile and compare current asthma management practice in the LMR. The workbooks were sent to all acute hospitals, community health centres and asthma educators in the LMR. The completed workbooks were returned and respondents elaborated on the workbook data at one of five subregional workshops. A survey was also undertaken to identify the range of asthma management strategies currently used by regional general practitioners (GPs) and to invite their views on ways to improve asthma management in the region. To gain consumer input into the RAMM a semi-structured group interview was held in an urban area and individual interviews were held in two rural areas in the region. A multidisciplinary reference group provided guidance to the project and a documentation design team was convened. RESULTS: Of the 19 workbooks sent to individual acute hospitals, 15 (78.9%) were completed and returned; 13 of 14 workbooks (92.8%) sent to individual community health centres were completed and returned. Fourteen of 15 asthma educators identified in the LMR were employed in the acute hospitals and community health centres that returned the workbooks; one asthma educator worked privately. Of the 215 GP surveys distributed, 38 surveys (17.6%) were returned. The majority of this small sample of GPs supported developing a uniform regional approach to asthma management based on NAC guidelines. Consumers interviewed suggested treating doctors, and/or EDs provide patients and carers with written instructions regarding acute asthma attacks and advice on management strategies for the ensuing 24-48 hours. A regional profile of asthma management practice was produced and compared with identified best practice. Gaps in practice and services were identified and responsive recommendations formulated. The National Asthma Campaign (NAC) guidelines were used as the basis for RAMM documentation, a package which consisted of a Regional Asthma Clinical Pathway and Emergency Department (ED) Package. CONCLUSION: The RAMM developed during the project provides documentation to assist best-practice asthma management by regional EDs and acute hospitals. The methodology and outcomes of the RAMM reflect the geography of the region, with multiple service providers from different locations managing a person with asthma across the primary, secondary and tertiary continuum. The RAMM methodology has the potential to be applied to other diseases and to other rural environments. Although the RAMM was designed for rural areas it could be easily adapted to suit the metropolitan environment. Implementation and evaluation of RAMM documentation is in progress.

Atrial fibrillation as a risk factor for stroke: a retrospective cohort study of hospitalized Medicare beneficiaries.

OBJECTIVES: This study examined the relationship between atrial fibrillation and (1) stroke and (2) all-cause mortality. METHODS: All eligible Medicare patients older than 65 years of age hospitalized in 1985 were followed up for 4 years. Kaplan-Meier and Cox proportional hazards models were used for assessment of risk of stroke and mortality. RESULTS: A total of 4,282,607 eligible Medicare patients were hospitalized in 1985. The mean age was 76.1 (+/- 7.7) years; 58.7% were female; 7.2% were Black; and 8.4% had a diagnosis of atrial fibrillation. During the follow-up period, 66,063 patients (32.6/1000 person-years) developed nonembolic stroke and 7285 (3.6/1000 person-years) developed embolic stroke. After adjustment for age, race, sex, and comorbid conditions, atrial fibrillation remained a significant risk factor for both nonembolic stroke (relative risk [RR] = 1.56) and embolic stroke (RR = 5.80) and for mortality (RR = 1.31). Approximately 4.5% of nonembolic and 28.7% of embolic strokes among hospitalized Medicare patients aged 65 years and older were attributable to atrial fibrillation. CONCLUSIONS: This study demonstrates that atrial fibrillation is associated with an appreciable increase in the risk of stroke (both embolic and nonembolic) and in the risk of mortality from all causes.

Preferences for cardiopulmonary resuscitation.

PURPOSE: To examine nurse-patient communication about preferences for cardiopulmonary resuscitation (CPR). DESIGN: Prospective cohort. Sampled were patients and nurses caring for patients enrolled in SUPPORT (1989-91), a multicenter study of seriously-ill hospitalized adults at four U.S. hospitals. METHODS: Information about patient preferences was obtained by interviews with patients and their designated surrogates. For selected patients, nurses were interviewed prospectively about their understanding of patients' preferences and whether they discussed these preferences with their patients. Nurse demographic information was obtained by questionnaire. Additional patient data were obtained by interview and chart review. Logistic regression was used to identify independent correlates of nurse-patient communication and nurses' understanding of patients' preferences. FINDINGS: For 1,763 study patients, 1,427 nurse interviews (response rate 81%) were obtained. The median age of interviewed nurses was 29 years; 96% were women, 68% had a bachelor's or master's degree, and 62% had worked for 5 years or more as a nurse. Nurses reported discussions about CPR with 13% of their patients, and these discussions were more likely if the nurse thought the patient did not want CPR (adjusted odds ratio [AOR] 2.68; 95% CI 1.84 to 3.90), if the nurse had spent more time with the patient (AOR 1.05; 95% CI 1.02 to 1.08) per 5 additional days, if the patient had metastatic cancer (AOR 3.56; 95% CI 1.86 to 6.78), or if the patient was in an intensive care unit at the time of study entry (AOR 2.08; 95% CI 1.26 to 3.42). Diagnosis and study site were also associated with nurses' reports of discussions with patients. Of 551 patients with available data, 58% (n = 317) wanted CPR and 30% (n = 164) did not. Nurses understood patients' CPR preferences correctly for 74% of the patients. Nurses were more likely to understand patients' preferences to forego CPR if the patient was 75 years of age or older (AOR 6.6; 95% CI 2.0 to 22.0) or if the nurse and patient had discussed the patient's preferences (AOR 25.3; 95% CI 6.5 to 98.6) or if the patient had cancer (AOR 10.9; 95% CI 2.3 to 50.1). Nurses' understanding of patients' preferences for CPR was no better than that of physicians or patients' surrogate decision-makers. CONCLUSIONS: In this sample of seriously ill hospitalized adults, discussions between patients and nurses about CPR were infrequent. Nurses' understanding of patients' preferences for care was similar to that of physicians and patients' surrogate decision-makers. Educational interventions should focus on increasing the frequency of nurse-patient discussions about end-of-life care and improving nurses' understanding of patients' preferences for care.

Patient classification system in a rural emergency department.

How sick are the patients? How many nurses are needed to care for them? These have been described as the perennial nursing questions. This paper explains that a patient classification system, as used in the nursing context, is an attempt to answer these question: to quantify and reduce to empirical data that which is abstract and complex. Nowhere are the 'perennial questions' more difficult to answer than in an Emergency department, where patient flow and patient acuity change so rapidly. This paper illustrates that it is, however, possible to apply a patient classification system (PCS) in an Emergency department. The author describes the steps involved in the implementation of such a system-including literature review, choice of system, validation, modification, reliability testing, staff education; and discusses calculation of time taken to care for each category of patient. The paper concludes with some suggestions for future research.