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An unusual case of bowel perforation in a 9 month old infant

In Australia, between 2009 and 2010 almost 290 000 cases of suspected child abuse and neglect were reported to Australian state and territory authorities. Child maltreatment may present insidiously, not allowing signs of the maltreatment to be elicited until after a culmination of events. Ms. LW, a 9-month- old Indigenous female, presented to the Alice Springs Hospital emergency department (ED) with complaints of bloody diarrhea. A provisional diagnosis of viral gastroenteritis was suggested and she was managed with fluids to which her vitals responded positively. She was discharged six hours post presentation but presented three days later in a worsened condition with a grossly distended abdomen. Exploratory laparotomy found a perforated jejunum, which was deemed as a non-accidental injury. This case outlines the pitfalls in collateral communication in which we discuss the lack of use of an interpreter or Aboriginal health worker. We also emphasise the onus on junior doctors to practice in a reflective manner with the burdens of ED, so that they do not miss key diagnostic clues. Early detection of chronic maltreatment is important in the prevention of toxic stress to the child, which has been shown to contribute to a greater burden on society in the form of chronic manifestations later in life.

Introduction

Maltreatment, especially that of children can be insidious in nature, whose signs may not be evident until a culmination of unfortunate events. In Australia, during 2010-2011, there were 286,437 [1] reports of suspected child abuse and neglect made to state and territory authorities with a total of 40,466 substantiations (Figure 1). These notifications include four maltreatment types: physical abuse, sexual abuse, emotional abuse and neglect (Figure 2). As of 30 June 2010, there were 11,468 Aboriginal and Torres Strait Islander children in out-of-home care as a result of this. The national rate of Indigenous children in out-of-home care was almost ten times higher than for non- Indigenous children. [1]

Child protection statistics shown above tells us how many children have come into contact with child protection services; however, they do not take in to account the silent statistics of those who suffer without seeking aid. In all jurisdictions in 2010-11, girls were much more likely than boys to be the subject of a substantiation of sexual abuse. In contrast, boys were more likely to be subject to physical abuse than girls in all jurisdictions except Tasmania and the Northern Territory. [1]

Unfortunately it is difficult to obtain accurate statistics regarding the number of children who die from child abuse or neglect in Australia, as currently comprehensive information is not collected in every jurisdiction. Taking this into account however latest data recorded indicated that in 2006, assault was the third most common type of injury causing death for Australian children aged 0-14 years, [2] and totaled 27 children mortalities in 2006-07. Medical practitioners must be aware of the signs of child maltreatment and their long- term consequences, as they possess the opportunity to intervene and change the consequences of this terrible burden on afflicted children.

Case Presentation

Ms. LW, a nine month old Indigenous female and her mother presented to the Alice Springs ED at 2100, with complaints of bloody diarrhea. Emergency department staff noted that on presentation the infant was notably uncomfortable and tearful. She was afebrile, with mild tachypnoea (50 respirations per min) all other vitals were normal. Examination of the infant revealed discomfort in the epigastric region with no other significant findings including no organomegaly or distention. No other abdominal signs in particular signs such as guarding or rigidity were noted on admission. Systemic review did not show any significant findings. Past medical history included recurrent chest infections with the last episode two months prior. No immunisation history was available. The staff had difficulty examining the child because she was highly irritable. It was also difficult to elicit a comprehensive history from the mother as she spoke minimal English and was relatively dismissive of questions. No interpreter was used in this setting.

The patient was diagnosed with viral gastroenteritis and treated conservatively by the administration of intravenous fluids to maintain hydration. After six hours of observation and a slight improvement in Ms. LW’s vitals she was sent home in the early morning hours after intense pressure from the family. No other treatments and investigations were done and the staff discharged her with the recommendation of returning if the symptoms worsened over the next day.

The patient returned three days later to ED with symptoms clearly of a different nature and not that of the previous diagnosis of gastroenteritis. On general observation the patient appeared unwell, irritable and was crying weakly. On examination she was found to be febrile (40°C) and toxic with tachycardia (168 bpm) tachypnoea (60 respirations per minute), and gross distention of her abdomen (Figure 3).

The case was referred to the on-call surgeon, who gave a provisional diagnosis of perforated bowel and decided to perform a laparotomy. She was immediately started on intravenous broad-spectrum antibiotics, ampicillin (200mg /6hourly), metronidazole (30mg /12 hourly) and gentamicin (20 mg/daily) before surgery.

Emergency laparotomy was performed, and on initial exploration it was found that the peritoneum contained foul smelling serous fluid with a mixture of blood and faecal matter. Further exploration found perforation of the jejunum with the mesentery torn from the fixed end of the jejunum (Figure 5). The surgeons resected the gangrenous portion of the jejunum and performed an end-to-end anastomosis of small bowel.

The abdomen was lavaged with copious amounts of warm saline and the abdominal wall was closed in interrupted layers. Post surgery the child remained intubated, ventilated and was admitted to the ICU. After 24 hours post surgery the infant was extubated successfully and oral feeding was commenced after 48 hours post surgery. The patient made an uneventful recovery and was later transferred to the paediatric ward.

The surgeons commented that the initial perforation to the jejunum fixed to the mesentery caused de-vascularisation of this portion, leading to the further degradation and gangrenous state of the intestine and thus worsening the child’s condition.

As the surgeons had indicated that this injury was of a non-accidental nature the parents of the infant were brought in to be interviewed by the consultant, with the aid of an interpreter. The parents denied any falls or injuries sustained in the events leading to the presentation, which the surgical team had already exclude, due to the absence of associated injuries and symptoms. The consultant noted that both parents were not forthcoming with information even with the aid of an interpreter. Further questioning from the allied health team finally led to an answer. The father admitted that on the morning of the initial presentation while he was sitting on the ground his daughter pulled his hair from behind him to which he responded by elbowing her in the mid-region of her abdomen. Upon obtaining this information a skeletal survey was undertaken, in which a hairline fracture of the shaft of the left humerus and minor bruising in this region was found.

Case resolution

The infant was assumed into care under the basis of neglect and the case was mandatorily reported to Child Protective Services. The parents were then reported to the police for further questioning and probable court hearings. Once the patient was stable, she was discharged into the care of her grandmother, with a further review to be made by Child Protective Services at a later date.

Discussion

Child abuse is still a cause for concern in Australia although there has been a decrease in substantiations since 2007. [3] Although the total substantiations have decreased, on a state level, Victoria, South Australia, Western Australia, Tasmania and the Northern Territory have recorded an increase in the number of abuse substantiations. The most common abuse type reported in the 2010-2011 was of emotional abuse (36%) followed by neglect (29%), physical abuse (22%) and sexual abuse (13%).

Children who suffer through maltreatment not only have physical burdens placed on them, they often have many associated long-term problems. [4] The term recently coined is ‘toxic stress’, which results from sustained neglect or abuse. Children are unable to cope and hence activate the body’s stress response (elevated cortisol levels). When this occurs over a prolonged period of time it can lead to permanent changes in the development of the immune and central nervous systems (e.g. hippocampus). [5] This combination results in cognitive deficits that result in unwanted manifestations during adult life including poor academic performance, substance abuse, smoking, depression, eating disorders, risky sexual behaviors, adult criminality and suicide. [6] These health issues contribute to a significant proportion of society’s health burden.

Medical practitioners and especially those working in ED, are in an advantageous position to be able to intervene in child toxic stress. It is important to be aware of signs or ‘red flags’ that may point to maltreatment including: failure to thrive, burn marks (cigarette), unusual bruising and injuries, symptoms that do not match the history, recurrent presentation to health services, recurrent vague symptoms, child being cold and withdrawn, lethargic appearance, immunodeficiency without specific pathology and less commonly Munchausen syndrome by proxy. [7]

Previously we alluded to the fact that the child protection data only reflects those reported to the child protective services. Economically disadvantaged families are more likely to come into contact with and be under the scrutiny of public authorities. This means that it is more likely that abuse and neglect will be identified in the economically disadvantaged, [4] however child abuse may occur in all socioeconomic demographics.

This case illustrates the common pitfalls in the clinical setting, one of these being the lack of a clear history obtained at initial presentation. It was mentioned that there was poor communication between the patient’s mother and the attending to gain any meaningful information, yet there was no use of an interpreting service or Aboriginal health workers. As Aboriginal health workers have usually lived in the community they work in and most have developed lasting relationships with the community and with the various government agencies. [8] This makes them experts at bridging the communication gap between the patient and the doctor.

Another clinical pitfall demonstrated by this case was the poor examination of this infant, and the failure to recognise important signs such as guarding and rigidity – highly suggestive of insidious pathology. These finding would lead a clinician to perform further investigations such as a CXR or CT-scan which would have determined the underlying pathology. Additionally, no systemic examination was conducted in the haste to discharge the patient from ED. However, this meant, another important sign of abuse – the bruising on the infant’s left arm, was missed. Additionally, no investigations were performed when the infant initially presented to ED and hence, the diagnosis of viral gastroenteritis was not confirmed. Furthermore, bacterial gastroenteritis was not properly excluded although it is highly likely in the context of bloody diarrhoea.

Emergency department physicians have many stressors and constant interruptions during their shifts and this combination is known to cause breaks in routine tasks. [9] In 2008, the Australian Medical Association conducted a survey of 914 junior doctors and found that the majority of individuals met well established criteria for low job satisfaction (71%), burnout (69%) and compassion fatigue (54%). [10] These factors indirectly affect patient outcomes and in particular, can lead to overlooking key diagnostic clues. With the recent introduction of the National Emergency Access Target (NEAT), also know as the ‘4 hour rule’, statistics have shown that there has been no change in mortality. [11,12] However, this is a recent implementation and there is a possibility that with junior doctors and nursing staff pushed for a high turnover of patients, that child maltreatment may be missed.

Recommendations

1. Early recognition of child abuse requires a high index of suspicion.

2. Be familiar with mandatory reporting legislation as it varies between state/territories.

3. As junior doctors it is imperative that we use all hospital services such as the interpreting services and the Aboriginal health workers. We can thus enhance optimum history taking.

4. It is important to practice in a reflective manner to prevent inexperience, external pressures and job dissatisfaction from affecting patient quality of care.

5. Services should be encouraged to have Indigenous social/case workers available for consultation.

Conclusion

Paediatric presentations within a hospital can be very challenging, and as junior doctors have the most contact with these patients, they must be aware of important signs of abuse and neglect. We have outlined the importance in communicating with Indigenous patients and the related pitfalls if this is done incorrectly. Doctors are in a position to detect child abuse and to intervene before the long-term consequences manifest.

Conflict of interest

None declared.

Consent declaration

Informed consent was obtained from the next-of-kin for publication of this case report and all accompanying figures.

Correspondence

M Jacob: matt.o.jacob@gmail.com

 

Categories
Review Articles Articles

Ear disease in Indigenous Australians: A literature review

Introduction

The Australian Indigenous versus non-Indigenous mortality gap is worse in Australia than in any other Organisation for Economic Coopera tion and Development nation with disadvantaged Indigenous populations, including Canada, New Zealand, and the USA. [1] This gap reached a stark peak of seventeen years in 1996-2001. [2] Otitis media affects 80% of Australian children by the age of three years, being one of the most common diseases of childhood. [3]

Whilst ear diseases and their complications are now rarely a direct cause for mortality, especially since the advent of antimicrobial therapy and the subsequent reduction in extracranial and intracranial complications, [4] the statistics of ear disease nevertheless illustrate the unacceptable disparity between the health status of these two populations cohabiting a developed nation, and are an indictment of the poor living conditions in Indigenous communities. [5] Moreover, the high prevalence of ear disease among Aboriginal and Torres Strait Islanders is associated with secondary complications that represent significant morbidity within this population, most notably conductive hearing loss, which affects up to 67% of school-age Australian Indigenous children. [6]

This article aims to illustrate the urgent need for the development of appropriate strategies and programs, which are founded on evidencebased research and also integrate cultural consideration for, and design input from, the Indigenous communities, in order to reduce the medical and social burden of ear disease among Indigenous Australians.

Methodology

This review covered recent literature concerning studies of ear disease in the Australian Indigenous population. Medical and social science databases were searched for recent publications from 2000-2011. Articles were retrieved from The Cochrane Library, PubMed, Google Scholar and BMJ Journals Online. Search terms aimed to capture a broad range of relevant studies. Medical textbooks available at the medical libraries of Notre Dame University (Western Australia) and The University of Western Australia were also used. A comprehensive search was also made of internet resources; these sources included the websites of The Australian Department of Health and Ageing, the World Health Organisation, and websites of specific initiatives targeting ear disease in the Indigenous Australian population.

Peer reviewed scientific papers were excluded from this review if ear disease pertaining to Indigenous Australians was not a major focus of the paper. Studies referred to in this review vary widely in type by virtue of the multi-faceted topic addressed and include both qualitative and quantitative studies. For the qualitative studies, those that contributed new information or covered areas that had not been fully explored in quantitative studies were included. Quantitative studies with weaknesses arising from small sample size, few factors measured or weak data analysis were included only when they provided insights not available from more rigorous studies.

Overview and epidemiology

The percentage of Australian Indigenous children suff ering otitis media and its complications is disproportionately high; up to 73% by the age of twelve months. [7] In the Australian primary healthcare settng, Aboriginal and Torres Strait Islander children are five times more likely to be diagnosed with severe otitis media than non-Indigenous children. [8]

Chronic suppurative otitis media (CSOM) is uncommon in developed societies and is generally perceived as being a disease of poverty. The World Health Organisation (WHO) states that a prevalence of CSOM greater than or equal to 4% indicates a massive public health problem of CSOM warranting urgent attention in targeted populations. [9] CSOM affects Indigenous Australian children up to ten times this proportion, [5] and fifteen times the proportion of non-Indigenous Australian children, [8] thus reflecting an unacceptably great dichotomy of the prevalence and severity of ear disease and its complications between Indigenous and non-Indigenous Australians.

Comparisons of the burden of mortality and the loss of disabilityadjusted life years (DALYs) have been attempted between otitis media (all types grouped together) and illnesses of importance in developing countries. These comparisons show that the burden of otitis media is substantially greater than that of trachoma, and comparable with that of polio, [9] with permanent hearing loss accounting for a large proportion of this DALY burden.

Whilst there are some general indications that the health of Indigenous Australian children has improved over the past 30 years, such as increased birth weight and lower infant mortality, there is evidence to suggest that morbidities associated with infections such as respiratory infections and otitis media have not changed. [10-12]

Middle Ear disease: Pathophysiology and host risk factors

The disease process of otitis media is a complex and dynamic continuum. [10] Hence there is inconsistency throughout the medical community regarding defi nitions and diagnostic criteria for this disease, and controversy regarding what constitutes “gold standard” treatment. [7,13] In order to form a discussion about the high prevalence of middle ear diseases in Indigenous Australians, one must first establish an understanding of their aetiology and pathogenicity. Host-related risk factors for otitis media include young age, high rates of nasopharyngeal colonisation with potentially pathogenic bacteria, eustachian tube dysfunction and palato-facial abnormalities, lack of passive immunity and acquisition of respiratory tract infections in the early stages of life. [7,9,10,14,15]

Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are the recognised major pathogens of otitis media. However, this disease has a complex, polymicrobial aetiology, with at least fifteen other genera having been identified in middle ear eff usions. [11] The organisms involved in CSOM are predominantly opportunistic organisms, especially Pseudomonas aeruginosa, which is associated with approximately 20-50% of CSOM in both Aboriginal, Torres Strait Islander and non-Indigenous children. [10]

Relatively new findings in otitis media pathogenicity have included the identification of Alloiococcus otitidis and human metapneumovirus. [13] A. otitidis in particular, a slow-growing aerobic gram positive bacterium, has been identified in as many as 20-30% of middle ear eff usions in children with CSOM. [13,16,17] The importance of interaction between viruses and bacteria (with the major identified viruses being adenovirus, rhinovirus, polyomavirus and more recently human metapneumovirus) is well recognised in the pathogenicity of otitis media. [13,18,19] High identification rates of viral-bacterial co-infection found in asymptomatic children with otitis media (42% Indigenous and 32% non-Indigenous children) underscore the potential value in preventative strategies targeted at specific pathogens. [19] The role of biofi lms in otitis media pathogenesis has been of great interest since a fluorescence in-situ hydridisation study detected biofi lms in 92% of middle ear mucosal biopsies from 26 children with recurrent otitis media or otitis media with eff usion. [20] This suggested an explanation for the persistence and recalcitrance of otitis media, as bacteria growing in biofi lm are more resistant to antibiotics than planktonic cells. [20]

However, translating all this knowledge into better health outcomes – by means of individual clinical treatment and community preventative strategies – is not straightforward. A more thorough understanding of the polymicrobial pathogenesis is needed if more effective therapies for otitis media are to be achieved.

Some research has been involved in the possibility of a genetic predisposition to otitis media, based on its high prevalence observed across several Indigenous populations around the world, including the Indigenous Australian, Inuit, Maori and Native American peoples. [10] However, whilst the suggestion that genetic factors may play a role in otitis media susceptibility is a worthwhile area of further research, its emphasis should not overlook the significance of poverty, which generally exists throughout colonised Indigenous populations worldwide and is a major public health risk factor. It should be remembered that socioeconomic status is a major determinant of disparities in Indigenous health, irrespective of genetics or ethnicity.

Environmental risk factors

The environmental risk factors for otitis media are well recognised and extensively documented. They include season, inadequate housing, overcrowding, poor hygiene, lack of breastfeeding, pacifier use, poor nutrition, exposure to cigarette or wood-burning smoke, poverty and inadequate or unavailable health care. [5,7,9,10,21]

Several recent studies have examined the impact of overcrowding and poor housing conditions on the health of Indigenous children, with a particular focus on upper respiratory tract infections and ear disease. [22-24] The results of these studies reinforced the belief that elements of the household and community environment are important underlying determinants of the occurrence of common childhood conditions, which impair child growth and development, contribute to the risk of chronic disease and to the seventeen year gap in life expectancy between Aboriginal and Torres Strait Islander people and non-Indigenous Australians. [22, 23] Interestingly, one study’s findings identified the potential need for interventions which could target factors that negatively impact the psychosocial status of carers and which could also target health-related behaviour, including maintenance of household and personal hygiene. [22]

Raised levels of stress and poor mental health associated with the psycho-spatial elements of overcrowded living (that is, increased interpersonal contact, lack of privacy, loss of control, high demand, noise, lack of sleep) may therefore be considered as having a negative impact on the health of dwellers, especially those whose health largely depends on care from others, such as the elderly and young children, who are more susceptible to disease. Urgent attention is needed to improve housing and access to clean running water, nutrition and quality of care, and to give communities greater control over these improvements.

Exposure to environmental smoke is another significant, yet potentially preventable, risk factor for respiratory infections and otitis media in Indigenous children. [25,26] Of all the environmental risk factors for otitis media mentioned above, environmental smoke exposure is arguably the most readily amenable to modification. A recent randomised controlled trial tested the efficacy of a family-centred tobacco control program, aimed at reducing the incidence of respiratory disease among Indigenous children in Australia and New Zealand. It was found that interventions aimed at encouraging smoking cessation as well as reducing exposure of Indigenous children to environmental smoke had the potential for significant benefit, especially when the intervention designs included culturally sound, intensive family-centred programs that emphasised capacitybuilding of the Indigenous community. [25] Such studies testify to the potentially high levels of interest, cooperativeness, pro-activeness and compliance demonstrated by Indigenous communities regarding public health interventions, given the study design is culturally appropriate and accepts that Indigenous people need to be meaningfully engaged in preventative health efforts.

Preventative strategies

The advent of the 7-valent pneumococcal conjugate vaccine has seen a substantial decrease in invasive pneumococcal disease. However, changing patterns of antibiotic resistance and pneumococcal serotype replacement have been documented since the introduction of the vaccine, and large randomised controlled trials have shown its reduction of risk of acute otitis media and tympanic membrane perforation to be minimal. [13,27] One retrospective cohort study’s data suggested that the pneumococcal immunisation program may be unexpectedly increasing the risk of acute lower respiratory infection (ALRI) requiring hospitalisation among vaccinated children, especially after administration of the 23vPPV booster at eighteen months of age. [28] These findings warrant re-evaluation of the pneumococcal immunisation program and further research into alternative medical prevention strategies.

Swimming pools in remote communities have been associated with reduced prevalence of tympanic membrane perforations (as well as pyoderma), indicating the long term benefits associated with reduction in chronic disease burden and improved educational and social outcomes. [6] No outbreaks of infectious diseases have occurred in the swimming pool programmes to date and water quality is regularly monitored according to government regulations. On the condition that adequate funding continues to maintain high safety and environmental standards of community swimming pools, their net effect on community health will remain positive and worthwhile.

Treatment: Current guidelines and practices, potential future treatments

Over the last ten years there has been a general tendency to reduce immediate antibiotic treatment for otitis media for children aged over two years, with the “watchful waiting” approach having become more customary among primary care practitioners. [7] The current therapeutic guidelines note that antibiotic therapy provides only modest benefit for otitis media, with sixteen children requiring treatment at first presentation to prevent one child experiencing pain at two to seven days. [29] Routine antibiotics are recommended only for infants less than six months and for all Aboriginal and Torres Strait Islander children at the initial presentation of acute otitis media. [8] Current guidelines acknowledge that suppurative complications of otitis media are common among Indigenous Australians; hence specific therapeutic guidelines apply to these patients. [30] For those patients in whom antibiotics are indicated, a twice-daily regimen, five day course of amoxicillin is the antibiotic agent of choice. Combined therapy with a seven day course of higher-dose amoxicillin and clavulanate is recommended for poor response to amoxicillin or patients in high-risk populations for amoxicillin-resistant Streptococcus pneumoniae. For CSOM, topical ciprofl oxacin drops are now approved for use in Aboriginal and Torres Strait Islander children, since a study in 2003 contributed to their credibility in the treatment of CSOM. [31,32]

Treatment failure with antibiotics has been observed in some Aboriginal and Torres Strait Islander communities due to poor adherence to the twice-daily regimen of five and seven day courses of amoxicillin. [33] The reasons for non-adherence remain unclear. They may relate to language barriers (misinterpretation or non-comprehension of instructions regarding antibiotic use), storage (lacking a home fridge in which to keep the antibiotics), shared care of the child patient (rather than one guardian) or remoteness (reduced access to healthcare facility and reduced likelihood of follow-up). Treatment failure with antibiotics has also been noted in cases of optimal compliance in Indigenous communities, indicating that poor clinical outcomes may also be due to organism resistance and/or pathogenic mechanisms. [11]

A recent study compared the clinical effectiveness of a single-dose azithromycin treatment with the recommended seven day course of amoxicillin among Indigenous children with acute otitis media in rural and remote communities in the Northern Territory. [33] Whilst azithromycin was found to be more effective at eradicating otitis media pathogens than amoxicillin, azithromycin treatment was associated with an increase in carriage of azithromycin-resistant Streptococcus pneumoniae. Another recent study investigated the antimicrobial susceptibility of Moraxella catarrhalis isolated from a cohort of children with otitis media in the Kalgoorlie-Boulder region of Western Australia. [34] It was found that a large proporstion of strains were resistant to ampicillin and/or co-trimoxazole. Findings from studies such as these indicate that the current therapeutic guidelines, which recommend amoxicillin as the antibiotic of choice for treatment of otitis media, may require revision.

Overall, further research is needed to determine which antibiotics best eradicate otitis media pathogens and reduce bacterial load in the nasopharynx in order to achieve better clinical outcomes. Recent studies indicate that currently recommended antibiotics may need to be reviewed in light of increasing rates of resistant organisms and emerging evidence of new organisms.

Social ramifications associated with ear disease

There is substantial evidence to demonstrate that ear disease has a significant negative impact on the developmental future of Aboriginal and Torres Strait Islander children. [35] Children who are found to have early-onset otitis media (under twelve months) are at high risk of developing long-term speech and language problems secondary to conductive hearing loss, with the specific areas of cognition thought to be affected being auditory processing, attention, behaviour, speech and language. [36] Between 10% and 67% of Indigenous Australian school age children have perforated tympanic membranes, and 14% to 67% have some degree of hearing loss. [37]

Sub-optimal hearing can be a serious handicap for Indigenous children who begin school with delayed oral skills, especially if English is not their first language. Learning the phonetics and grammar of a second language with the unrecognised disability of impaired hearing renders the classroom experience a difficult and unpleasant one for the student, resulting in reduced concentration and increased distractibility, boredom and non-attendance. Truancy predisposes to anti-social behaviour, especially among adolescents, who by this age tend to no longer have infective ear disease but do have established permanent hearing loss. [38] Poor engagement in education and employment, alcohol-fuelled interpersonal violence, domestic violence, and communication difficulties with police and in court have all been linked to the disadvantage of hearing loss and the eventuation of becoming involved in the criminal justice system. [39]

In the Northern Territory, where the Indigenous population accounts for only 30% of the general population, 82% of the 1100 inmates in Northern Territory correctional facilities in the year 2010 were found to be Aboriginal or Torres Strait Islander. [40] Two recent studies conducted within the past two years investigated the prevalence of hearing loss among inmates in Northern Territory correctional facilities. They found that more than 90% of Australian Indigenous inmates had a significant hearing loss of >25dB. [39] A third study in a youth detention centre in the Northern Territory demonstrated that as many as 90% of Australian Indigenous youth in detention may have hearing loss, [41] whilst yet another study found that almost half the female Indigenous inmates at a Western Australian prison had significant hearing loss, almost ten-fold that of the non-Indigenous inmates. [37]

The fact that the Northern Territory study of adult inmates showed a comparatively low prevalence of hearing loss among Indigenous persons who weren’t imprisoned (33% not imprisoned compared with 94% imprisoned) [39] demonstrates a strong correlation between the high prevalence of hearing loss and the over-representation of Indigenous people in Australian correctional facilities. Although this area warrants further research, the data from these studies demonstrate that the higher prevalence of hearing loss among Indigenous inmates suggests that ear disease and hearing loss may have played a role in many Aboriginal and Torres Strait Islander people becoming inmates.

Changes and developments for the future

As we have discussed throughout this article, the unacceptably high burden of ear disease among Indigenous Australians is due to a myriad of medical, biological, socio-cultural, pedagogical, environmental, logistical and political factors. All of these contributing factors must be addressed if a reduction in the morbidity and social ramifications associated with ear disease among Indigenous Australians is to be achieved. The great dichotomy in health service provision could eventually be eradicated if there is the political will and sufficient, specific funding.

Addressing these factors will require the integration of multi- disciplinary efforts from medical researchers, health care practitioners, educational professionals, correctional facilities, politicians, and most importantly the members of Indigenous communities. The latter’s active involvement in, and responsibility for, community education, prevention and medical management of ear disease are imperative to achievement of these goals.

The Government’s response to a recent federal Senate inquiry into Indigenous ear health included $47.7 million over four years to support changes to the Australian Government’s Hearing Services Program (HSP). This was in addition to other existing funds available to eligible members of the hearing-impaired, such as the More Support for Students with Disabilities Initiative and the Better Start for Children With a Disability intervention. [42] Whilst this addition to the federal budget may be seen as a positive step in the Government’s agenda to ameliorate the burden of ear health among the Indigenous Australian population, it will not serve any utility if the funding is not sustainably invested and effectively implemented along the appropriate avenues, which should:

1. Specifically target and reduce identified risk factors of otitis media.

2. Support the implementation of effective, evidence-based, public health prevention strategies, and encourage community control over improvements to education, employment opportunities, housing infrastructure and primary healthcare services.

3. Support constructive and practical multidisciplinary research into the areas of pathogenicity, diagnosis, treatment, vaccines, risk factors and prevention strategies of otitis media.

4. Support and encourage training and employment for healthcare and educational professionals in regional and remote areas. These professionals include doctors, audiologists, speech pathologists, and teachers, and all of these professions should off er programs that increase the number of practising Aboriginal and Torres Strait Islander clinicians and teachers.

5. Adequately fund ear disease prevention and medical treatment programs, including screening programs, so that they may expand, increase in their number and their efficacy. Such services should concentrate on prevention education, accurate diagnosis, antibiotic treatment, surgical intervention (where applicable) and scheduled follow-up of affected children. An exemplary program is Queensland’s “Deadly Ears” program. [43]

6. Support the needs of students and inmates with established hearing loss in the educational and correctional environments, for example, through provision of multidisciplinary healthcare services and the use of sound field systems with wireless infrared technology.

7. Support community and family education regarding the effects of hearing loss on speech, language and education.

All of these objectives should be fulfi lled by cost-effective, sustainable, culturally-sensitive means. It is of paramount importance that these objectives should be well-received by, and include substantial input from, Indigenous members of the community. Successful implementation of these objectives reaching the grass-roots level (thus avoiding the so-called “trickle-down” effect) will not only require substantially increased resources, but also the involvement of Indigenous community members in intervention design and deliverance.

Conclusion

Whilst there remains a continuous need for valuable research in the area of ear disease, it appears that failure to apply existing knowledge is currently more of a problem than a dearth of knowledge. The design, funding and implementation of prevention strategies, community education, medical services and programs, and modifications to educational and correctional settings should be the current priorities in the national agenda addressing the burden of ear disease among Aboriginal and Torres Strait Islander people.

Acknowledgements

Thank you to Dr Matthew Timmins and Dr Greg Hill for providing

feedback on this review.

Conflicts of interest

None declared.

Correspondence

S Hill: shillyrat@hotmail.com

 

Categories
Original Research Articles Articles

Recognition and response to the clinically deteriorating patient

Background: Early recognition of clinical deterioration has been associated with a lower level of intervention and reduced adverse events. A widely-used approach in Australia is the Medical Emergency Team (MET) system. Research suggests having a multi-faceted approach to patient monitoring such as Modified Early Warning Score (MEWS) improves early review. Aim: To assess MET call initiation and response. Objectives: (1) In adult patients who have a MET call, was the call made immediately after meeting MET criteria? (2) In adult patients who have a MET call, was a MEWS scored > 4 reached prior to the call? Methods: 20 adult patients (> 18 years) that had a MET call made on acute medical or surgical wards at a Western Australian outer metropolitan secondary teaching hospital between 1 January and 30 April 2011 were selected. Records and observations were reviewed to determine whether MET call response was made immediately, and if MEWS were used, whether earlier review may have occurred. Results: Adjusted MET call response times (observations < 180 minutes) revealed 20% of patients did not have MET call made immediately (< one minute) and did not meet the standard. Ten percent warranted an earlier MET call and 25% achieved MEWS criteria > four within 180 minutes before MET call. Identification and responding to the patients with MEWS > 4 may have prevented 25% of MET calls. Conclusion: While all MET calls should have an immediate response, this is not always achieved. Implementation of MEWS may improve recognition and response to the deteriorating patient.

Introduction

Early recognition of clinical deterioration, followed by prompt response is associated with a lower level of intervention to stabilise patients and reduced adverse events. [1-3] Effective recognition and response to deterioration requires defined observation parameters, trained staff, appropriate equipment, policies, escalation protocol, communication and rapid response. [4] Adverse patient outcomes impact on the patient and health system, such as increased length of stay, unplanned return to theatre, increased morbidity, mortality, decreased bed availability and inefficient re-allocation of limited health resources. [5,6]

Early recognition and warning systems aim to identify and intervene before a patient deteriorates, reducing adverse outcomes. A widely-used approach in Australia is the Medical Emergency Team (MET) system, which includes staff education of the dangers of physiological instability, defining MET call criteria, improving communication and establishing policies, procedures, and systems for immediate response to patient deterioration. [7]

This study was conducted at a Western Australian outer metropolitan secondary teaching hospital (de-identified for publication and referred to herein as “health service”) to look at recognition and response to the clinically deteriorating patient. The health service uses the MET call system. According to MET Call Policy [8], calls should be made as soon as a patient meets any MET call criterion (Figure 1). An internal audit [9] looked at observation tools, adherence to protocol, documentation and response. Results revealed 62.5% of patient deterioration were recorded and 25% of deterioration were not acted upon (i.e. no MET call or escalation for review). In addition multiple forms were used to record observations, resulting in gaps on charts, reducing the ability to identify trends. These findings are similar to a randomised controlled study where the MET call system was introduced in twelve of 23 Australian hospitals. Researchers [7] found that when there were documented physical abnormalities and MET call criteria were reached, MET was called for only 30% of patients prior to unplanned intensive care unit (ICU) admissions. Furthermore, the MET system increased emergency team calling but did not substantially alter occurrence of cardiac arrest, unplanned ICU admission or unexpected death.

The Australian Commission on Safety and Quality in Healthcare has identified recognising and responding to clinical deterioration as a key issue. [4] The health service was introducing the COMPASS Modified Early Warning Score (MEWS) System (Figure 2 for calculation and Figure 3 for response). [12] Researchers reviewed outcomes of COMPASS and concluded that having a multi-faceted approach to patient monitoring improved early medical review following clinical instability. [11] The COMPASS system was being implemented to consolidate recordings and allow for a score (MEWS) to be calculated to flag early deterioration in addition to existing MET call processes.

The topic was chosen to enhance understanding of METs and early warning systems, including impact on outcomes and compliance with MET policy. The aim was to assess MET call initiation and response (process of care).

Objectives:

1. In adult patients who have a MET call, is the call made immediately after meeting MET criteria? (Compliance with policy).

2. In adult patients who have a MET call, was MEWS > 4 reached prior to the call? (MEWS > 4 requires medical review which may prevent MET call).

Methods

Setting

A Western Australian outer metropolitan secondary teaching hospital with a total of 13,070 medical and 4,558 surgical admissions in 2011 (average 1,089 medical and 380 surgical admissions per month). On general surgery areas, there is medical cover during the day and an on call consultant 24 hours. On general medical areas, there is medical cover during the day, Resident / Registrar cover after hours until 22:00 and on call consultant 24 hours. Emergencies on both wards are covered by the MET. The health service has one MET and one backup team.

Standard

The MET Call Policy is the standard for MET calls (Figure 1). [8] One hundred percent of MET call cases must have a documented response immediately after an observation that meets MET call criteria (Figure 1).

There is Level III-1 NHMRC evidence for MERIT Study Investigators who found MET calls were made for 30% of patients before unplanned intensive care admission and equivocal improvements in outcome based on MET call alone. [7] There is Level III-3 NHMRC evidence for findings on the effectiveness of COMPASS. [11]

Case Definition

A case is any adult patient (> 18 years) on the acute medical or general surgical ward at the health service that had a MET call made between 1 January and 30 April 2011.

Patient Selection

MET calls are documented in the medical record. The Resuscitation Educator maintains a log of all MET calls. Only MET calls that occurred in patients aged 18 years and over on acute medical or surgical areas were chosen. In patients with multiple MET calls in one admission only the first MET call was reviewed and patients with altered MET criteria were excluded. A sample size of 20 was selected due to time constraints in reviewing multiple forms and calculating MEWS by transcribing observations using a collection tool.

Sample Size and Analysis

A pilot study was conducted on three records from March 2011. Descriptive data were used for analysis. Confidence intervals (CI) were calculated using the modified Wald method. [15]

Data Collection

Data were obtained from medical records selected as per Patient Selection. The MET calls log was obtained for 1 January to 30 April 2011. MET calls for non-medical and non-surgical patients, patients less than 18 years and piloted records were removed. The first 20 MET calls where medical records could be located were chosen.

The Author collected data by reviewing medical records and records checked for altered MET criteria statements. Observations < 180 minutes to the MET call were checked on all forms in the admission. Within 180 minutes was chosen, as MET call criteria requires urine output over 3 hours to be checked. MEWS was calculated to the observation greater than but closest to 180 minutes before the MET call using MEWS Collection Tool. Data were entered into Microsoft Excel using data collection tool and dictionary. Demographic, exposure and outcome variables are listed in Figure 4. Missing, conflicting and ambiguous data were recorded as ‘missing’.

Other Issues

Cases were de-identified. Electronic data were password protected and collection tools stored securely. Identifying staff and patient information were not recorded, patient interaction was not required and patient consent was not necessary as per NHMRC. [16] Stakeholders included staff involved in initiating or attending METs and Executive. Clinical Quality and Safety Committee approval was obtained.

Results

Twenty of the 36 adult medical and surgical patients who had MET calls during January to March 2011 were selected (55.6% of MET calls). Age range of patients selected was 29 to 89 years, with a mean age of 74.7 years (median 79 years). In comparison, age range for the 36 patients from which patients were sampled was 29 to 92 years, with a mean age of 72.3 years and median 77.5 years. There were no patients with altered MET criteria.

Reason for MET call is summarised in Table 1. Five patients (25%) achieved two MET call categories, while no patients reached three or more categories. The most common reason for MET call was circulation problem (i.e. pulse rate < 40 or > 130 beats per minute (bpm)), with seven patients (35%) having MET call for this reason.

MET call response times varied between zero and ten minutes (Figure 5). Seventeen patients (85%) had a response within and including one minute. Three patients had a delay exceeding one minute (15%). The mean response time was one minute and median zero minutes.

Two patients (10%) were identified as reaching MET call criteria in observations before the one that resulted in MET call. The delay was 14 and 160 minutes, with an average of 87 minutes (Table 2). The patient with a 14 minute delay had a further four minute deferral after the second observation that achieved MET call criteria. The patient with 160 minute delay had the MET call made immediately after the subsequent observation that achieved MET call criteria. Consequently four patients (20%) had an adjusted MET call response time greater than one minute (mean 9.5 minutes, range 0-160 minutes, median 0 minutes, 95% CI 0.0749-0.4218).

For two patients (10%), it could not be determined whether an earlier observation fell into MET call criteria. One patient had missing progress notes and observation chart. The other had documented deviated observations in the progress notes without time recorded. It could not be ascertained whether this occurred within 180 minutes of the MET call.

Five patients (25%) achieved a calculated MEWS > 4 within the last observation greater than but closest to 180 minutes of the MET Call (Table 3). The 95% CI extends from 0.1081-0.4725. Of these, four were < 180 minutes of the MET call. Time period between MEWS > 4 and MET call ranged between five and 210 minutes (3 hours 30 minutes), with a mean of 113 minutes.

Five patients (25%) were discharged the same day as the MET call (Table 4). Of the five patients, one patient deceased (5%) and four patients (20%) were transferred to an acute hospital for further management (i.e. Royal Perth or Sir Charles Gairdner Hospitals).

Discussion

Adjusted MET call response times (inclusive of observations < 180 minutes) revealed 20% of patients did not have MET call made immediately (< one minute) and did not meet the standard. Ten percent warranted an earlier MET call and 25% achieved MEWS criteria > four within 180 minutes before MET call. Identification and responding to the patients with MEWS > 4 may have prevented 25% of MET calls. The CI of 0.1081 to 0.4725 warrants further study with increased sample size.

Twenty percent may not have met the standard due to delayed MET call response (e.g. hesitation or watchful waiting), inexperience, not recording altered MET criteria, and inaccurate documentation of times on the Resuscitation Record. The Resuscitation Record contained pulse rate > 140 bpm whereas hospital policy states pulse rate > 130 bpm warrants MET call. While this did not appear to affect data, it may create confusion for staff.

Ten percent of patients required earlier MET call, showing an improvement to a previous audit [9] where 25% of deterioration were not acted upon. While not achieving the standard, results are better than those found by MERIT Study Investigators where only 30% of patients admitted to the ICU had a MET call. [7] This study looked at various patients, not just ICU admissions which may contribute to this variance. Besides revealing current practice, the study provides a baseline for evaluation of COMPASS and effectiveness of MEWS post-implementation in achieving the standard.

Twenty-five percent of patients were discharged on the same day as the MET call. One patient who achieved a MEWS > 4 was discharged the same day and earlier identification with MEWS may have allowed for earlier planning or transfer. The deceased patient had an unpreventable condition.

Limitations:

  • Patients without MET call may have reached calling criteria. These were not included as the audit looked at MET calls made. Failure to meet the standard may be higher.
  • Observations in the preceding 180 minutes were reviewed. Patients may have had observations warranting MET call earlier than this.
  • Not all observations used in MEWS calculation were recorded in every observation set. MEWS > 4 may have been reached yet could not be determined.
  • Adult surgical and medical patients were included. Responses for other groups may differ.
  • Sample was determined from the MET call log. Missing forms or accidental omissions during logging of cases may have affected accuracy.
  • Audit period included January which may include increased agency and relief staff. This was intentional as staff should respond to and be familiar with MET call processes.
  • Patients with multiple MET calls only had the first MET call reviewed.
  • This was a single site and results may not be externally valid.
  • While data collected by the author was pre-recorded in the medical record, the author was not blinded to the study aims.

Results, feedback and recommendations were communicated with stakeholders at the health service through a summary report which was distributed by email, followed by presentation of findings and feedback session. Recommendations were as follows:

  • Record observations on a single form.
  • MET call policy requires a definition of “immediate” (e.g. less than one minute) to provide clarification and measurable outcome.
  • Reiterate to staff the importance of accurate documentation (e.g. times).
  • Conduct research to assess patient outcomes and compare with other hospitals.
  • Re-audit following MEWS Observation Chart implementation. Compare MET call response with other Australian hospitals that utilise COMPASS.
  • Obtain further stakeholder feedback on existing practice and potential for improvement (e.g. verbal discussion, email, team meetings).
  • Adjust pulse rate on the Resuscitation Record to > 130 bpm to reflect hospital policy.

Recommendations may be applicable to other health services utilising MET call system and MEWS, particularly defining what “immediate response” is with a timeframe to allow for review of compliance. Further research could review a selection of patients regardless of whether MET call was made and review observations to determine whether MET call should have been made. While this is a time consuming task, hospitals utilising MEWS charts will make this process easier.

Conclusion

While all MET calls should have an immediate response, this is not always achieved. Implementation of MEWS or secondary warning system may improve recognition and response to the clinically deteriorating patient. Responding to a patient at an early stage in their deterioration may reduce adverse outcomes and use of resources. To improve review and audit of response to clinical deterioration, further clarification of what “immediate” means is required in the standard.

Acknowledgements

Ms Deborah Goddard, Department of Health Western Australia

Conflict of interest

None declared.

Correspondence

G Parham: glenn.parham@gmail.com

References

[1] Australian Commission on Safety and Quality in Healthcare. National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration [Internet]. Sydney: ACSQHC; 2010 [cited 2011 Mar 13]. Available from: http://www.health.gov.au/internet/safety/publishing.nsf/Content/EB5349066738C24CCA2575E70026C32A/$File/
national_consensus_statement.pdf.

[2] National Institute for Health and Clinical Excellence. Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital [Internet]. London: NICE; 2007 [cited 2011 Mar 13]. Available from: http://www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf.

[3] Hillman KM, Bristow PJ, Chey T, Daffurn K, Jacques T, Norman SL, et al. Antecedents to hospital deaths. Intern Med J. 2001;31: 343-8.

[4] Australian Commission on Safety and Quality in Healthcare. Recognising and Responding to Clinical Deterioration: Background Paper [Internet]. ACSQHC; 2008 [cited March 2011]. Available from: http://www.health.gov.au/internet/safety/publishing.nsf/Content/AB9325A491E10CF1CA257483000C9AC4/$File/
BackgroundPaper-2009.pdf.

[5] Dacey MJ, Mirza ER, Wilcox V, Doherty M, Mello J, Boyer A, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007;35(9):2076-82.

[6] Devita MA, Bellomo R, Hillman K, Kellum J, Rotondi A, Teres D, et al. Findings of the first consensus conference on rapid response teams. Crit Care Med. 2006;34:2463-78.

[7] MERIT Study Investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005:365:2091-7.

[8] [name deleted] Health Service. Practice Standard for the Management of Medical Emergencies and Cardiorespiratory Arrest [Hospital Work Practice]. WA: [name deleted] 2011 Jan.

[9] [name deleted] Health Service. Audit of Observational Tools [Unpublished Audit Paper]. WA: [name deleted] 2010 Jul.

[10] [name deleted] Health Service. Practice Standard for the Management of Medical Emergencies and Cardiorespiratory Arrest [Hospital Work Practice]. WA: [name deleted] 2011 Jan. P.6.

[11] Mitchell IA, McKay H, Van Leuvan C, Berryd R, McCutcheond C, Avarda B, et al. A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation. 2010;81:658-66.

[12] COMPASS. Pointing You in the Right Direction – Adult (2nd ed.). Australian Capital Territory: ACT Publishing; 2010.

[13] COMPASS. Pointing You in the Right Direction – Adult (2nd ed.). Australian Capital Territory: ACT Publishing; 2010. P.8,9.

[14] COMPASS. Pointing You in the Right Direction – Adult (2nd ed.). Australian Capital Territory: ACT Publishing; 2010. P.11.

[15] Agresti A, Coull BA. Approximate is better than “Exact” for interval estimation of binomial proportions. Am Stat 1998:52:119-26.

[16] National Health & Medical Research Council. When does quality assurance in health care require independent review. Canberra: NHRMC; 2003.

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Feature Articles

A very good iDEA: The inaugural gathering of the student division of Doctors for the Environment Australia

The result of one attendee’s bright iDEA.

In early December 2009, just prior to the much-hyped COP15 round of United Nations climate negotiations in Copenhagen, 40 medical students, representing six states and eleven medical schools, descended upon Melbourne for iDEA, the inaugural gathering for the student division of Doctors for the Environment (DEA). Attendees were encouraged to be mindful of their carbon footprints whilst travelling to the conference, with many students opting for train or coach rather than air travel. Most impressively, three Tasmanians cycled for three days from Hobart to Melbourne University (with the assistance of the Bass Strait ferry).

Education and networking were the focus of this three day gathering at Newman College within the University of Melbourne, where a plethora of distinguished speakers presented talks and interactive workshops to enlighten the receptive minds in attendance: academics, environmental activists, clinicians and all combinations of the three.

All present agreed that it was long overdue that medical students gathered to discuss environmental issues relevant to health; issues that for various reasons have been sidelined by the medical fraternity. These issues often traverse traditional subject boundaries, implying a perceived or real lack of academic expertise. Additionally, the lack of confidence in using one’s ‘authority’ as a medical professional plays a part. Climate change, for instance, is often seen as a political or economic concern rather than a threat to health. Being too busy, self-preservation, fear over allegations of hypocrisy, ignorance, inertia and ‘donor fatigue’ all contribute to the reluctance of doctors to speak up.

According to Costello et al., climate change “is the biggest global health threat of the 21st century” and the repercussions to health will be global in reach, but with a disproportionately large impact falling on the developing world. [1] Matthew Wright, co-founder of Beyond Zero Emissions, a Melbourne-based organisation promoting the rapid transition to a zero carbon future, raised the interesting point that planning for a zero-carbon future is different to planning for a low emissions future, which, in turn, is different to planning for a doubtful emission reduction trading scheme in which concessions are made to big polluters. Although it seems paradoxical, government inaction in the short term could thus be preferable to legislating a hurried, binding scheme, that is in fact ineffectual in preventing an unsafe average global warming of two or more degrees.

Richard Di Natale, a former GP and Public Health physician, provided insight into how one might make the transition from clinician to environmental activist and politician. His non-linear career trajectory has seen him transition through positions in primary care, HIV programme development, Government Health Department bureaucracy and community-building. Most recently, he is persuading Victorian voters to give him the job of a Greens Senator at the next Federal election…