Medicine (Austin & Northern Health) - Theses
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ItemA study to identify risk factors in the aetiology and cause of traumatic spinal cord paralysis( 1986)This thesis is primarily concerned with determining: I. Primary and Secondary risk factors in traumatic spinal cord paralysis. (a) PRIMARY RISK FACTORS are those factors which predispose an individual to develop traumatic spinal cord paralysis. (b) SECONDARY RISK FACTORS are those factors which determine prognosis from time of injury to the time the patient is admitted to the emergency room of the Spinal Injuries Unit. II. Developing a preventive programme based on the elucidated Primary and Secondary risk factors. All patients who sustained significant spinal cord injuries in Victoria or within 25 kilometres of the Victorian border who were admitted to the Victorian Spinal Injuries Unit, Austin Hospital during the study period (1st March 1983 to 28th December 1984) were included in the study.
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ItemIntensive care access, patient flow, and outcome from critical illness( 2004)Does resource allocation, timely access to intensive care, patient flow, and continuity of care during hospitalisation impact on the outcome of critically ill patients? A 3-month audit (pilot study) of 10 public hospitals within metropolitan Melbourne revealed that 9.4% of ICU admissions (3.1 patients per day) were unable to be admitted to the ICU of first choice due to limited staffing (52%) and bed shortage (46%.) Acute inter-hospital transfer (AIHT; 1.7 per day) was the most common (57%) immediate triage outcome. A cohort of 3,548 consecutive critically ill patients, admitted to the Intensive Care Unit (ICU) of The Northern Hospital, formed the core dataset for further study. Patient outcomes from this cohort compared favourably to the national benchmarks and therefore the conclusions are likely to be applicable to other Australian hospitals. A three-year case-control study of 73 AIHT (unable to be admitted to the ICU of first choice) revealed that AIHT was associated with a significant delay in admission to ICU (median = 5.0 hours), and a significant increase in length of stay in ICU and in hospital, and 6.9% increase in mortality-risk (OR= 1 .5; 95% CI = 0.68-3.4.) Management of low-risk patients in the general medical or surgical ward (instead of ICU or HDU) was associated with a 26% risk of delayed admission to ICU. A prospective cohort study of 619 critically ill patients requiring ventilator support and/or renal replacement therapy, admitted directly to ICU within 24 hours of arrival in the Emergency Department revealed that ICU lead-time (admission delay) is associated with an increased mortality risk (OR=1.06 per hour, 95% CI =1.01-1.10.) A prospective cohort study of 1870 ICU survivors found that at the time of ICU discharge to the ward three factors are predictive of hospital outcome: nightshift discharge (RR=1.7; 95% CI 1.03-2.9), limitation of treatment or resuscitation orders, and initial illness severity. Premature ICU discharge (of ICU survivors) is also associated with an increased mortality risk and unexpected ICU readmission rate.
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ItemLife after life-support( 1998)This research project examined the 639 admissions to the intensive care unit at the Royal Melbourne Hospital between 1 July and 31 December 1993. The data were examined from a biopsychosocial perspective using both qualitative and quantitative methods. I demonstrate that the lack of commitment to provide ongoing health and social services in the community diminished the efforts made in the intensive care unit. Although the commitment to “save lives” in the intensive care unit was evident in the 90% survival rate, the failure to provide adequate follow-up care in the general wards and the community contributed to both the 10.5% readmission rate to the intensive care unit and the 101 unplanned readmissions to hospital. Six months after discharge from the intensive care unit, patients’ perceived health status, functional recovery and “quality of life” were assessed by personal interviews and self-reported questionnaires. Although 90% of the survivors were living at home, this did not always imply a “successful” outcome. While the degree of dependency varied, many patients required ongoing care in the community. The reliance on families to provide this care is located within a broader social and political ideology. In this thesis, I argue that there was a failure to recognise the integral relationship between intensive care units and other parts of the health care system. This resulted in life-saving crisis interventions in the intensive care unit without a continuity of care. To ensure that the life-saving efforts in the intensive care unit are worthwhile, the current biomedical and economic perspective needs to be complemented with a more holistic approach to health care. Recognising that patients have special needs after discharge from the intensive care unit, that the technological “fix” does not occur in isolation, and that the recovery process may be slow and long, is crucial. Continuity of care in both the general hospital wards, the rehabilitation hospital and the community makes the difference between patients thriving and merely surviving.