Masters theses conferred to rural docs

Tuesday, May 21st, 2019 | Rory | No Comments

Congratulations to two rural docs who were conferred their Masters degrees very recently from the University of Otago. Both theses are available free and open access from the University of Otago

Histories of Chest Pain from a Master of GP (credit) – Trevor Lloyd

Lloyd, T. (2018). Histories of Chest Pain: history of the presenting complaint as recorded by different health care providers of patients presenting to a rural hospital with suspected acute myocardial infarction (Thesis, Master of General Practice). University of Otago. Retrieved from Permanent link to OUR Archive version: http://hdl.handle.net/10523/8612

“Although there are many parallels between literature and clinical records, they are not the same thing. Clinical records are produced in a different way – typically by a team. They have different intended audiences. They have different associated ethical issues. Most importantly, they have different purposes.Clinical records are not designed to entertain, or to tell a story merely to find out “what happens next”. It is important to understand, for its purpose of facilitating clinical care, that the record is not merely a description of events. Each piece of information recorded by each health care provider is part of a carefully constructed document, that can be used for multiple purposes.The most important of these is to co-operate in describing, interpreting, and determining the best course of action, in the unique way that clinicians refer to as history and examination, diagnosis, and treatment.“

Abstract:

This thesis investigates how different health professionals record the history of the presenting complaint of patients with suspected acute myocardial infarction admitted to a rural hospital. Different health professionals, each with their own ways of working and communicating, co-operate in diverse teams that ideally have more to offer the patient than individual professionals working alone. This includes the taking and recording of the patient’s history. This account should not be regarded as merely a way of copying a component of a clinical encounter, but as part of a sophisticated tool to guide and organise patient care. This is a case study conducted by a participant observer. A range of qualitative research analysis methods for document analysis are used to analyse what is written in patients’ clinical records by general practitioners, ambulance officers, hospital nurses, and rural hospital doctors, about their presenting complaint. Of 347 patients admitted to the hospital in 2011 who had a Troponin I blood test ordered, the clinical characteristics recorded of 50 are compared, and 10 of these are selected for more in-depth analysis. The 10 records are analysed in terms of style, vocabulary, abbreviations, what gets recorded, what gets repeated, what gets added, what gets deleted, and what gets modified. Three of the 10 records are analysed to explore how the individual records are constructed. The clinical record emerges an incremental, multi-authored, multi-layered, intertextual account, being co-produced by a range of health providers, using information from a variety of sources. The different health providers, at different stages, and using their different voices, interact to record the history of the presenting complaint. In addition, the clinical record can be seen as a way of telling the patient’s story, like a novel where the central narrative is explored from the perspectives of different characters or commentators. The record is a carefully constructed document, whose chief purpose is to develop a shared understanding of the patient’s progress and the care that needs to be provided. Good documentation is equated with good care. It is important for practising clinicians to understand how the clinical record is constructed, as an organised interdisciplinary process, and how it is used in care. Furthermore, with a move to electronic health records, it is essential that those responsible for their introduction have a similar understanding of the nature of clinical records.

Impact of RHM vocational scope in the Hokianga from A Master of Health Sciences (distinction) – Kati Blattner

Blattner, K. (2019). The impact of the rural hospital medicine vocational scope on the Hokianga Health service (Thesis, Master of Health Sciences). University of Otago. Retrieved from http://hdl.handle.net/10523/9067

The study found that RHM with its associated targeted rural training and professional development programs has enabled the strengthening of both clinical practice and wider quality systems and standards at Hokianga hospital, thus meeting the intentions of the new scope at this site. Challenges arising from the new RHM scope were also identified at both the individual practitioner and the health service level. It is acknowledged that, ten years from the introduction of the RHM scope, it is still too early for the full impact of the RHM scope to be assessed. Though focused on one rural health service with a unique, long-established model of care, findings from the study are applicable to other rural health services in NZ and internationally.

Abstract

Rural Hospital Medicine was recognised in New Zealand as a vocational scope of medical practice in 2008. The intention was to provide recognised standards of training and professional development for doctors working in rural hospitals and to encourage quality systems to become established in rural hospitals. Hokianga Health is an integrated community owned health service including a hospital in the far north of New Zealand, serving a rural Māori community. The aim of this thesis was to explore the impact of the Rural Hospital Medicine scope at Hokianga Health.

Methods A case study design using qualitative methods comprising a document analysis and interviews was chosen. A thematic analysis of key documents tracking change and development at Hokianga Health was undertaken. Twenty-six documents (ten internal and sixteen external to Hokianga Health) were included. Eleven individual semi-structured interviews were undertaken with past and present employees of Hokianga: eight were medical practitioners, three were senior non-medical staff. The interview explored the participant’s view of the Rural Hospital Medicine scope of practice. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken. The two data sources were analysed separately followed by a process of convergence and corroboration of findings.

Results Before 2008 there was a mismatch between the scope of medicine practiced at Hokianga and available medical training and professional development programmes: the hospital aspect of practice fell outside the General Practice scope. This created a vulnerability for individual practitioners and the hospital service. The Rural Hospital Medicine scope brought a specific focus to hospital practice and thus validation of this aspect of the medical practitioners’ work. The Rural Hospital Medicine and General Practice scopes together provided the right fit for medical practice at Hokianga. The strengthening of clinical practice and improved scope of services resulting from the alignment with Rural Hospital Medicine and the associated rural hospital regulatory policy, systems and processes, strengthened clinical safety and thus the viability of the hospital service. The Rural Hospital Medicine movement also strengthened Hokianga Health’s external strategic alliances helping to create a sense of belonging, and facilitating alignment with the changing external regulatory environment including nomenclature. Challenges resulting from the Rural Hospital Medicine scope at the individual practitioner level mirrored those at the health service level: rural practitioners and the rural hospital service attempting to deliver to regulatory systems and processes that had not been set up with their scope of practice and model of care in mind.

Conclusions The new vocational scope of Rural Hospital Medicine enabled the strengthening of both clinical practice and wider quality systems and standards at Hokianga Hospital, thus meeting the intentions of the new scope. In highlighting wider challenges to rural health the study supports the notion that New Zealand implements a process of rural health impact assessment. Though focused on one rural health service, findings are applicable to other rural health services in New Zealand and internationally.

Most rural hospitals reliant on POC troponin

Wednesday, April 17th, 2019 | Rory | No Comments

Miller R, Stokes T, Nixon G. Point-of-care troponin use in New Zealand rural hospitals: a national survey. New Zealand Medical Journal. 2019;132(1493):13.

Not a great surprise: most rural hospitals do not have timely access to the same troponin assays that metropolitan hospitals rely on, instead reliant on less sensitive point-of-care troponin. A significant number of NSTEMI maybe missed using POC troponin at the manufacturer’s cut-off and we have an observational study underway evaluating a pathway that will limit these missed AMI.(1,2) This pathway has been shown to be effective in a pilot run in a low-risk primary care population.(3) There is also hope as discussed previously that a new high precision point-of-care assay will bring rural chest pain assessment in line with urban hospitals.(4)

“The results of this survey reinforce the importance of considering the context and resources of all New Zealand hospitals when making recommendations at a national level, such as the adoption of ADPs. Failure to do so can confuse clinical practice in our small rural hospitals that have access to fewer resources and risks exacerbating existing inequities.”

Abstract

AIMS: Accelerated diagnostic chest pain pathways (ADP) have become standard of care in urban emergency departments. It is, however, unknown how widely they are used in New Zealand’s rural hospitals because ADP require immediate access to contemporary or high-sensitivity troponin (hs-Tn). We aimed to determine for rural hospitals the troponin assay being used, if they were using an ADP and if they had access to on-site exercise tolerance testing (ETT).

METHODS: An online survey was sent to 27 rural hospitals providing acute care in New Zealand.

RESULTS: Most rural hospitals (23/27, 85%) responded to the survey. Most (17/23, 74%) used point-of- care cardiac troponin (POC-cTn) and the majority of these hospitals (15/17, 88%) were reliant on this assay 24-hours per day. All hospitals that had timely access to hs-Tn (8/23, 35%) used an ADP but only a minority (4/17, 24%) of hospitals using POC-cTn used an ADP. Only a minority of the larger rural hospitals (7/23, 30%) had access to on-site ETT.

CONCLUSIONS: Most New Zealand rural hospitals rely on POC-cTn to assess chest pain and are not using an ADP. There are limited data available to support this approach in rural settings especially with patients who are not low-risk.

References

1. Miller R, Nixon G. The assessment of acute chest pain in New Zealand rural hospitals utilising point-of-care troponin. Journal of Primary Health Care. 2018;10(1):90–2.

2. Schneider HG, Ablitt P, Taylor J. Improved sensitivity of point of care troponin I values using reporting to below the 99th percentile of normals. Clinical Biochemistry. 2013 Aug;46(12):979–82.

3. Norman T, Devlin G, Than M, George P, Young J, Egan G, et al. Measured Implementation of an Accelerated Chest Pain Diagnostic Pathway in Primary Care. Heart, Lung and Circulation. 2018 Jan;27:S4–5.

4. Pickering JW, Young JM, George PM, Watson AS, Aldous SJ, Troughton RW, et al. Validity of a Novel Point-of-Care Troponin Assay for Single-Test Rule-Out of Acute Myocardial Infarction. JAMA Cardiology. 2018 Oct;

Research networks in Aotearoa

Monday, April 15th, 2019 | Rory | No Comments

Editorial from the latest edition of the NZMJ from two members of the Rural post-graduate programme; Marc and Sampsa.

Gutenstein M, Kiuru S. Building collaborative research networks across rural and provincial Aotearoa. New Zealand Medical Journal. 2019;132(1493):3.

“Rural and provincial research faces many of the same obstacles that clinical teams face, with fragmented and dispersed rural hospitals lacking a formal research network. Research networking is essential for disseminating and sharing knowledge, meeting local population health needs and promoting appropriate non-urban health policies.”

“Greater involvement of rural and provincial providers in health research will increase visibility of these journeys, build collaborative academic, educational and clinical networks, and allow research data to be translated back into clinical practice for all.”

Reflections on rural medical schools

Thursday, April 11th, 2019 | Rory | No Comments

Two articles in the latest edition of the Journal of Primary Care on rural medical schools for New Zealand. Dr. John Burton writes a piece on his time at the Northern Ontario Medical School and reflects what that experience means in the NZ context.

Burton John (2019) Experiencing a rural medical school. Journal of Primary Health Care 11, 6-11.

https://doi.org/10.1071/HC18096

Open access

The other is a guest editorial by Dr. Garry Nixon and Dr. Ross Lawrenson contextualising this in the current political climate. Hopefully the health minister has a read (and he might of given the comments at the National Rural Health Conference). Fingers crossed

Nixon Garry, Lawrenson Ross (2019) Failing to thrive: academic rural health in New Zealand. Journal of Primary Health Care 11, 4-5.

https://doi.org/10.1071/HCv11n1_ED2

Open access