Implementing a behaviour management approach in the hospital setting for individuals with challenging behaviours during acute traumatic brain injury

Block, H.1

1 Southern Adelaide Local Health, SA Health


Behaviours of concern in acute traumatic brain injury (TBI) present risks including harm to patients, equipment destruction, and workplace violence. This study aimed to determine if implementing a clinically pragmatic behaviour management approach for behaviours of concern in acute TBI reduces use of restraints, security incidences, acute length of stay admission and cost, thereby improving progress to rehabilitation. The intervention group (n = 23) consisted of acute TBI patients exhibiting behaviours of concern who received a behaviour management approach at two acute hospitals in South Australia, compared with a historical control group from both sites (n = 74). Fidelity results demonstrated high level of adherence to the implemented behaviour management approach. Intervention group had significant lower use of mechanical restraints (p = 0.03), and significantly lower acute admission costs (p = 0.034). Trends in lower pharmacological restraint usage, lower acute hospital length of stay and time from admission to rehabilitation acceptance were recorded. These pilot results contribute to improving quality of health care. Future studies are required to investigate evidence-based behaviour management interventions for acute TBI patients using rigorous knowledge translation implementation designs.

Heather Block


Scars of childhood stress exposures: A Systematic Review

Wood, N..1, Trebilco, T.1, & Cohen-Woods, S.1

1 College of Education, Psychology & Social Work, Flinders University


Childhood socioeconomic position (SEP) has potential to alter epigenetic pathways associated in the development of adulthood psychiatric outcomes. We present a systematic review synthesising the literature investigating childhood SEP and DNA methylation, with a focus on pathways involved in the development of psychiatric outcomes. We reviewed literature up to October 2019 from three databases. Studies investigating childhood SEP and DNA methylation were identified, resulting in inclusion of thirty-two publications. In total seventeen studies focused on candidate genes, typically focusing on genes implicated with the stress response and/or development of psychiatric conditions. There was little overlap of genes studied, with three genes were studied more than once. These studies typically investigated different regions of the genes, which revealed inconsistent results. Six studies calculated epigenetic age, with a small number revealing a significant association with childhood SEP. Epigenome-wide studies revealed altered patterns of DNA methylation, but patterns varied between the nine studies. This research area is emerging, and no clear patterns identified across studies. It is critical to consider factors that contribute to these variances to inform research practice, and long-term uncover replicable findings. Multiple methodological shortcomings are identified, including at the phenotypic level where construct validity of childhood SEP is highly problematic, with studies using a wide range of measures. At the epigenomic and epigenetic level studies fail to consistently use suitable controls. Study designs often utilised small samples sizes, and no pre-registered studies are reported. Larger cohorts will be required with international collaborations to strengthen this research area.

Natasha Wood

Natasha is a PhD candidate (Clinical Psychology) in the Behavioural Genomic and Environmental Mechanisms Lab at Flinders University. Natasha completed her Bachelor of Psychology (First Class Honours) in 2016 and commenced her Clinical PhD in 2018. Her research focuses on investigating the association between social disadvantage, genomic outcomes, and child and adult behaviour. Natasha is also undertaking clinician training at Flinders University and develops her clinical skills through placements and skill-based assessments. She is currently on placement as a Provisional Psychologist at Older Persons Mental Health Service in the Eastern Community team (Central Adelaide Local Health Network) and will be undertaking her next placement at the Central Australian Aboriginal Congress in Alice Springs in the latter half of 2020.

Paliperidone 3-monthly injection – experience in a real world setting

Wisdom, A.1, Cole, S.1, Ingole, A.2.  

1 Northern Adelaide LHN, SA Health, 2 Central Adelaide LHN, SA Health


Background: Paliperidone palmitate (Invega Trinza) is currently the only 3-monthly antipsychotic formulation approved for the treatment of schizophrenia. While clinical trials have demonstrated successful results, post-marketing data is limited.

Objectives: To assess rates of successful transition to the 3-monthly paliperidone injection, while exploring whether the longer dosing interval has an effect on consumer contact with mental health clinicians.

Methods: Community mental health consumers initiated on the 3-monthly paliperidone injection were followed for 6 months following their first 3-monthly injection.  Successful transition was defined as transition to the 3-monthly injection without one or more of the following events occurring within 6 months: hospital admission, additional or increased supplemental antipsychotic therapy, or change or cessation of the 3-monthly injection.

Findings: During the 6 months post transition 41 of 65 (63.1%) consumers successfully transitioned to the 3-monthly injection. Hospital admission was required for 8 (12.3%) consumers and 12 (18.5%) required increased or new antipsychotic supplementation. The 3-monthly injection was discontinued in 11 (16.9%) consumers including 7 (10.8%) who returned to the 1-monthly preparation. Consumers had fewer mean face-to-face contacts with clinicians compared to the 6 months prior to transition (8.2 vs 11.1, p<0.001). This was true for both medical (1.8 vs 2.3, p=0.01) and non-medical contacts (6.4 vs 8.8, p<0.01).

Conclusions: Challenges may be present when transitioning to a long acting antipsychotic injection with a longer dosing interval in a real world setting.  Dissemination of these findings to multi-disciplinary community teams is anticipated to increase purposeful engagement with consumers during this transition period.

Alice Wisdom

Alice is currently a Senior Pharmacist within the Northern Adelaide Local Health Network, working in Mental Health and Research.  Her areas of interest include promoting and sustaining quality use of medicines and expanding the role of pharmacists to improve patient care. Alice also has a special interest in research within the area of mental health. Alice has over 5 peer-reviewed publications and has presented her work at several national conferences. Within her research role, partnering with SA Pharmacy, Alice supports and promotes quality, innovative and collaborative research within NALHN.

“HPE App”: Creating a High Protein and Energy diet app to promote interactive learning for rehabilitation patients.

Lawless, C.1, Wakeham N.1, Buring, T. 1 & McGrath, A 1.

1 Division Rehabilitation, Aged Care and Palliative Care, SALHN, SA Health


Background: A paper based pamphlet is the traditional means of delivering generic nutritional information to patients. However, in an increasingly technology driven health environment, a digital application (app) may be an alternative to deliver nutrition information to patients in an interactive way.

Aims:  To develop and pilot an app, to allow patients to undertake self-directed or clinician-supported learning on the general principals of a High Protein and Energy (HPE) diet.

Methods:  The app content was written by dietitians who are expert in delivering nutrition information to patients; based on evidence and current food and food product knowledge. The app was designed and created by the SALHN Telerehab IT specialist and piloted with consumers and clinicians. The app was continually modified based on feedback regarding readability, ease of use and visual appeal, until it was well accepted by consumers.

Results: Initial data suggests the introduction of a HPE diet app is an effective, enjoyable and engaging way to support patient learning. The app allows patients to complete a pre and post learning quiz, in order to understand baseline knowledge and provide an outcome measure for patients’ knowledge gain. The app also includes a survey to gather feedback after each use so, that the platform can continue to be improved.

Conclusions:  The app has been used successfully in a home rehabilitation setting. Future plans are to explore the use of the app in other settings and to create additional apps covering different nutrition topics.

Natalie Wakeham

Natalie Wakeham is the Acting Director for Dietetics in the Rehabilitation, Aged and Palliative Care Division in SALHN and has significant experience in clinical practice in a rehabilitation setting. She has expertise designing and maintaining therapy interventions and quality initiatives for rehabilitation patients. Natalie is leading her dietetics team to strive to continuously improve the service and innovate in line with evidence based guidelines. She is passionate about interdisciplinary practice and improving the patient’s hospital experience and is currently working on several projects in this space.

Cassandra Lawless

Cassandra Lawless is an enthusiastic Accredited Practising Dietitian (APD) and author who has worked with rehabilitation clients ​for the majority of her career. Cassandra uses food science to underpin her practice in helping clients reach their optimum health and has a particular interest in best nutrition to prevent sarcopenia and frailty. She continually strives to modernise health care and has spent the last year working with IT to develop a high energy high protein application. She is also currently undertaking her Honours degree looking at the validity of digitally diagnosing malnutrition.

Weekly versus fortnightly Allied Health early intervention for children with diagnosed/suspected developmental delay

Varvounis, N.1, Frost, J.1, Stott, J.1, Ward, E. 2, Lefmann, S. 2, Boyle, T. 2, Boshoff, K. 2

1 Northern Adelaide LHN, SA Health, 2 University of South Australia


Background and aims: NALHN Children & Families team provides Allied Health assessment and blocks of therapy for children with diagnosed/suspected developmental delays. This study compared the impact of a weekly versus fortnightly therapy model for client attendance rates, clinician caseload management and service efficiency.

Methods: A pre-post group comparison study was conducted between fortnightly intervention over 10 weeks in school term 2 and weekly intervention over 5 weeks in term 3. Pre- and post-intervention data on “did-not-attend” rates and clinical outcome measures (Canadian Occupational Performance Measure–COPM) were compared and open-ended data collected via questionnaires given to clinicians, carers and administrative staff.

Results: A non-statistically significant difference (P>0.05) between fortnightly (n=843) and weekly (n=1117) attendance rates (85.6% vs 84.3%) was recorded. No statistically significant difference between groups (group 1 n=25, group 2 n=29) (p>0.05) was obtained for the COPM pre-intervention versus post-intervention scores. Qualitative responses from parents (n=96) and clinicians (n=34) indicate a variety of preferences for intervention frequency, indicating the impact of individual child and family factors along with clinician workload pressures.

Conclusions: It is recommended that where possible, a flexible model of frequency for service delivery be adopted to suit the needs of children and families, in alignment with clinician clinical reasoning related to the intervention type for each child. Considerations to the decision making around frequency should include: child’s condition, type of therapy; relationship building with child and family, family practicalities, vulnerability of the family and benefits of contact time with the service.

Nicolette Varvounis

Nicolette is the Senior Manager of Speech Pathology for the Northern Adelaide Local Health Network which includes leadership of adult and paediatric Speech Pathology services in the acute and community settings. Nicolette has been working as a Speech Pathologist since 2009 with her professional background primarily including broad experience with the adult population presenting with swallowing and communications disorders in the acute setting.

Jessica Frost

Jessica is the Allied Health Clinical Educator for the Northern Adelaide Local Health Network, Allied Health Division which involves coordinating, developing and delivering divisional wide education to the allied health professions. Jessica has been working as a Physiotherapist since 2008 with her professional background primarily including broad experience in the adult acute care setting and providing clinical education to Physiotherapy students on placement.

Effects of standard versus energy dense feeds on gastric retention, calorie delivery, and glycaemia in critically ill patients

Chapple LS1,2, Summers MJ1,2, Weinel L1,2, Ali Abdelhamid Y1,3, Kar P1, Calnan D4, Hatzinikolas S5, Lange K5, Poole A1, O’Connor S2, Horowitz M5, Jones KL5, Deane A3,5, Chapman M1,2.

1Discipline of Acute Care Medicine, University of Adelaide, 2Intensive Care Unit, Royal Adelaide Hospital, CALHN, SA Health, 3Intensive Care Unit, The Royal Melbourne Hospital, Victoria, 4Nuclear Medicine, Royal Adelaide Hospital, CALHN, SA Health, 5Discipline of Medicine, University of Adelaide


Background: Critically ill patients frequently exhibit delayed gastric emptying and associated feed intolerance, which are frequently managed by the prescription of energy-dense formulae. However, these formulae have a higher lipid content and may delay gastric emptying (GE) further.

Aim: To compare the rate of GE of isocaloric 1 and 2 kcal/ml liquid nutrient boluses in critically ill patients.

Methods: A randomised, blinded, cross-over study was performed in mechanically ventilated adults on two consecutive days following a four hour fast. They received an isocaloric, radiolabeled, intragastric bolus of either 200ml of a 1kcal/ml or 100ml of a 2kcal/ml enteral formula. GE was measured using scintigraphy. Total areas under the curve from baseline to 120 minutes (AUC120) were determined for gastric retention and small intestinal calorie delivery. Group differences were compared using a paired mixed effects model. Data are presented as mean ± SE.

Results: Fifteen patients were studied (M:F 11:4; age 55.9 ± 5.9 years). There was no difference in the rate of GE (AUC120: 1 kcal/ml 5640±524 vs 2 kcal/ml 7009±745 %.min; p=0.059) or gastric retention at 120 mins (16.8±3.7 vs 31.4±9.5; mean difference 14.6 (95% CI -6.2, 35.4); p=0.147). There was no difference in small intestinal calorie delivery (AUC120: 13078 (1048) vs 9527 (1501) kcal; p=0.057) or calorie delivery per unit time (AUC120: 172±25 vs 153±26 kcal/min.120min; p=0.513).

Conclusion: In critically ill adults, does not appear to markedly augment calorie delivery to the small intestine.

Matt is a Research Dietitian who has been working within the ICU Research team for over 10 years. Matt completed his undergraduate Bachelor of Science majoring in nutrition in 2007 and commenced a Research Scientist role within ICU Research shortly thereafter. A few years later Matt undertook a Master of Dietetics, graduating in 2014.

Matt’s research interests include nutrient absorption in critically ill patients, as well as nutritional intake and outcomes following ICU stay. In addition to research experience in ICU, Matt has experience as a clinical dietitian in the outpatient setting as well as dietitian experience in the elite team sport environment.

Cognitive reserve and functional, psychological and cognitive ability following stroke

Rosenich, E.1, Hordacre, B.1 & Hillier, S. L.1

1 Innovation, Implementation & Clinical Translation in Health (IIMPACT), University of South Australia


Background & aims: Cognitive reserve (CR) is a feature of brain structure and function said to mediate the effects of brain pathology or injury on clinical outcomes. Extensively studied in neurodegeneration, CR demonstrates increasing applicability to acute neurological injury, such as stroke, but has not been comprehensively explored. Here we report stroke outcomes at baseline and 3-months for those with low and high CR.

Methods: Thirty-three acute, first-ever stroke patients admitted to a specialised stroke unit at the Royal Adelaide Hospital, were assessed on CR, cognition, function, quality-of-life and self-efficacy at baseline. Participants were dichotomised into high or low CR-groups based on Cognitive Reserve Index questionnaire criteria. Fugl-Meyer Assessment (upper-limb) and Montreal Cognitive Assessment were completed to describe clinical characteristics of high/low CR groups. Outcomes measured disability, independence, self-efficacy, and quality-of-life.

Results: Baseline characteristics were similar between groups, except for cognitive ability, where those with high CR (M= 23.5, SD= 4.8) significantly outperformed those with low CR (M= 19, SD= 1; p= 001). Preliminary 3-month data shows a trend for the low CR group to demonstrate poorer outcomes (M difference from baseline) on measures of independence (M=-21.5), disability (M=+0.17), quality-of-life (M=+14.8), and self-efficacy (M=-19.7).

Conclusions: While current findings are preliminary and should be interpreted with caution, CR may be an important mediator of stroke outcomes. Importantly, CR is modifiable across the lifespan and might demonstrate utility for primary/secondary prevention, health promotion/intervention, prediction of recovery following stroke and clinical decision-making.

Emily Rosenich

Emily holds a Bachelor of Psychology with honours and is a final-year PhD candidate in the Division of Health Sciences at the University of South Australia. Her doctoral research focuses on understanding how cognitive reserve influences cognitive, motor, and psychological impairment and recovery, as well as neurophysiological brain change (functional connectivity), following stroke. Throughout her PhD, Emily has been awarded an emerging early-career researcher in cognitive ageing travel award and has conducted a research internship at the prestigious Institute for Stroke and Dementia at the Ludwig-Maximillian’s University of Munich, Germany. In addition to her scientific work, Emily is a passionate science communicator and advocate for young people and women in science and is frequently involved in community outreach activities aimed at increasing the visibility of women in science.

An observational study of the provision of nutrition to Neonates <34 weeks gestation in the Lyell McEwin Hospital Special Care Nursery

Ritan, A1 & Chiro, L1

1 Lyell McEwin Hospital, NALHN, SA Health


Early nutrition interventions for pre-term infants in the first few weeks of life are associated with improved growth and better neurodevelopmental outcomes. This study investigated the types of early nutrition provided to preterm infants <34 weeks gestation within the Special Care Nursery (SCN) and the time taken to meet recommended nutritional requirements. A retrospective audit of eligible individual infant medical records was used to collect primary (timing, types and mode of delivery of feeding interventions) and secondary (growth) measures from 16 preterm infants who met the inclusion criteria.

Enteral nutrition was commenced in all preterm infants. The time of commencement from birth varied and there was no standardised approach to enteral feed upgrade. The mean time to achieve goal rate was 5½ days post-birth. 37.5% received a term infant formula as the first source of enteral feed and 62.5% received expressed breast milk. 75% of preterm infants commenced fortification during their admission with a human milk fortifier or a preterm formula. 87.5% of preterm infants received a first breastfeed attempt at a mean of 5½ days post birth. 75% of pre-term infants met recommended nutritional requirements at a mean age of 7 days post birth. 56% of pre-terms dropped weight Z score between 0.8 – 2 standard deviations. This study concludes that suboptimal nutrition is provided to preterm infants <34 weeks on the SCN. The lack of standardised feeding practices on the unit results in delays meeting nutrition requirements. Further investigation into standardising feeding practices with specialist Dietetic support is recommended.

Anna Ritan is Senior Paediatric Dietitian at Lyell McEwin Hospital (LMH), where Anna provides Dietetic assessment and advice for infants and children presenting with nutrition related concerns. Anna has over ten years of experience working in clinical dietetics and has a keen interest in promoting adequate nutritional intake in early life. Anna provides a consultative role to other staff and disciplines regarding paediatric dietetics. Anna developed and completed this observation study to investigate current practices in the LMH Neonatal ward and to provide a base for ongoing service development.

Lucilla Chiro is Acting Senior Paediatric Dietitian at Lyell McEwin Hospital. Lucilla has ten years’ experience working as a dietitian in inpatient, outpatient and community based sites in Australia and the UK. Lucilla has a keen interest in optimising health outcomes by supporting appropriate nutrition in the first 1000 days of life.

NALHN Pilot 12-Week Group Program for People with Borderline Personality Disorder

Nettle, F1

1 Northern Community Mental Health, NALHN, SA Health


Background and aims: The NALHN Borderline Personality Disorder Service Plan (June 2019) proposed a stepped model of care (MOC) in Community Mental Health. The goal of this project was to evaluate a 12-week group program for people with BPD (“12-Week BPD Group”), which forms step two of the MOC. Depending on outcomes of the evaluation, it was anticipated this program may be rolled out to both NALHN mental health sites as part of the stepped MOC.

Methods: 7 participants with BPD were assessed as suitable and offered a place in the 12-Week BPD Group. Participants were recruited from people who had been referred to the DBT Skills Group living in the NALHN catchment area. Participants were aged 21-58 years, 6 female and 1 male. People with active psychotic symptoms, significant antisocial traits, or cognitive impairment were not included. Evaluation was based on clinical outcome measures (K10, Borderline Symptom List 23, BSL – Supplement: Items for Assessing Behaviour, Emotion Regulation Scale – 18, WHO Quality of Life-BREF), client feedback, and clinician feedback. Qualitative feedback was collated and descriptive statistics were used to summarise the evaluation data.

Results: On average there were no significant differences on the clinical outcome measures. Qualitative feedback was centred on the value of supportive peer interactions, criticism of group structure; expectations as a barrier; limited uptake of skills and insufficient behavioural change.

Conclusions: Outcomes of this study will be used to inform and implement the stepped MOC. Communication with clients will be key in managing expectations of care.

Frances Nettle

Frances is a Senior Clinical Psychologist at Northern Community Mental Health, NALHN. Frances has worked in community mental health settings for the past 7 years, during which time she has specialised in working with people with Borderline Personality Disorder (BPD). As part of her role, she co-ordinates the Dialectical Behaviour Therapy program in NALHN and has recently been involved with development of a stepped Model of Care for people with BPD. Frances brings a warm, empathetic and expert approach to working with highly complex BPD presentations. She is passionate about supporting the growth and development of new and emerging clinicians with a specialised interest in BPD.

Stroke survivors’ perspectives of factors influencing adherence to an intensive upper limb exercise program.

Levy, T.1 , Laver, K.1 , Killington, M.1 , Crotty, M.1 , Lannin, N.2 , Christie, L.3

1SALHN, SA Health and Flinders University, South Australia, 2Department of Neuroscience, Monash University, Victoria, 3Allied Health Research Unit, St Vincent Health Network, New South Wales


Background: Up to 80% of stroke survivors will experience upper limb impairments immediately post stroke and less than half will be able to use their arm at 6 months. Guidelines recommend the use of intensive upper limb exercise programs to optimise recovery, however there has been limited research exploring experiences of stroke survivors participating in intensive programs.

Aim: To identify factors influencing adherence to an intensive upper limb exercise program in people with stroke.

Methods: Qualitative design. Semi structured interviews were conducted with 20 stroke survivors (mean time since stroke = 8.3 years) who had participated in an intensive upper limb rehabilitation program as part of a randomised controlled trial (the InTENSE trial). We explored perspectives of participation, including perceived barriers and enablers to adherence with the program.

Interviews were audio-recorded, transcribed and imported into Nvivo for analysis. Using deductive coding, two authors mapped themes to the Capabilities, Opportunities, Motivation- Behaviour (COM-B) behaviour change model to identify barriers and enablers to exercise adherence and engagement.

Results: Enablers influencing adherence included routine practice times (Motivation – automatic), accountability to staff (Motivation – reflective), social support (Opportunity – social) and face to face contact with staff (Opportunity – physical). Barriers to adherence included exercises being too difficult, reliance on others to help, fatigue (Capability – physical) and difficulty ‘fitting it in’ (Motivation – reflective).

Conclusion: Findings will inform recommendations for the delivery of intensive upper limb exercise programs to improve adherence, and ultimately assist services to provide rehabilitation in a manner that enables self-directed practice by stroke survivors.

Tamina Levy

Tamina works as an Advanced Practitioner, Neurological Rehabilitation at Division of Rehabilitation, Aged & Palliative Services (Southern Adelaide LHN) and has over 30 years’ experience in neurological physiotherapy. She completed a Graduate Diploma in Neurology in 1998 and is currently a PhD candidate at Flinders University where she is exploring ‘Exercise Adherence in People with Stroke’. In her clinical leadership role, Tamina has significant experience in implementing and evaluating evidence-based programs and in developing best practice amongst junior practitioners in this field. She has a strong background in stroke rehabilitation and in the management of spasticity after neurological deficit. Tamina has presented research findings from her PhD at numerous conferences and has published papers in two highly ranked journals.

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