Patient, family and provider experiences with transfers from intensive care unit to hospital ward: a multicentre qualitative study [Research]

BACKGROUND:

Transfer of patient care from an intensive care unit (ICU) to a hospital ward is often challenging, high risk and inefficient. We assessed patient and provider perspectives on barriers and facilitators to high-quality transfers and recommendations to improve the transfer process.

METHODS:

We conducted semistructured interviews of participants from a multicentre prospective cohort study of ICU transfers conducted at 10 hospitals across Canada. We purposively sampled 1 patient, 1 family member of a patient, 1 ICU provider, and 1 ward provider at each of the 8 English-speaking sites. Qualitative content analysis was used to derive themes, subthemes and recommendations.

RESULTS:

The 35 participants described 3 interrelated, overarching themes perceived as barriers or facilitators to high-quality patient transfers: resource availability, communication and institutional culture. Common recommendations suggested to improve ICU transfers included implementing standardized communication tools that streamline provider–provider and provider–patient communication, using multimodal communication to facilitate timely, accurate, durable and mutually reinforcing information transfer; and developing procedures to manage delays in transfer to ensure continuity of care for patients in the ICU waiting for a hospital ward bed.

INTERPRETATION:

Patient and provider perspectives attribute breakdown of ICU-to-ward transfers of care to resource availability, communication and institutional culture. Patients and providers recommend standardized, multimodal communication and transfer procedures to improve quality of care.

AMA President opens his last conference

Dr Michael Gannon opened the AMA National Conference 2018 by figuratively saying goodbye.

In his last opening address as AMA President, which was at times emotional, Dr Gannon detailed a long list of achievements secured by the AMA during his two-year tenure.

And he poured praise on the organisation he said he enjoyed leading since 2016.

“I must say that it has been a huge honour and privilege to serve the AMA and the medical profession as Federal President,” Dr Gannon said.

“It is demanding, challenging, rewarding, and life-changing. The issues, the experiences, the depth and breadth of policy and ideas, and the interface with our political leaders and the Parliament are unique to this job.

“The responsibility is immense. The payback is the knowledge that you can achieve great things for the AMA members, the whole medical profession and, most importantly, the community, and the patients in our care.”

His address focused largely on the ground covered since the AMA met for national conference in 2017.

Describing it as a “very busy and very successful year for the Federal AMA,” Dr Gannon said time had passed very quickly in the job but much had been accomplished.

“Throughout the last 12 months, your elected representatives and the hardworking staff in the Secretariat in Canberra have delivered significant achievements in policy, advocacy, political influence, professional standards, doctors’ health, media profile, and public relations,” he said.

“We all worked tirelessly to ensure that health policy and bureaucratic processes were shaped to provide the best possible professional working environments for Australian doctors and the highest quality care for our patients.

“The unique role of the AMA in health advocacy is that we are looked to for commentary on the breadth and depth of health policy, social policy, and the health system.”

Dr Gannon said strong and robust advocacy led to a number of policy outcomes at the federal political level.

He said many organisations get nothing for their efforts, but the AMA never gives up.

“To be successful in Canberra, you have to learn to take the knocks along with the wins, then go back again and again for a better outcome,” he said.

“It is breathtakingly naïve to think it works otherwise. And that is what we have done, and keep doing.”

In 2017, the AMA launched its regular Safe Hours Audit Report, which gave added focus to the emerging issue of doctors’ health.

To enhance this focus on doctors’ health, AMA coordination of Doctors’ Health Services continues all around the country, with funding support from the Medical Board of Australia.

“We maintained a strong focus on medical workforce and training places, which resulted in the National Medical Training Advisory Network significantly increasing its workforce modelling work,” Dr Gannon told the conference.

“We secured a number of concessions in the proposed redesign of the Practice Incentive Program, as well as a delay in the introduction of changes.

“The AMA lobbied at the highest level for a more durable solution to concerns over Pathology collection centre rents. We focused on effective compliance, and achieving a fair balance between the interests of GP members and Pathologist members.

“We led the reforms to after-hours GP services provided through Medical Deputising Services to ensure that these services are better targeted, and there is stronger communication between them and a patient’s usual GP.

“We successfully lobbied the ACCC to renew the AMA’s existing authorisation that permits GPs to engage in intra-practice price setting. This potentially saves GPs thousands of dollars every year in legal and other compliance costs.

“We ensured a proportionate response from the Government in response to concerns over the security of Medicare card numbers. This avoided more draconian proposals that would have added to the compliance burden on practices, and added a barrier to care for patients.

“We fundamentally altered the direction of the Medical Indemnity Insurance Review.”

The AMA campaigned on the issue of doctors’ health and the need for COAG to change mandatory reporting laws, promoting the WA model.

It led a nationally coordinated campaign with the State AMAs and other peak bodies to uphold the TGA’s decision to up-schedule Codeine.

It campaigned against an inadequate, poorly conceived, and ideological National Maternity Services Framework, which has now been scrapped.

The 2018 AMA Public Hospital Report Card put the political, media, and public focus on the stresses and pressures on public hospitals and all who work in them. The current funding model, based entirely around payments for activity, discourages innovation and is inadequate in addressing the demands placed by an ageing population.

“We prosecuted the case for vastly improved Private Health Insurance products through membership of the Private Health Ministerial Advisory Committee, my annual National Press Club Address, an appearance before a Senate Select Committee, and regular and ongoing media and advocacy,” Dr Gannon said.

“This work was complemented by the launch of the AMA Private Health Insurance Report Card.

“We successfully lobbied for a fundamental change in the direction of the Anaesthesia Clinical Committee of the MBS Review. The Australian Society of Anaesthetists were grateful for our assistance and leadership. Many other Colleges, Associations and Societies have worked out that partnership with, rather than competing with, the AMA is the smartest way to get results.

“We launched a new AMA Fees List with all the associated benefits of mobility and regular updates.

“We saw a number of our Aged Care policy recommendations included in a number of Government reviews.

“We lobbied against what could easily have been an ill-thought-out UK-style Revalidation proposal. Our work resulted in a vastly improved Professional Performance Framework based around enhanced Continuing Professional Development.”

Dr Gannon said the AMA had provided strong leadership right across the busy public health landscape over the past year.

The AMA Indigenous Health Report Card focused on ear health, and specifically chronic otitis media.

The Federal Council endorsed the Uluru Statement from the Heart, acknowledging that Recognition is another key social determinant of health for Aboriginal and Torres Strait Islander Australians.

A product of a policy session at last year’s AMA National Conference was the subsequent updating of the AMA Position Statement on Obesity,

“I think that it is inevitable that we will eventually see a tax on sugar-sweetened beverages similar to those recently introduced in Britain and Ireland,” Dr Gannon said.

“In fact it is so simple, so easy, and so obvious, I worry that it will be seen by a future Government as a ‘silver bullet’ to what is a much more complex health and social policy issue.”

Position Statements on an Australian Centre for Disease Control; Female Genital Mutilation; Infant Feeding and Maternal Health; Harmful Substance Use, Dependence, and Behavioural Addiction; and Firearms were also highlighted.

“We conducted ongoing and prominent advocacy for the health and wellbeing of Asylum Seekers and Refugees,” he said.

“We promoted the benefits of immunisation to individuals and the broader community. Our advocacy has contributed to an increase in vaccination rates.

“We provided strong advocacy on climate change and health, among a broader suite of commentary on environmental issues.

“We consistently advocated for better women’s health services. And released a first ever statement on Men’s Health.”

New Position Statements were also released on Mental Health, Road Safety, Nutrition, Organ Donation and Transplantation, Blood Borne Viruses, and Rural Workforce.

“We promoted our carefully constructed position statement on Euthanasia and Physician Assisted Suicide during consideration of legislation in Tasmania, Victoria, New South Wales and WA,” Dr Gannon said.

“That advocacy was not universally popular. Our Position Statement acknowledges the diversity of opinion within the profession…

“We led the medical community by being the first to release a Position Statement on Marriage Equality, and advocated for the legislative change that eventuated in late 2017.”

In July 2017, AMA advocacy was publicly recognised when the Governance Institute rated the AMA as the most ethical and the most successful lobby group in Australia.

Dr Gannon added that the highlight of the 2017 international calendar for him was the annual General Assembly of the World Medical Association.

“Outcomes from that meeting included high level discussions on end-of-life care, climate change and environmental health, numerous other global social and ethical issues, and seeing the inclusion of doctors’ health as a core issue in both medical ethics and professionalism,” he said.

“I get goosebumps when I read aloud the Declaration of Geneva. It is a source of immense personal pride that I was intimately involved with its latest editorial revision, only the fifth since 1948.

“But our focus remained at home, and your AMA was very active in promoting our Mission: Leading Australia’s Doctors – Promoting Australia’s Health.

“We had great successes. We earned and maintained the respect of our politicians, the bureaucracy, and the health sector.

“We won the support of the public as we have fought for a better health system for all Australians.”

Dr Gannon thanked his family, staff, the AMA Secretariat, Board and Federal Council.

CHRIS JOHNSON

OBITUARY

Neville Maurice Newman
9 July 1923 – 27 April 2018

Neville Newman was born in Sydney on July 9, 1923, to Horace and Ella Kate (Dids) Newman and spent his school years at Scots College, Sydney, where, in addition to this academic studies, he played rugby union and rowed for the School.

In 1941, aged 17, Neville was admitted to study Medicine at the University of Sydney and resided at St Andrew’s College, where he went on to be Treasurer and President of the student body and also Senior Student in 1945. 1941 was the first year of the war-time accelerated medical course, in which the clinical years were compressed by reducing the breaks between semesters. Neville therefore graduated in 1945 with MB BS with second class Honours, after spending his clinical years at Royal Prince Alfred Hospital (RPAH).

His preclinical years were punctuated by summer holidays spent in a Mills Bomb manufacturing facility or out in the country picking fruit. He also played rugby union for the University of Sydney, being awarded a Blue in 1943.

In 1946, Neville began his residency at RPAH. Then, after a short period as an assistant in general practice, he moved to a training position at the Royal Alexandra Hospital for Children. This was the beginning of a long career in Paediatrics.

On May 10, 1948, Neville married Peg Friend, a nurse he had met at RPAH and in 1949 they moved to London so that Neville could continue his paediatric training. After a series of jobs in the Middlesex group of hospitals and several training courses, Neville passed the Fellowship exam of the London Royal College of Physicians in 1951. He was then able to obtain a paediatric registrar position at the Hillingdon Hospital, Uxbridge.

With one small daughter and a son on the way, Peg and Neville decided to return to Australia in October 1952, moving to Hobart in May 1953 to join the private paediatric practice of Arch and John Millar. This was a demanding job, with office consultation during the day and home visits all over Hobart and surrounds, every evening and often on unpaved suburban streets. Two more daughters were born in Hobart.

In 1962, Neville was awarded a Fulbright Fellowship to Johns Hopkins Hospital, Baltimore, Maryland, USA, where he took part in a developmental study of children from birth to five years of age, with Dr Janet Hardy. The whole family went with him from May 1962 to September 1963.

During this year in Baltimore, Neville developed his love for newborn babies. He was able to bring back with him a specialised three-way tap which allowed efficient exchange transfusion of babies with jaundice due to Rhesus incompatibility. For these exchange transfusions, Neville perfected the cannulisation of the umbilical vein.

On his return to Hobart, Neville began to specialise in Neonatology, attending most of the caesarean sections and multiple births.

In 1964, he was appointed Senior Paediatrician at the Royal Hobart Hospital (RHH), a practice which included neonatology and paediatric oncology. However, not long after this, John Millar retired. This meant that Neville was left as the sole paediatrician in Southern Tasmania until Dr Graham Bury arrived in Hobart in 1975 to set up a second paediatric practice.

In 1975, Neville was appointed as Senior Lecturer at the University of Tasmania and began his research into Sudden Infant Death Syndrome (SIDS) together with Drs David Megirian and John Sherry.

In 1980, Neville retired from private practice to become the Inaugural Director of the Neonatal Intensive Care Unit in the Queen Alexandra Division of the RHH, a position he held until his retirement in December 1989. During this time Neville continued his research into SIDS and in 1992 was awarded an Advance Australia Award for outstanding contribution to Medical Research into Sudden Infant Death Syndrome.

In retirement, Neville continued his interest in Medicine and was made a life member of the Tasmanian Branch of the Australian Medical Association.

Neville was lovingly cared for in the later years of his life by his family and in 2015 moved into St Andrew’s Village, Hughes, ACT. He died peacefully at on April 27, 2018, aged 94.

Neville was a leader and innovator in Neonatology, a researcher and a wonderful father. His service to the community was immense. He will be sadly missed.

By Jane Twin B Med Sc, MBBS, FRCPA
(Dr Newman’s daughter)

[Comment] Excess oxygen in acute illness: adding fuel to the fire

Oxygen is essential for life and is the third most abundant element in the universe. This abundance is evident in the treatment of acutely ill adults admitted to intensive and progressive care units around the world, in whom excess oxygen is frequently provided for inhalation. The typical motivation for liberal oxygen administration is the prevention of hypoxaemia. By contrast, few health-care providers are concerned about hyperoxaemia—ie, highly elevated arterial oxygen concentrations (arterial oxygen tension >100 mm Hg).

Traditional Aboriginal healing and western medicine meet with Ngangkari project

A hospital upgrade usually focuses on new equipment and revamped wards. But the $32 million upgrade of the Alice Springs Hospital, due for completion this year, included an unusual and culturally significant part of traditional Aboriginal healing.

A Ngangkari – an Anangu traditional healer – recently went through the entire hospital looking for lost spirits.

Ngangkari have received special tools and training from their grandparents, and attribute many illnesses and emotional states to harmful elements in the Anangu spiritual world.

The Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women’s Council employs 10 Ngangkari to work in communities in the region, and in hospitals, nursing homes, hostels, health services, and jails in regional centres.

“The hospital has been very supportive,” project manager Angela Lynch said.

“The goal is to make people better – the way you go about it doesn’t matter.

“Healing is a very strong part of Aboriginal tradition, and when the Ngangkari can explain better what they do, there will be more acceptance by western medical professionals.

“The younger doctors in particular are really interested in what the Ngangkari do, which has come about through people having a really good understanding of what traditional healing can offer.

“People are frightened to be in hospital, they are worried about having an operation – the Ngangkari can calm them. Ngangkari are peacemakers.”

AMA President Dr Michael Gannon, who visited the NPYWC during his April visit to the Northern Territory, said that traditional healing and western medicine were not necessarily exclusive.

“As doctors, we spend a lot of time warning people against non-medical treatments, but we also acknowledge the importance of spirituality and, although I don’t personally like the word, wellness.

“The concept of wellness has been hijacked to a degree. Wellness isn’t something that you buy in a bottle.

“Concepts of healing and wellness aren’t foreign to medicine, but so much of what we do is focused on intervention and science.

“Medicine needs to look at traditional healing methods sometimes, rather than reach for the script.”

The Ngangkari look for ways to complement and work with western medicine, rather than present themselves as the alternative, Ms Lynch said.

“A lot of the Ngangkari have chronic illnesses themselves, and they have enormous faith in western medicine to fix things they can’t, like dialysis, and the effects of petrol sniffing,” she said.

“They tell their patients that there are two paths, and you also need to go to the doctor. You need to stop smoking. Smoking marijuana and drinking alcohol are not good for your spirit.”

NPYWC chief executive officer Andrea Mason said that the level of trauma in Aboriginal communities was only now being recognised.

Family and domestic violence is a major factor in trauma, whether the person experiences it or witnesses it, she said.

“Psychological unwellness is a big factor in chronic disease,” Ms Mason said.

“Does one trigger the other, or do these factors work together?

“The rolling-in of the rhythm of western culture – going to school or work every day, driving not walking – this rhythm is a sandpaper to the Aboriginal culture.

“Once we begin treating the causes of trauma, the next step is saturation – to counter the level of trauma with the level of healing resources, and wrap people in healing.”

Ms Lynch said that one of the problems was the lack of a word for “depression” in Pitjantjatara.

“People don’t ask for help, and there is no help to give for suicide,” she said.

“We have started a new project to try to address this, with Ngangkari sitting down with families and psychiatrists in clinics to develop an understanding that incorporates both traditional and western views.”

The project has turned into an app, “Kulila!”, available for both iPhones and Androids, which translates different words for feelings from Pitjantjatara to English, and vice versa. Words like “kawa-kawa”, which means muddle-headed or mixed up, of “kulintja kurra”, meaning troubled mind.

It can be used in intensive care units and other medical settings to get some depth and understanding of how people are feeling.

“We also use mood cards to help people identify what’s going on in their lives,” Ms Lynch said.

“We’ve come to understand that a lot of behaviour is the result of trauma – seeing domestic violence, car accidents, etc.”

The Women’s Council has also put together a storybook for children, available from the Centre’s gift shop, which tells the lives of two children, Tjulpu and Walpa, whose lives take different paths based on early trauma.

The book was illustrated by a doctor at Alice Springs Hospital, and it is also being turned into a digital story.

The Centre also provides colouring books, and not just for children.

“When I first came to a meeting here, I saw that there were notepads and coloured pens on the tables in front of the women,” Ms Mason said.

“As the meeting went on, they all started to doodle. The more intense or confronting the conversation got, the more intense the doodling became. It’s a calming mechanism, so we’ve incorporated it into our regular activities.”

You can learn more about the activities of the NPYWC at https://www.npywc.org.au/.

MARIA HAWTHORNE

[Correspondence] Type 2 diabetes

We read with great interest the Seminar (Feb 9, 2017, p 2239)1 on type 2 diabetes by Sudesna Chatterjee and colleagues. However, we were surprised by the articles selected and believe that detailed selection criteria with the level of evidence of reported studies would have been useful to the reader. According to the research method described, we would expect other papers to be cited, including meta-analyses of randomised controlled trials that could have balanced the authors’ outlook.2–6 For example, intensive glycaemic control probably has some beneficial effect on diabetic complications, such as non-fatal myocardial infarctions3–5 or retinopathy assessed with the Early Treatment Diabetic Retinopathy Study scale.

[Comment] Atraumatic lumbar puncture needles: practice needs to change

Lumbar puncture is a procedure used to obtain cerebrospinal fluid for diagnostic or therapeutic purposes and spinal anaesthesia. A retrospective study1 showed that in 2014, lumbar puncture was done in 1·4% of patients admitted to hospital and 0·8% of patients who were admitted to Accident and Emergency departments in France. Extrapolating these figures to the National Health Service Accident and Emergency attendance data indicates that more than 160 000 lumbar punctures are done in the UK annually.

[Articles] Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial

Among patients with recent cerebral ischaemia, intensive antiplatelet therapy did not reduce the incidence and severity of recurrent stroke or TIA, but did significantly increase the risk of major bleeding. Triple antiplatelet therapy should not be used in routine clinical practice.

[Comment] Learning from TARDIS: time for more focused trials in stroke prevention

Antithrombotic therapy immediately following stroke is important to minimise the risk of recurrence, but the optimum choice and number of drugs to use are unclear, and efficacy in preventing thrombosis needs to be weighed against bleeding risk. In The Lancet, the TARDIS investigators report findings from a randomised trial1 that tested intensive antiplatelet therapy with three agents (aspirin, clopidogrel, and dipyridamole) against therapy based on current UK guidelines2 (either clopidogrel, or aspirin plus dipyridamole) for 30 days in patients with transient ischaemic attack (TIA) or ischaemic stroke.

AMA shines in Australia Day Honours

Former Australian Medical Association President Dr Mukesh Haikerwal has been awarded the highest honour in this year’s Australia Day awards by being named a Companion of the Order of Australia (AC).

He is accompanied by the current Editor-in-Chief of the Medical Journal of Australia, Laureate Professor Nick Talley, as well as longstanding member Professor Jeffrey Rosenfeld – who both also received the AC.

The trio top a long and impressive list of AMA members to receive Australia Day Honours this year.

AMA Federal Councillor, Associate Professor Julian Rait, received the Medal of the Order (OAM).

A host of other members honoured in the awards are listed below.

AMA President Dr Michael Gannon said the accolades were all well-deserved and made he made special mention of those receiving the highest Australia Day Honours.

“They have dedicated their lives and careers to helping others through their various roles as clinicians, researchers, teachers, authors, administrators, or government advisers – and importantly as leaders in their local communities,” Dr Gannon said.

“On behalf of the AMA, I pay tribute to all the doctors and other health professionals who were honoured today for their passion for their profession and their dedication to their patients and their communities.

“The great thing about the Honours is that they acknowledge achievement at the international, national, and local level, and they recognise excellence across all avenues of human endeavour.

“Doctors from many diverse backgrounds have been recognised and honoured again this year.

“There are pioneering surgeons and researchers, legends across many specialties, public health advocates, researchers, administrators, teachers, and GPs and family doctors who have devoted their lives to serving their local communities.

“The AMA congratulates all the doctors and other health advocates whose work has been acknowledged.

“We are, of course, especially proud of AMA members who are among the 75 people honoured in the medicine category.”

Dr Haikerwal, who was awarded the Officer in the Order of Australia (AO) in 2011, said this further honour was “truly mind-blowing” and another life-changing moment.

“To be honoured on Australia Day at the highest level in the Order of Australia is beyond imagination, beyond my wildest dreams and extremely humbling,” Dr Haikerwal said.

“For me to be in a position in my life and career to receive such an honour has only been made possible due to the unflinching support and unremitting encouragement of my closest circle, the people who have been with me through every step of endeavour, adversity, achievement, and success.”

CHRIS JOHNSON

AMA MEMBERS IN RECEIPT OF HONOURS

COMPANION (AC) IN THE GENERAL DIVISION

Dr Mukesh Chandra HAIKERWAL AO
Altona North Vic 3025
For eminent service to medical governance, administration, and technology, and to medicine, through leadership roles with a range of organisations, to education and the not-for-profit sector, and to the community of western Melbourne.

Professor Jeffrey Victor ROSENFELD AM
Caulfield North, Vic
For eminent service to medicine, particularly to the discipline of neurosurgery, as an academic and clinician, to medical research and professional organisations, and to the health and welfare of current and former defence force members.

Professor Nicholas Joseph TALLEY
Black Hill, NSW
For eminent service to medical research, and to education in the field of gastroenterology and epidemiology, as an academic, author and administrator at the national and international level, and to health and scientific associations.

OFFICER (AO) IN THE GENERAL DIVISION

Emeritus Professor David John AMES
East Kew, Vic
For distinguished service to psychiatry, particularly in the area of dementia and the mental health of older persons, as an academic, author and practitioner, and as an adviser to professional bodies.

Dr Peggy BROWN
Sanctuary Cove, Qld
For distinguished service to medical administration in the area of mental health through leadership roles at the state and national level, to the discipline of psychiatry, to education, and to health care standards.

Professor Creswell John EASTMAN AM
St Leonards, NSW
For distinguished service to medicine, particularly to the discipline of pathology, through leadership roles, to medical education, and as a contributor to international public health projects.

Professor Suzanne Marie GARLAND
Docklands, Vic
For distinguished service to medicine in the field of clinical microbiology, particularly to infectious diseases in reproductive and neonatal health as a physician, administrator, researcher and author, and to professional medical organisations.

Dr Paul John HEMMING
Queenscliff, Vic
For distinguished service to higher education administration, to medicine through contributions to a range of professional medical associations, and to the community of central Victoria, particularly as a general practitioner.

Professor Anthony David HOLMES
Melbourne, Vic
For distinguished service to medicine, particularly to reconstructive and craniofacial surgery, as a leader, clinician and educator, and to professional medical associations.

Dr Diana Elaine O’HALLORAN
Glenorie, NSW
For distinguished service to medicine in the field of general practice through policy development, health system reform and the establishment of new models of service and care.

MEMBER (AM) IN THE GENERAL DIVISION

Dr Michael Charles BELLEMORE
Croydon, NSW
For significant service to medicine in the field of paediatric orthopaedics as a surgeon, to medical education, and to professional medical societies.

Dr Colin Ross CHILVERS
Launceston, Tas
For significant service to medicine in the field of anaesthesia as a clinician, to medical education in Tasmania, and to professional societies.

Associate Professor Peter HAERTSCH OAM
Breakfast Point, NSW
For significant service to medicine in the field of plastic and reconstructive surgery as a clinician and administrator, and to medical education.

Professor Ian Godfrey HAMMOND
Subiaco, WA
For significant service to medicine in the field of gynaecological oncology as a clinician, to cancer support and palliative care, and to professional groups.

Dr Philip Haywood HOUSE
WA
For significant service to medicine as an ophthalmologist, to eye surgery foundations, and to the international community of Timor Leste.

Adjunct Professor John William KELLY
Vic
For significant service to medicine through the management and treatment of melanoma, as a clinician and administrator, and to education.

Dr Marcus Welby SKINNER
West Hobart, Tas
For significant service to medicine in the field of anaesthesiology and perioperative medicine as a clinician, and to professional societies.

Professor Mark Peter UMSTAD
South Yarra, Vic
For significant service to medicine in the field of obstetrics, particularly complex pregnancies, as a clinician, consultant and academic.

Professor Barbara S WORKMAN
East Hawthorn, Vic
For significant service to geriatric and rehabilitation medicine, as a clinician and academic, and to the provision of aged care services.

MEDAL (OAM) IN THE GENERAL DIVISION

Professor William Robert ADAM PSM
Vic
For service to medical education, particularly to rural health.

Dr Marjorie Winifred CROSS
Bungendore, NSW
For service to medicine, particularly to doctors in rural areas.

Associate Professor Mark Andrew DAVIES
Maroubra, NSW
For service to medicine, particularly to neurosurgery.

Dr David William GREEN
Coombabah, Qld
For service to emergency medicine, and to professional organisations.

Dr Barry Peter HICKEY
Ascot, Qld
For service to thoracic medicine.

Dr Fred Nickolas NASSER
Strathfield, NSW
For service to medicine in the field of cardiology, and to the community.

Dr Ralph Leslie PETERS
New Norfolk, Tas
For service to medicine, and to the community of the Derwent Valley.

Associate Professor Julian Lockhart RAIT
Camberwell, Vic
For service to ophthalmology, and to the development of overseas aid.

Mr James Mohan SAVUNDRA
South Perth, WA
For service to medicine in the fields of plastic and reconstructive surgery.

Dr Chin Huat TAN
Glendalough, WA
For service to the Chinese community of Western Australia.

Dr Karen Susan WAYNE
Toorak, Vic
For service to the community of Victoria through a range of organisations.

Dr Anthony Paul WELDON
Melbourne, Vic
For service to the community, and to paediatric medicine.

PUBLIC SERVICE MEDAL (PSM)

Dr Sharon KELLY
Yeronga, Qld
For outstanding public service to the health sector in Queensland.

Professor Maria CROTTY
Kent Town, SA
For outstanding public service in the rehabilitation sector in South Australia.