In vivo visualization of the human lymphatic system is limited by the mode of delivery of tracing agents, depth of field and size of the area examined, and specificity of the cell markers used to distinguish lymphatic endothelium from the blood vessels and the surrounding tissues. These limitations are particularly problematic when imaging human lymphatic abnormalities. First, limited understanding of the lymphatic disease aetiology exists with respect to genetic causes and phenotypic presentations. Second, the ability of a tracer to reach the entire lymphatic network within the diseased tissue is suboptimal. Third, what is known about the expression of lymphatic endothelial cell (LEC) markers, such as podoplanin, lymphatic vessel endothelial hyaluronan receptor, Drosophila melanogaster homeobox gene prospero-1 and vascular endothelial growth factor receptor-3 in rodent lymphatic vessels and healthy human LECs may not necessarily apply in human lymphatic disease settings. The aim of this review is to highlight challenges in visualizing lymphatic vessels in human lymphatic abnormalities with respect to distribution patterns of the cellular markers currently employed to visualize abnormal human lymphatic vessels in experimental settings. Allowing for these limitations within new diagnostic visualization technologies is likely to improve our ability to image human lymphatic diseases.

OBJECTIVE: We aimed to assess the impact of a new model of care for patients presenting to the ED with acute behavioural disturbance. METHODS: This pre-/post-intervention study involved creating a dedicated, highly resourced six bed unit, the behavioural assessment unit (BAU). Co-located with the ED at the Royal Melbourne Hospital, the unit was designed to fast-track the admission of patients affected by intoxication, mental illness or psychosocial crisis and provide front-loaded interventions. RESULTS: In 12 months from 1 April 2016, 2379 patients were admitted to the BAU. They were compared with a similar cohort of 3047 patients from the entire 2015 ED population. The BAU resulted in a decreased wait to be seen (40 min [interquartile range (IQR): 17-86] vs 68 min [IQR: 24-130], P < 0.001), a decreased wait for a mental health review (117 min [IQR: 49-224] vs 139 min [IQR: 57-262], P = 0.001) and a decreased ED length of stay (180 min [IQR: 101-237] vs 328 min [IQR: 227-534], P < 0.001). Patients admitted to the BAU were less likely to have a security code (349 (14.7%) vs 538 (17.7%), P = 0.003) and less likely to have mechanical restraint (156 episodes (6.6%) vs 275 (9.0%), P < 0.001) or therapeutic sedation (156 episodes (6.6%) vs 250 (8.2%), P < 0.001). CONCLUSION: A unit specifically designed to improve the care of patients requiring prolonged ED care due to mental illness and/or intoxication reduces the time spent in the ED and the use of some restrictive interventions. We recommend this model of care to EDs that care for this complex and challenging group of patients.

AIMS AND OBJECTIVES: To obtain an understanding of how Hospital in the Home (HITH) nurses recognise and respond to clinical deterioration in patients receiving care at home or in their usual place of residence. BACKGROUND: Recognising and responding to clinical deterioration is an international safety priority and a key nursing responsibility. Despite an increase in care delivery in home environments, how HITH nurses recognise and respond to clinical deterioration is not yet fully understood. DESIGN: A prospective, descriptive exploratory design was used. A survey containing questions related to participant characteristics and 10 patient scenarios was used to collect data from 47 nurses employed in the HITH units of three major health services in Melbourne, Australia. The 10 scenarios reflected typical HITH patients and included medical history and clinical assessment findings (respiratory rate, oxygen saturation, heart rate, blood pressure, temperature, conscious state and pain score). RESULTS: The three major findings from this study were that: (i) nurse and patient characteristics influenced HITH nurses' assessment decisions; (ii) the cues used by HITH nurses to recognise clinical deterioration varied according to the clinical context; and (iii) although HITH nurses work in an autonomous role, they engage in collaborative practice when responding to clinical deterioration. CONCLUSION: Hospital in the Home nurses play a fundamental role in patient assessment, and the context in which they recognise and respond to deterioration is markedly different to that of hospital nurses. RELEVANCE TO CLINICAL PRACTICE: The assessment, measurement and interpretation of clinical data are a nursing responsibility that is crucial to early recognition and response to clinical deterioration. The capacity of HITH services to care for increasing numbers of patients in their home environment, and to promptly recognise and respond to clinical deterioration should it occur, is fundamental to safety within the healthcare system. Hospital in the Home nurses are integral to a sustainable healthcare system that is responsive to dynamic changes in public health policies, and meets the healthcare needs of the community.

AIM: To explore specialist and generalist palliative care provision for people with non-malignant respiratory disease, in rural and urban areas in the North and Republic of Ireland. BACKGROUND: Globally, palliative care is recommended as an appropriate healthcare option for people with advanced non-malignant lung disease. Yet, there is limited evidence regarding the integration of palliative care for this client group. DESIGN: Qualitative study. METHODS: Convenience sample of 17 bereaved carers and 18 healthcare professionals recruited from two rural and two urban sites on the Island of Ireland. Data were collected throughout 2012 and 2013 through semi-structured interviews with carers of patients with Chronic Obstructive Pulmonary Disease (N = 12), interstitial lung disease (N = 4) or bronchiectasis (N = 1) who had died 3-18 months previously; and four focus groups with healthcare professionals. Data were analysed using a thematic analysis framework. RESULTS: Carers' interviews yielded three overarching themes: (1) lack of preparedness for death, due to ambiguity regarding disease trajectory; (2) lack of consistency in palliative care delivery, in relation with the receipt of generalist and specialist palliative care; and (3) role ambiguity, related to their caregiving role. Focus groups identified two overarching themes: (1) barriers to appropriate palliative care; and (2) the future direction of palliative care for patient with non-malignant respiratory disease. CONCLUSION: The uncertain disease trajectory was not only experienced by carers but also healthcare professionals. Although referral to specialist palliative care services was perceived as increasing, the availability and coordination of generalist and specialist palliative care services were fragmented and varied dependent on geographical location.

AIMS AND OBJECTIVES: To explore healthcare providers' and patients' perspectives on self-management of medication during the patients' hospital stay. BACKGROUND: Self-administration of medications relates to the process in which hospitalised patients-instead of healthcare professionals-prepare and consume medications by themselves. Literature suggests possible advantages of medication self-management such as increased patient satisfaction, adherence to pharmacotherapy and self-care competence. DESIGN: A qualitative descriptive study design was adopted, using semistructured interviews and qualitative content analysis to examine data. METHODS: Six physicians, 11 nurses, six hospital pharmacists and seven patients were recruited from one regional hospital and two university hospitals, situated in Belgium. Interviews were conducted between October 2014-January 2015. RESULTS: Strengths of medication self-management were described by participants, relating to benefits of self-management for patients, time-saving benefits for nurses and benefits for better collaboration between patients and healthcare providers. Weaknesses were also apparent for patients as well as for nurses and physicians. Opportunities for self-management of medication were described, relating to the organisation, the patient and the process for implementing self-management. Threats for self-management of medication included obstacles related to implementation of self-managed medications and the actual process of providing medication self-management. A structured overview of conditions that should be fulfilled before allowing self-management of medication concerned patient-related conditions, the self-managed medication and the organisation of self-management of medication. CONCLUSIONS: This study provides new insights on the strengths, weaknesses, opportunities and threats from the perspectives of key stakeholders. Interpretation of these findings resulted in an overview of adaptations in the medication management process to facilitate implementation of self-management of medication. RELEVANCE TO CLINICAL PRACTICE: A medication management process for self-management of medication was proposed. Further interventional studies are needed to test and refine this process before implementing it in daily practice.

There has been increased focus on the use of family-centred care interventions, such as skin-to-skin contact (SSC) in Neonatal Intensive Special Care (NISC) Units over the past two decades. SSC between a parent and their neonate has previously shown to promote positive mental and emotional health in parents and assist in bonding and attachment between parent and neonate. The purpose of this study was to investigate the effect that SSC between parent and their neonate has on the parent's heart rate (HR) and blood pressure (BP). There has been a lack of prior research investigating the physiological responses from SSC on parents, hence the need to conduct this study. The study was conducted as an observational cohort study at The Royal Women's Hospital NISC Unit in Melbourne, Australia. One SSC between parent and neonate was recorded, and three repeated measures analysis of variance (anova) were conducted to investigate the relationship between SSC and the parent's HR, systolic BP and diastolic BP. The study found statistically significant differences between the parent's initial HR and BP, to measurements taken during the SSC (p < 0.05). This may suggest that parents' find SSC with their neonate to be a stress-reducing intervention, whilst they are in a NISC Unit. This may in turn promote associated benefits, such as a decrease in parental depression and anxiety, whilst they are in the NISC Unit, physical health benefits, as well as increased feelings of bonding between parent and their neonate. Based on the findings, it is suggested that SSC should be promoted in NISC Units as a family-centred care intervention that lowers parent's HR and BP and may provide associated health benefits.

BACKGROUND: Emergency airway management is commonly associated with life-threatening hypoxia and hypotension which may be preventable. AIMS: The aim of this quality improvement study was to reduce the frequency of intubation-related hypoxia and hypotension. METHODS: This prospective quality improvement study was conducted over 4 years in the Emergency Department of The Royal Children's Hospital, Melbourne, Australia. A preintervention cohort highlighted safety gaps and was used to design study interventions, including an emergency airway algorithm, standardized airway equipment, a preintubation checklist and equipment template, endtidal carbon dioxide monitoring, postintubation team debriefing, and multidisciplinary team training. Following implementation, a postintervention cohort was used to monitor the impact of study interventions on clinical process and patient outcome. Process measures were as follows: use of a preintubation checklist, verbalization of an airway plan, adequate resuscitation prior to intubation, induction agent dose titration, use of apneic oxygenation, and use of endtidal carbon dioxide to confirm endotracheal tube position. The primary outcome measure was first pass success rate without hypoxia or hypotension. Potential harms from study interventions were monitored. RESULTS: Forty-six intubations were included over one calendar year in the postintervention cohort (compared to 71 in the preintervention cohort). Overall clinical uptake of the 6 processes measures was 85%. First pass success rate without hypoxia or hypotension was 78% in the postintervention cohort compared with 49% in the preintervention cohort (absolute risk reduction: 29.0%; 95% confidence interval 12.3%-45.6%, number needed to treat: 3.5). No significant harms from study interventions were identified. CONCLUSION: Quality improvement initiatives targeting emergency airway management may be successfully implemented in the emergency department and are associated with a reduction in adverse intubation-related events.

Restrictive practices are used in response to conflict and aggression in psychiatric inpatient settings. Reducing such practices is the focus internationally of policy and legislative change, many initiatives, and a growing body of research. Safewards is a model and a set of 10 interventions designed to reduce conflict and containment in inpatient services. In the current study, we aimed to assess the impact of implementing Safewards on seclusion in Victorian inpatient mental health services in Australia. The study used a before-and-after design, with a comparison group matched for service type. Thirteen wards opted into a 12-week trial to implement Safewards and 1-year follow up. The comparison group was all other wards (n = 31) with seclusion facilities in the jurisdiction, matched to service type. Mandatorily-reported seclusion event data for all 44 wards over a 15-month period were analysed using negative binomial regression. Adherence to Safewards was measured via fidelity checklists at four time points: twice during the trial, post-trial, and at 1-year follow up. Seclusion rates were reduced by 36% in Safewards trial wards by the 12-month follow-up period (incidence rate ratios (IRR) = 0.64,) but in the comparison wards seclusion rates did not differ from baseline to post-trial (IRR = 1.17) or to follow-up period (IRR = 1.35). Fidelity analysis revealed a trajectory of increased use of Safewards interventions after the trial phase to follow up. The findings suggest that Safewards is appropriate for practice change in Victorian inpatient mental health services more broadly than adult acute wards, and is effective in reducing the use of seclusion.

This study aimed to ascertain the systemic barriers encountered by oncology health professionals (HPs) working with patients from ethnic minorities to guide the development of a communication skills training programme. Twelve medical and five radiation oncologists and 21 oncology nurses were invited to participate in this qualitative study. Participants were interviewed individually or in a focus group about their experiences working with people from minority backgrounds. All interviews were transcribed verbatim and analysed thematically. HPs encountered language and communication barriers in their interactions with patients and their families, which were perceived to impact negatively on the quality and amount of information and support provided. There was a shortage of, and poor processes for engaging, interpreters and some HPs were concerned about the accuracy of interpretation. HPs expressed a need for training in cultural awareness and communication skills with a preference for face-to-face delivery. A lack of funding, a culture of "learning on the job", and time constraints were systemic barriers to training. Oncologists and oncology nurses encounter complex challenges in clinical interactions with minority patients and their families, including difficulties working with interpreters. Formal training programmes targeted to the development of culturally competent communication skills are required.

BACKGROUND: The postpartum haemorrhage (PPH) rate in Victoria in 2009 for women having their first birth, based on information reported to the Victorian Perinatal Data Collection (VPDC), was 23.6% (primiparas). Prior to 2009 PPH was collected via a tick box item on the perinatal form. Estimated blood loss (EBL) volume is now collected and it is from this item the PPH rate is calculated. Periodic assessment of data accuracy is essential to inform clinicians and others who rely on these data of their quality and limitations. AIMS: This paper describes the results of a state-wide validation study of the accuracy of EBL volume and EBL-related data items reported to VPDC. MATERIALS AND METHODS: PPH data from a random sample of 1% of births in Victoria in 2011 were extracted from source medical records and compared with information submitted to the VPDC. Accuracy was determined, together with sensitivity, specificity, positive predictive value and negative predictive value for dichotomous items. RESULTS: Accuracy of reporting for EBL ≥ 500 mL was 97.2% and for EBL ≥ 1500 mL was 99.7%. Sensitivity for EBL ≥ 500 mL was 89.0% (CI 83.1-93.0) and for EBL ≥ 1500 mL was 71.4% (CI 35.9-91.8). Blood product transfusion, peripartum hysterectomy and procedures to control bleeding were all accurately reported in >99% of cases. CONCLUSIONS: Most PPH-related data items in the 2011 VPDC may be considered reliable. Our results suggest EBL ≥ 1500 mL is likely to be under-reported. Changes to policies and practices of recording blood loss could further increase accuracy of reporting.

AIMS AND OBJECTIVES: The aim of this study was to investigate the effect of chronic wounds on the physical, emotional, social, lifestyle and financial domains of quality of life among people who self-treat their wounds. BACKGROUND: Patient-centred models of care have received increased attention over recent decades because of the potential to contribute positively to the patient's health and well-being. A contemporary understanding of the effect of chronic wounds on quality of life may assist care providers and healthcare systems to respond to patient needs and improve patient outcomes. METHOD: A qualitative, exploratory study was conducted in Victoria, Australia. Participants were aged 18 years or older and had a chronic wound that was currently or previously self-treated. A sample of 25 participants was recruited from the community, and in-depth interviews were conducted in participants' homes. A thematic analysis was conducted to identify themes that represented the physical, emotional, social, lifestyle and financial domains of quality of life. RESULTS: Study participants (n = 25) were 71 years of age (average), and the majority had a leg wound. Participants experienced a negative effect on quality of life. Physical limitations affected activity and compromised the management of other health conditions. Participants felt frustrated with and distrusting of healthcare professionals from whom they received advice and care. Daily lifestyle and workforce participation were disrupted when receiving professional care. Wound treatment and professional care expenses negatively affected personal finances. CONCLUSION: Continued effort is required to develop relationships and treatment regimens that are conducive to healing and to optimise well-being. Additionally, healthcare systems should identify and address structural shortcomings of care services to create more patient-centred models of wound care in the community setting.