June - APNA

Supporting nurses in general practicePrimary TimesVolume 8 June 2010THIS ISSUEISSN 1838-0840APNA Golden Opportunities ConferenceWhat’s happening in sexual healthThe silent chronic diseasesBest practice for chronic wounds

Are you vaccinating more patientsAged Over 70with pneumococcal vaccine this year?Up to 800,000 patients received their first dose ofpneumococcal vaccine in 2005 1 and these patientsare now due for their 5 year booster. 2Some clinics are finding that the current method of recording an immunisation isdifferent to how it was recorded in 2005; e.g. entered in patient notes rather thanrecorded as an immunisation on the medical software.As a result, practice software prompts and recalls can be ineffective in findingeligible patients and these patients could now miss out on their pneumococcalbooster, prior to the onset of winter.It is recommended that you ACT NOW to identify andvaccinate all eligible patients aged over 70 before winter.Reference: 1. CSL Data on File. 2. NHMRC The Australian Immunisation Handbook. 9th Edition 2008, Chapter 3.15.CSL Biotherapies Pty Ltd, ABN 66 120 398 067, 45 Poplar Rd, Parkville, 3052. 8570_PT.

CONTENTSEDITORIAL BOARDAPNA NEWSPresident and CEO messages 2Impact of new government health funding 3Board welcomes new memberAPNA conference another success 4FEATURESWhat’s happening in sexual health? 8Sexually transmitted infections: Chlamydia 11Coping with an STI diagnosis 12Working in sexual health nursing 14The silent chronic diseases 16General practices to ACCEPt the challenge 19Best practice for chronic wounds 20National Practice Nurse Workforce Survey 22Reflecting on patient care outcomes 24INDUSTRY NEWSBook review: General Practice Nursing 27Pap test providers in Victoria on the rise 28Adrenaline auto-injector now availableNew hormone replacement therapy patchesFirst Australian National Male Health PolicyNew evidence paper on antioxidants 30New resource for bleeding disordersAsthma inhaler ‘how to’ video for childrenGo red for women 32Revised standards of wound management 34New online course on BBVs and STIsRemember pneumococcal vaccination 35this yearOsteoporosis guidelines 36Guidelines for constipation and impactionmanagementPrimary TimesThe Primary Times is the official publication of the AustralianPractice Nurses Association (APNA) and is published 4 timesa year in March, June, September and December.APNA is the professional association for nurses working ingeneral practice. It provides representation, clinical education,support and networking at national, state and local levels.AUSTRALIAN PRACTICE NURSES ASSOCIATION INC.149 Drummond Street, Carlton, Victoria, 3053ABN 30 390 041 210T: (03) 9669 7400 F: (03) 9669 7499www.apna.asn.auGreetings from the Editorial BoardWelcome to the Golden Opportunitiesissue of the June Primary Times.The second APNA Conference, held on theGold Coast 6–8 May, was indeed a golden event.We endeavour to provide readers, who were notfortunate to attend, a glimpse of our interestingand inspiring speakers; the relevant knowledgegained on primary healthcare; and, fun delegateshad networking and enjoying the organisedentertainment. (The cover photo shows NicolaRoxon, the Federal Minister for Health andAgeing, addressing delegates during the openingceremony.)A nursing milestone also took place at theConference—the launch of the first textbookdeveloped specifically for Australian practicenurses, General Practice Nursing. Ruth Mursaprovides a comprehensive review of the textbookon page 27.As a result of the Federal Budget beingannounced on 11 May, APNA CEO BelindaCaldwell provides a brief outline on page 3 ofthe changes that will impact primary healthcareand practice nursing.Sexually Transmitted Infections (STIs) andHepatitis B and C are feature articles of the issue.Chlamydia has been highlighted due to theincreasing number of people being diagnosedwith the condition over the past 10 years. SimonPowell, a practice nurse from Melbourne,APNA CHIEF EXECUTIVE OFFICERbelinda.caldwell@apna.asn.auPRIMARY TIMES CORRESPONDENCE Editoreditor@apna.asn.auAdvertisingadvertising@apna.asn.auAPNA EDITORIAL BOARDVal McKenzie (Editor) Belinda CaldwellCarmen Pearce-Brown Matt HallRuth MursaDr Elizabeth HalcombAssoc. Prof. Meredith Temple-SmithCOPY EDITORMary PetroWriterNigel DearDESIGNPerry Watson Designdescribes his experiences from hospital-basednursing many years ago to his role in a specialisedsexual health clinic.Sue Jackson, a practice nurse from Canberra,provides readers with an insight into her ownreflective nursing practices when undertakingchronic disease management.This is my last issue as Editor of Primary Times.I have resigned from the Editorial Board due topersonal commitments. I wholeheartedly thankmy colleagues on the Editorial Board and APNAstaff for their assistance and support over the pasttwo years.I encourage members to apply for the EditorialBoard and to continue to produce a high qualitymagazine that is relevant and interesting for allmembers. It is truly a fantastic opportunity tofurther your journalism skills and increase yourknowledge on a wide range of primary healthcaretopics.Val McKenzieGENERAL DISCLAIMERThe views expresses in articles are those of the contributorsand not necessarily those of APNA. Statements of fact arebelieved to be true, but no legal responsibility is accepted forthem. Primary Times reserves the right to edit, or not publish,any material submitted for publication. APNA takes noresponsibility for the advertising content in Primary Times anddoes not necessarily endorse any products or servicesadvertised. © Australian Practice Nurses Association Inc,2010. No part of Primary Times may, in any form, or by anymeans, be reproduced without prior written permission fromthe Chief Executive Officer.Platinum partnersJune 2010 Primary Times1

PRESIDENT AND CEO MESSAGESCongratulations for another great conferenceMy sincere apologies to members for notmeeting with you at the second APNAConference held on the Gold Coast recently.I was unable to attend due to family concerns.All participants—delegates, presenters andstaff—are to be congratulated for the greatwork done.Once again we were honoured by the attendance ofthe Federal Minister for Health and Ageing, NicolaRoxon. Many people have taken the time to tell methat it was a wonderful and inspiring conference, and Ilook forward to seeing all the photos when I am nextin the Melbourne office.APNA wishes Jenny Dandeaux the very best asshe moves on from the Board to other endeavours inprimary healthcare, and welcomes Susie Halsey for atwo-year term. We thank Maurice Wrightson and PeterLarter, our invited board members, for their ongoinginterest in APNA and look forward to working withthem for another year.Now is the time for further action as we move toenact those inspiring messages and learnings todevelop policy for the growth and development ofprimary healthcare nursing; as we understand anddigest the implications of the Federal Budget fundingchanges; and as we prepare to face an electioncampaign later in the year.As always, please send through your thoughtsand stories.Anne MatyearPresidentMember of theBoard of DirectorsAustralian PracticeNurses Associationpresident@apna.asn.auA great time of changeIt has been an exciting three months at APNA,since our last issue of Primary Times.The second national APNA Conference, GoldenOpportunities, was a great success withevaluations grading it higher than our first conference,which also had a great outcome. This places us undera lot of pressure to deliver an even better conferencenext year!The Federal Budget, following the conference,was anticipated with much excitement. The Budgetdelivered significant increases and a complete changein the funding arrangements for nursing services ingeneral practice.While there was positive news, there were alsoareas of great concern. We will continue to have veryclose and active input into the design of this incentive,and welcome nurses to make their views known toAPNA.Alongside all of these extraordinary activities, APNAlaunched its new website. The website has had a verypositive response and has attracted an overwhelmingnumber of unique users. A majority of members alsotook the opportunity to check their membershipdetails, which has significantly increased the accuracyof our database.A CPD portal will also be made available on thewebsite as of 1 July. The portal will enable all nursesin primary healthcare to record their CPD, upload anddownload certificates, and print a report of CPDcompletion, if ever required to provide evidenceto the Nursing and Midwifery Board Australia.At the end of June, Julianne Badenoch, ConnieRyan from AGPN and I will be attending the NZprimary healthcare nurses conference and we will betaking the opportunity to visit practices and PrimaryHealth Organisations. (At the conference, I will also bepresenting a paper on nursing in general practice inAustralia and the reform environment.) We expect theknowledge acquired during this time will inform ourlobbying around budget proposals such as thediabetes incentive package, nurse funding and theMedicare Locals.Critical to APNA is its connectedness with membersand its ability to accurately represent what the majoritywant in terms of a new primary healthcare system,which has nurses front and centre. Please engagein the debate within APNA, your division and yourpractice.I would like to add my appreciation of the workdone by our long-time editor Val McKenzie. Theattention to detail and passion for this publication hasmeant that our small organisation could consistentlydeliver a high-quality and relevant member magazine.Val, I wish you the best in all your endeavours.Belinda Caldwell, MPHChief Executive OfficerAustralian Practice NursesAssociationbelinda.caldwell@apna.asn.au2Primary Times June 2010

APNA NEWSImpact of new government health fundingCommencing in January 2012, the government will invest almost $400 millionover four years to nursing services in general practice.Accredited general practices, including those inurban areas and Aboriginal Medical Services,will be eligible to receive an incentive of $25 000per general practitioner (GP) to offset the cost ofemploying a practice nurse (PN). The incentivesinclude $25 000 for each registered nurse and$12 500 for an enrolled nurse—capped at$125 000 per practice.The PN Practice Incentive Program (PIP) subsidyand PN ‘for and on behalf of’ Medicare items will beredirected to this new incentive program. However,nurse contribution to GP item numbers such ashealth assessments and GP Management Planswill not be changed.The positives of the new government funding forPNs include:• Replacement of the ambiguous ‘for and on behalfof’ concept with block incentives to reduceconfusion over legal accountability and ensurecorrect allocation of funding.• Increased scope of duties for PNs, to allowgreater flexibility in operation of practices.• Recognition of nurses varying qualification levels.• Increased opportunity for development of skillsand new nursing services.The areas APNA will advocate for clarity orimprovement are:• Recognition of and incentives for advancednursing roles.• Disincentives for practices to allocate inappropriateadministrative tasks to nurses’ duties.• Continued recognition of nursing contribution.• Assessment of the impact of the new fundingscheme on practices with a high PN to GP ratio,to ensure continued security for jobs and thatpractices efficiently meet patients’ needs.• Funding for infrastructure to allow for increasednurse employment.• Further incentives for high quality care.The areas that may cause GP concern include:• Employed or contractor GPs may resent theloss of income from allocation of money frompresent PN Medicare items.• A lack of clear definition of the job descriptionand role of the PN.The introduction of such significant changesnaturally presents anxiety for many of us. You maybe concerned about the change of focus in your newrole. You may also be concerned about your positionif your practice considers the new scheme isdetrimental to having a PN.At this stage it is important to remain calm andwait for more details and work with the governmentand other stakeholders towards the implementationof the new scheme in 2012. We recommend liaisingwith your practice team to learn more about howthey feel the new scheme will affect your practice.Members are welcome to contact the APNA officeto discuss their concerns or ideas about how tomake these new changes work best for nurses andtheir patients. More detailed explanatory documentsabout the new changes are available for membersfrom the APNA website: www.apna.asn.au underNews & Issues/Position Statements.Board welcomes new memberAPNA congratulates and welcomes Susan Halsey as a Director to the Board, and thanksoutgoing Board member Jenny Dandeaux for her significant contribution to the Association.Susan HalseyI qualified as a registered nurse in 1973 in theUnited Kingdom. Since then, I have had a variedand broad nursing experience across manydifferent settings and in different countries.I had my first introduction to practice nursingin 1979.My husband and I moved to the Gold Coastin 1982. During this time practice nursingjobs did not appear to exist. I worked part timein theatres and studying, and occasionallyfacilitating for Griffith University nursingstudents. Since settling here, I have completeda post registration Bachelor of Nursing and aMaster in Health Administration.In 1998 we moved to Townsville, where Ibegan my career as a practice nurse in 2000.I worked in a small practice with farsighted,considerate GPs and two wonderful nurses whoshared their knowledge and skills. In 2001 theTownsville Division of General Practice beganholding small educational and networkmeetings, bringing together nurses from otherpractices. It was at this time I heard about thenewly formed APNA. I joined APNA in 2002and have been an active member, committed topromoting APNA and the role of practice nursesever since.For the past four years I have been working atthe Pindara Medical Centre on the Gold Coast,mostly in a clinical role. My expertise lies inwound management and immunisation. Myother interests are teaching and supportingnurses new to practice nursing, encouragingthem to question and become reflectivepractitioners.June 2010 Primary Times 3

APNA NEWSAPNA conferenceanother success‘A fun-filled feast of factual figures, effective fiscal forums, and efficient forms of funding,all fulminating in a fabulous, frivolous, frolicking fiesta … ’ Jenny Dandeaux, outgoing APNABoard Member and Conference Committee member.would add to this ‘fast paced, and friendshipsI new and renewed’. There are dozens ofsuperlatives to sum up the wonderful secondnational APNA Conference held at the RoyalPines Resort on the Gold Coast, 6–8 May. Thisconference has proved equally as successful aslast year’s inaugural Right Stuff Conference andthe venue was a winner for most delegates.Following registration on Thursday afternoon,a number of pre-conference workshops wereheld covering topics such as writing skills, cancerprevention and early detection, behaviourmodification, occupational health and safety,and continence management. Thursday evening’spoolside Getting to Know You social functionincluded the launch, by Lynne Walker, ElizabethPatterson and McGraw Hill, of the firstAustralian practice nursing textbook GeneralPractice Nursing.Bright and early Friday morning, setting thetheme for the Golden Opportunities Conferencewas a stage background of golden opulence.The opening ceremony commenced with a videoensemble of talented APNA member TanyaCross, giving us not just a glimpse into the life ofa busy practice nurse and her family role, but alsoshowcasing her hobby of music and singing.At the end of the video presentation, Tanya,accompanied by her children, was shown singingthe song Shine. Suddenly the stage lights shoneon a side stage and a ‘live’ Tanya appeared tocontinue her powerfully uplifting renditionof the song, setting the scene for the rest ofthe conference.Master of Ceremonies extraordinaire, MichaelPope, introduced the guest speakers, andentertained and enlivened participantsthroughout the two days.Aunty Patricia Leavy, an Aboriginal Elder ofthe Kombumerri people, warmly welcomed theaudience to the region of the Yugambeh families.She also delivered a passionate plea regarding theurgent need to improve and increase indigenoushealthcare and spoke of the necessity to employmore indigenous nurses and receptionists ingeneral practice.Concluding the opening ceremony, NicolaRoxon, the Federal Minister for Health andAgeing, addressed delegates for the secondconsecutive year and spoke of the Government’svision of an improved primary healthcare system.She also mentioned the forthcoming FederalBudget and alluded to the possibility of additionalhealth announcements that will impact onprimary health outcomes and highlighted theimportance that government places on generalpractice nurses.Golden Opportunities was launched, and theextensive program was underway. Keynotenational and international speakers motivateddelegates during the two days, with subjects suchas: innovative integrated primary care; mentalhealth; comparisons of primary health andgeneral practice environments between NewZealand and Australia; a snapshot of peopleencountered in general practice; and, improvingcommunication using your voice and bodylanguage. There was also an address from theAustralian Nursing Federation Secretary.In addition, there were master classes,workshops, an array of free papers on multipleprimary care topics and the panel discussionBeachside chat – The irate patient, complete witha fantastic stage setting. There was something foreveryone and delegates were treated to manyinspirational, outstanding and thought provokingpresentations.Friday night’s Copacabana Gala Dinner of4Primary Times June 2010

APNA NEWSDelegates enjoying the festivities during the Copacabana Gala DinnerEnjoying lunch in the Queensland sunAt one of the workshopsA big thanks to oursponsorsThe APNA wishes to thank the followingsponsors for support of the 2010 GoldenOpportunities Conference:• 3M Healthcare• AGPAL/QIP—practice accreditation• Andrology Australia• ASHM (Aust Soc HIV Medicine)• Aspen Pharmacare• Boehringer Ingelheim—Spiriva• Bright Sky Australia• Cancer Council NSW• Cancer Institute• Clifford Hallam Healthcare CH2• The College of Nursing• Continence Foundation• CSL Biotherapies• Department of Veterans’ Affairs• HACC/MASS Continence ProjectQueensland Health• Heinz• Hydralyte• Independence Australia Health Solutions• Intouch direct• McGraw-Hill Australia• Medical Observer• Medical Search.com.au• MG Nutritionals• Molnlycke• National Prescribing Service• NEHTA—National E-Health TransitionAuthority• Neilmed Pharamceuticals• Nestle Healthcare Nutrition• Nestle Infant Nutrition• Novartis Australia• PEPA• Pfizer Australia Pty Ltd• RACGP• Raising Children Network• Royal College of Nursing Aust. (RCNA)• Reckitt Benckiser Healthcare—Nurofen forChildren• Roche Diagnostics Australia Pty Ltd• Sanofi Pasteur• Smith and Nephew—Healthcare Division• Terumo Corporation• Therapeutics Guidelines• Ultrafeedback• Unilever• The Wesley Centre for Hyperbaric MedicineCocktails by the poolTanya Cross on the dance floorJune 2010 Primary Times 5

APNA NEWSKeynote speaker Debra DaviesThe exhibition areaThe main plenaryNetworkingKeynote speaker Dr Tony HobbsPresenter Philippa DavisMardi Gras masks, maracas, scrumptious foodand wine, and Latin music and dancing was anevening to wind down and enjoy oneself!This conference would not have been thesuccess it was without the support of the valuedpartners and sponsors, and their products,resources and tools, not to mention the sweettreats and coffee made available to delegates.The exhibition areas were abuzz during breaktimes and it was evident the delegates availedthemselves of opportunities to browse, engageand acknowledge the wonderful chance tovalue- add to the more formal learning sessionsof the program.Saturday’s closing ceremony was equally aswell received as the opening. Jonathon Welch ofThe Choir of Hard Knocks fame rounded off theconference with a moving account of his journeyof opportunities and finished by mesmerising theaudience with the song You raise me up.A large screen overview of the conference thendepicted the conference highlights and enthusiasticdelegate reviews. A final thank you was extendedto the event organisers Corporate Communiquéand their innovative team led by Jenny Boden,and also to the conference committee of APNAmembers and staff who worked together over thepast 12 months.We left this Golden Opportunities Conferencefeeling exhilarated and exhausted, having beenenlightened, entertained, enriched and enthused,and endeavouring to mark the calendar for nextyear’s APNA Conference.Sue Alexander, RN MWGrand Prom Medical Centre, Scarborough,Western Australia6Primary Times June 2010

A different type of pain 1aEFFECTIVE RELIEF OFNEUROPATHIC PAIN. 2-9PBS Information: This product is not listed on the PBS. RPBS Information: Authority required“For the treatment of refractory neuropathic pain not controlled by other drugs”.aThe causes and treatments of neuropathic pain differ to the other main type of pain, nociceptive pain. BEFORE PRESCRIBING, PLEASEREVIEW FULL PRODUCT INFORMATION AVAILABLE FROM PFIZER AUSTRALIA PTY LTD. Minimum Product InformationLYRICA ® (pregabalin) capsules Indications: Neuropathic pain in adults; adjunctive therapy in adults with partial seizures with or withoutsecondary generalisation. Contraindications: Hypersensitivity to pregabalin or excipients. Precautions: Pregnancy; lactation; dizziness;somnolence; congestive heart failure; galactose intolerance; withdrawal symptoms; renal impairment; peripheral oedema; creatine kinaseelevation; weight gain; blurred vision; hypersensitivity reactions; *increased risk of suicidal thoughts or behaviour. See full PI. Interactions:CNS depressants; alcohol; lorazepam; oxycodone; medications causing constipation. See full PI. Adverse effects: Most common: dizziness,somnolence. Others include: blurred vision, fatigue, weight gain, dry mouth, headache, ataxia, peripheral oedema, impaired balance, diplopia,sedation. Post-marketing, serious: angioedema, allergic reaction, loss of consciousness, mental impairment, congestive heart failure, keratitis,pulmonary oedema. See full PI. Dosage: 150 to 600 mg orally/day given as 2 divided doses. Neuropathic pain: Start at 150 mg/day, increase to300 mg/day after 3 to 7 days. If needed, increase to a maximum of 600 mg/day after a further 7 days. Epilepsy: Start at 150 mg/day, increase to300 mg/day after 7 days. Maximum dose of 600 mg/day may be given after a further week. Renal impairment: reduce dose. See full PI. Pfizer AustraliaPty Ltd, ABN 50 008 422 348, 38-42 Wharf Road, West Ryde, NSW 2114. Based on TGA approved Product Information of 31 March 2005 and amended18 December 2009. ® Registered trademark*Please note changes to Product Information. References: 1. The Merck Manual Medical Library:The Merck manual of medicalinformation - Home edition (www.merck.com/mmhe/index) 2. LYRICA Approved Product Information. 18 December 2009 3. Dworkin RH et al.Neurology 2003 60: 1274-1283 4. Rosenstock J et al. Pain 2004; 110: 628-638 5. Lesser H et al. Neurology 2004 63: 2104-2110 6. SabatowskiR et al. Pain 2004; 109: 26-35. 7. Freynhagen R et al. Pain 2005; 115: 254-263 8. Richter RW et al. J Pain 2005; 6: 253-260 9. van Seventer R et al.Curr Med Res Opin 2006; 22: 375-84. Pfizer Medical Affairs 1800 675 229. www.pfizer.com.au 04/10 LYR0031/BACK

CLINICAL CAREWhat’s happeningin sexual health?Australia’s young people face a number of challenges to their sexual health. With each sexuallytransmissible infection (STI) different, and each affecting different populations, there is a needfor practice nurses (PNs) to become ‘practice champions’ for the detection and management ofthese important conditions.Unfortunately, fewerthan 12% of youngwomen and 5% of youngmen are being tested forchlamydia in Australiangeneral practices.General practitioners generally see STIsin their patients as part of their clinicalresponsibility, while sexual health services arefocused on high risk populations—people unableor unwilling to access GPs, and patients requiringspecialist diagnosis or care. Most STI cases arerelatively easy to diagnose and manage. Thedifficult parts are recognising which patients areat risk and initiating the STI screening process.This can be a frightening or embarrassingmoment for both the patient and healthcareworker, particularly if the patient presented foranother reason.PNs will increasingly take a leading role insexual health. In part, this is because screeningof at risk but asymptomatic patients (e.g. Papsmear screening) and the provision of preventionprograms (e.g. vaccination) are core componentsof general nursing practice. An example of theleading role PNs can take can be seen in theimplementation of the quadrivalent humanpapillomavirus (HPV) vaccine program, whichresulted in Australia becoming a world leader inreducing HPV-related disease.ChlamydiaGenital Chlamydia trachomatis infection(chlamydia) has become Australia’s most commonnotifiable disease with over 60 000 cases notifiedin 2009, and with cases doubling about every fiveyears. Even then, it is likely that less than a quarterof all infections are ever diagnosed. We worryabout chlamydia because it may result in pelvicinfections, infertility and ectopic pregnancy.Chlamydia is usually asymptomatic in bothmen and women; a fact often poorly understoodby the public and health professionals. In recentyears it has become much easier to test forchlamydia via a first-catch (rather than amid-stream) urine in men, a self-collected analswab in gay men or self-collected vaginal swab inwomen. All authorities, including the RACGPRed Book, recommend annual screening of allsexually active people under the age of 25 years,due to the largely asymptomatic nature of thisepidemic. Unfortunately, fewer than 12% ofyoung women and 5% of young men are beingtested for chlamydia in Australian generalpractices.Recognising this need, state health departmentsare developing sexual health training courses forpractice nurses. Once diagnosed, chlamydia iseasily eradicated with a single dose ofazithromycin; though contact tracing is a highpriority. Nevertheless, it has been modelled thatif screening rates increase to over 30%, chlamydiamight be brought back under control.Genital warts and other HPV-related conditionsAround 1% of young Australians used to developgenital warts each year. The CommonwealthGovernment launched the HPV vaccinationprogram in mid 2007, wherein all schoolgirlsfrom the age of 12 years and all women in thecommunity up to the age of 26 years were offeredthe vaccine free-of-charge. This program hasbeen a phenomenal success, with almost 80%vaccinated by the end of 2008. This vaccinationlevel is more than twice as high, and was achievedmuch faster, than any other country and we arebeginning to document the benefits.By the end of 2009 the number of diagnosesof genital warts in Australian women attendingsexual health services had dropped by over 60%,with no drop seen in older (unvaccinated)women. There was even a flow-on to heterosexualmen who, presumably because of reducedexposure to HPV types 6 and 11 in their femalepartners, were also beginning to present lessfrequently with warts.In time we would also expect to see cervicalcytological abnormalities and, eventually, cervicaland other ano-genital cancers decline.Genital herpesIn recent years herpes simplex virus type 1(HSV-1)—the virus that causes oral coldsores—has overtaken HSV-2 as the main cause ofgenital herpes in young people. Presumably, thisis the result of the increasing popularity of oralsex and the common use of condoms for vaginalsex (condoms provide partial protection againstHSV-2). Fortunately, HSV-1 tends to cause fewerrecurrences of symptoms than HSV-2, so mostdo not require long-term antiviral suppressivetherapy. While recurrent genital herpes does notusually seriously threaten a patient’s physicalhealth, primary infections can be very nasty,resulting in complications such as urinaryretention and meningitis in up to 10% of patients.First-episode genital herpes should be treated as amedical emergency.The treatment objectives for genital herpes arecentred on patient education and support and,occasionally, anti-viral drugs to controlsymptoms. Until we have a vaccine, we will not beable to control genital herpes—around 12% ofAustralian adults harbour HSV-2 and about 80%harbour HSV-1.Gonorrhoea and syphilisThese two ‘classical’ STIs are well controlled in thegeneral population in Australia, even though theyare commonly asymptomatic. The exceptions areremote Aboriginal communities, where healthservices are limited, and gay men in our cities.Gay men are affected because they often havemultiple sexual partners or because their partnersmay have multiple partners. Both conditions arereadily transmitted by oral sex.Tests for these two conditions are a routinepart of STI screening for gay men, including analand throat swabs for gonorrhoea. Either conditionshould be considered in heterosexual patientswho have recently travelled to or from highprevalence countries.8Primary Times June 2010

CLINICAL CAREGonorrhoea is notorious for its growingresistance to common antibiotics, so it is alwayswise to check recent guidelines (Table 1) beforetreating it.HIV infectionWhile treating HIV with anti-viral drugs requiresan accredited doctor, the long-term prognosis forpeople with HIV is now excellent. Also, becausefew people with HIV now die from the condition,the number of people living with HIV is growingin the community. As people with HIV infectionare now capable of growing old and are livingnormal lives they are increasingly in need of GPcare in addition to their specialist care. This careincludes regular STI screening—typically at leastannually and more often if they report multiplesexual partners. All patients requesting a HIV testshould be considered for testing for other STIs.Viral hepatitisHepatitis C is not normally considered to besexually transmitted, except in some HIV positivepeople. Hepatitis A is sexually transmissibleamong gay men, so routine vaccination isrecommended. Hepatitis B is also sexuallytransmissible among gay men, heterosexuals withmultiple sexual partners and people whose sexualpartners have hepatitis B. All these groups shouldbe vaccinated.ConclusionAs STIs become increasingly amenable toprevention through screening or vaccination, wesee a growing and central role for PNs. Integral tothis role is imparting frank advice on safer sex andthe use of condoms. The challenge for all of us isto introduce the issue to our young patientswithout sounding judgmental.Basil DonovanProfessor and Head, SexualHealth Program, NationalCentre in HIV Epidemiologyand Clinical Research,University of New SouthWalesVickie KnightClinical Nurse Consultant,Sydney Sexual HealthCentre, Sydney/SydneyEye HospitalTable 1. Diagnosis and management of common sexually transmissible infections in adultsCondition Diagnosis Treatment CommentChlamydia(Urethritis/cervicitis)GonorrhoeaSyphilisPelvic inflammatorydiseaseGenital wartsGenital herpesNucleic acid amplification test(NAAT) of swab or urine.Culture of a swab or NAAT (NAATmust be confirmed by a secondtest).Serology. If asymptomatic, thescreening test needs to beconfirmed with a second test.For ulcers or other lesion, asklaboratory which specimen tocollect (immunofluourescent smearor NAAT).Clinical diagnosis, after excluding(ectopic) pregnancy and urinarytract infection.Clinical, with biopsy of atypicallesions.Clinical for first episode, but collectswab for NAAT.Azithromycin 1g po statim.Ceftriaxone 500mg imi statim (dissolved in 2 mlsof 1% lignocaine).Procaine penicillin G 1g imi daily for 10 days, orbenzathine penicillin G 1.8g imi statim, ordoxycycline 100mg po twice a day for 14 days.Ceftriaxone 250mg imi statim plus doxycycline100mg po twice a day for 14 days plusmetronidazole 400mg po twice a day for 14 days.Cryocautery (usually weekly), orpodophyllotoxin 0.5% tincture or 0.15% creamtwice a day for 3 days (up to 4 cycles), orimiquimod 5% cream three times a week for 6+weeks.Aciclovir 400mg three times a day, orvalaciclovir 500mg twice a day for 5–10 days.Patient self-collected urine, vaginal or anal swab aresensitive and may be more acceptable for the patient.Uncomplicated infection at any site.Because of the high risk of concurrent chlamydia, manyadd azithromycin 1g.15 days for infection that may be >12 months oldWeekly for 3 weeks if infection may be > 12 months oldDoxycycline if penicillin allergy or averse to injections.Doxycycline for 28 days if infection may be >12 monthsold.The diagnosis is reinforced if chlamydia or gonorrhoeais detected. Reconsider the diagnosis if the response totreatment is poor after 4–5 days. Weekly azithromycin(1g) is an alternative to doxycycline if adherence is poor.If few lesions, or inaccessible for patientSelf-applied; repeat cycles if responding.Especially if recurrent (expensive and slow).First EpisodeContacttracingpriority*HighHighHighHighLowLowNAAT of a swab.Type-specific serology may beuseful for managing couples.Aciclovir 400mg three times a day, orvalaciclovir 500mg twice a day, orfamciclovir 125mg twice a day.Aciclovir 400 twice a day, orvalaciclovir 500mg once a day, orfamiciclovir 250mg twice a day.Recurrent episodes(2–3 days is as good as 5 days,in higher doses).Suppressive therapy(valaclovir 500mg bd may be needed if very recurrent).HIV/AIDS Serology, confirmed by WB. Requires specialised care. HighAdapted from: National Management Guidelines for Sexually Transmissible Infections, Venereology Society of Victoria & Australasian Chapter of Sexual Health Medicine, 2002; the Australasian Contact Tracing Manual,2006 [available at: www.ashm.org.au/contact-tracing]; and European and US Guidelines, summarised in Donovan B. Lancet 2004;363:545–556.June 2010 Primary Times 9

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CLINICAL CARESexually transmittedinfections: ChlamydiaChlamydia was the most frequently reported notifiable condition inAustralia in 2008, with 58 456 reported diagnoses 1 .Chlamydia notifications havecontinually increased over the pastten years. Among males, the populationrate of reported chlamydia diagnosesper 100 000 population more thandoubled, from 58.8 in 1999 to 124.8in 2003 and almost doubled again to221.9 in 2008. Among females, therate of chlamydia diagnoses doubledfrom 89.5 in 1999 to 179.7 in 2003,and almost doubled again to 323.5 in2008 1 . Australia-wide, the people mostlikely to get chlamydia are under 29years of age.Most men and women infected withchlamydia display no symptoms ofinfection. As a consequence of theasymptomatic nature of chlamydia, theinfection may progress further in thereproductive system and cause pelvicinflammatory disease, and potentiallyectopic pregnancy, in women andepididymo orchitis in men. If leftuntested and untreated, chlamydiamay lead to infertility in both sexes.GuidelinesThe guidelines for preventive activitiesin general practice 2 support the testingof both males and females under 25years for chlamydia and refers to othertarget groups for testing. These includemen who have sex with men (MSM),people who have inconsistent or nocondom use, those who have partnersthat have been diagnosed with ansexually transmitted infection (STI) andthose who are asymptomatic and askfor an STI check up.Making general practice ‘sexualhealth friendly’Speak to your local sexual health clinicand request resources about currentSTI campaigns, and keep Sexual HealthInfoline stickers handy for patients.Also, get a copy of the STI Testing Tooland talk to a nurse at the sexual healthclinic about how you can be supportedintroducing more STI testing intoyour practice.Seize opportunitiesWound dressings, vaccinations, Papsmears and giving contraceptive adviceto patients all provide opportunities foryou to raise the issue of sexual healthwith both male and female clients under25 years of age. Some patients may beaware of the need to have an STI checkup and bring up the subject, whileothers could need encouragement todiscuss. Examples of how to approachthe subject include:‘We are offering chlamydia testing toall sexually active people under theage of 25. Would you like to have atest while you’re here or find outmore about chlamydia?’‘Since you’re here today for ... couldwe also talk about some otheraspects of sexual health, such as anSTI check up?’Testing for STIsTesting for STIs has become a whole loteasier. A simple urine test will now testfor chlamydia and patients can easilycollect their own samples. For womena first pass urine sample or a selfcollected vaginal swab and for malepatients a first pass urine sample isenough to do a test.What happens if the test is positive?As a practice nurse you already have arange of skills to discuss a positivediagnosis with a patient. These includeknowledge, empathy, understandingand rapport with the patient. Afterdiscussing treatment with the patient, youcould also offer fact sheets on the STIs.Informing sexual partners isimportant to reduce the risk of furthertransmission and possible reinfection ofchlamydia. This is essential as we knowmost people may not have symptoms ofchlamydia and do not know they areinfected. This might be difficult to dofor some patients and they may needsupport from you and other services. Itis important to know that most peopledo want to know if they are at risk of aninfection and where to get tested andtreated. Further support about treatment,contact tracing and follow up can beaccessed by calling a sexual healthclinic or from the Australasian Societyof HIV medicine (ASHM) website.TrainingA new and exciting online course,developed by the NSW STI ProgramsUnit (STIPU) and ASHM, is available onthe APNA website. This course is aimedat giving practice nurses the necessaryskills in managing STIs. For those inNSW, the first 200 practice nursesreceive the course for free!References1. National Centre in HIV Epidemiology and ClinicalResearch. 2009 Annual Surveillance Report—HIV/AIDS, viral hepatitis and sexually transmissibleinfections in Australia. Accessed 22 April 2010:.www.nchecr.unsw.edu.au/NCHECRweb.nsf/resources/SurvReports_3/$file/ASR2009-updated-2.pdf2. The Royal Australian College of General Practitioners(RACGP), Red Book Taskforce. Guidelines forpreventive activities in general practice. 7 Edition,2009. Accessed 22 Apr 2010: www.racgp.org.au/redbook/download/2009Redbook_7th_ed.pdfResources1. WA Health Guidelines for ManagingSexually Transmitted Infections (theSilver Book) 2010: http://silverbook.health.wa.gov.au/2. Specimens for Sexually TransmittedInfections chart: www.stipu.nsw.gov.au/pdf/SELF_TESTING_CARD.pdf3. STI Testing Tool: www.stipu.nsw.gov.au/pdf/FINAL_NSW-GPSexual_Health_Services_Tool_web.pdf4. NSW Health STIs and blood borneviruses factsheets: www.health.nsw.gov.au/publichealth/sexualhealth/sex_factsheets.asp5. ASHM Contact Tracing Manual:www.ashm.org.au/Projects/contactTracingManual/6. The 7 Cs of Clymydia—educationalgame, designed by nurses for nurses:www.stipu.nsw.gov.au/pdf/SevenCs/index.html7. Practice Nurse Postcard—MBS itemnumbers for practice nurses to test forSTI: www.stipu.nsw.gov.au/pdf/PracticeNurses_postcard_web.pdf8. APNA online training (underProfessional Development):www.apna.asn.au9. Australasian Society for HIV Medicine(ASHM), education and training:www.ashm.org.au/default2.asp?active_page_id=11810. NSW STIPU: www.stipu.nsw.gov.au11. NSW Sexual Health Infoline:1800 451 624Carolyn Murray, RN, BHSC (Nursing), MIPHCarolyn Murray is the Manager of the General PracticeSexual Health Project at the NSW STI Programs unit, fundedby NSW Health and based at Sydney Sexual Health Centre.The aim of the project is to support practice nurses andgeneral practitioners in the management of STIs within theirpractices. Carolyn has worked in the area of HIV and SexualHealth since 1993 as a registered nurse, a health promotionofficer and a manager.June 2010 Primary Times 11

CLINICAL CARECoping with anSTI diagnosisSexually transmitted infections (STIs) affect millions of people aroundthe world, with the incidence of these infections increasing annually 1 .Within Australia, some of themost common STIs include:herpes simplex virus type 2 (HSV2),which is estimated to affect aboutone in eight adults (12 per cent)over 25 years 2 ; and chlamydia andgonorrhoea, which predominatelyaffect individuals aged between15 and 24 years 3,4 .Many individuals considerthemselves not at risk of contractingan STI due to these infectionshaving a long historical associationwith deviant behaviour 5 . Thisperception is particularly heightenedin young people due to their generalperception of invulnerability 6,7 ,which often hinders the thought ofthe possible consequences ofengaging in high-risk behaviours,such as practising unsafe sex 8 . Dueto these perceptions, beingdiagnosed with an STI can lead todenial and non-disclosure of havingan STI to sexual partners 9 .A PhD study undertaken byDr Leah East at the University ofWestern Sydney focused on youngwomen who had been diagnosedwith an STI (genital herpes,chlamydia and HPV between theages of 18 to 30 years). This studyfound that the participants did notbelieve they were at risk ofcontracting this type on infectiondue to holding negative views ofpeople who contract STIs 9 . Due tothese perceptions, participantsdescribed feeling overcome withshame at the diagnosis. The shamefelt by some of these women ledthem to deny being diagnosed withan STI to themselves and others,which in turn led to participantsnot disclosing having an STI withsubsequent sexual partners 9 .Denying having an STI andsubsequent non-disclosure, allowed… being diagnosedwith an STI can lead todenial and non-disclosureof having an STI to sexualpartners.these women to preserve theirintegrity and project a healthy selfand sexual image to potentialpartners 9 . This behaviour has thepotential to increase the incidenceof STIs and limit the ability ofindividuals to cope and acceptbeing diagnosed with an STI.Clinicians and healthcareprofessionals involved in diagnosingand educating individuals aboutSTIs, should be aware of the impactbeing diagnosed can have and thedefence mechanisms such as denialthat are used to cope with beingdiagnosed with this type of infection.Implementing and promotingstrategies to facilitate acceptance ofbeing diagnosed with an STI has thepotential to minimise non-disclosurerates, reduce the incidences of theseinfections and can possibly reducethe number of individuals whoengage in high-risk sexualbehaviours that expose peopleto STIs.References1. World Health Organization. Globalstrategy for the prevention and controlof sexually transmitted infections:2006–2015: Breaking the chain oftransmission. Geneva, 2007.2. Cunningham A, Taylor R, Taylor J, MarksC, Shaw J and Mindel A. Prevalence ofinfection with herpes simplex virustypes 1 and 2 in Australia: a nationwidepopulation based survey. SexuallyTransmitted Infections. 2006;82(2):164–168.3. Australian Government Department ofHealth and Ageing. National NotifiableDiseases Surveillance System. Numberof notifications of gonococcal infections,Australia, 2009 by age group and sex.DoHA 2010. Accessed 15 March 2010:www9.health.gov.au/cda/Source/Rpt_5.cfm4. Australian Government Department ofHealth and Aging CommunicableDiseases Australia National NotifiableDiseases Surveillance System. Number ofnotifications of Gonococcal infection,Australia, 2008 by age group and sex.DoHA 2009. Accessed 15 March 2010:www9.health.gov.au?cda/Source/Rpt_5.cfm.5. Bunting S. Sources of stigma associatedwith women with HIV. Advances inNursing Science. 1996;19(2):64–73.6. Redston-Iselin A. Adolescent psychiatricnursing. In: Stuart G and Laraia M (eds.)Principles and practices of psychiatricnursing. Mosby: St. Louis. 2001;779–802.7. Morojele N, Brook J and Kachieng’a M.Perceptions of sexual risk behaviours andsubstance abuse among adolescents inSouth Africa: A qualitative investigation.AIDS Care. 2006;18(3):215–219.8. Rew L. Adolescent health: Amultidisciplinary approach to theory,research, ad intervention. 2005,Thousand Oaks: Sage.9. East L et al. Disrupted sense of self:Women and sexually transmittedinfections. Jounal of Clinical Nursing,In press.Dr Leah EastRN BN (Hons) PhDLecturer, School of Nursing andMidwifery, University of WesternSydney12Primary Times June 2010

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PRACTICE NURSEWorking in sexualhealth nursingSimon Powell is a registered nurse at The Centre Clinic, Gay Men’s Health Centre in St Kilda, Melbourne.Simon was runner up for the GSK Best Practice Nurse Award for Chronic Disease Management 2009.Simon shares with readers his day-to-day movements as a sexual health nurse ...started my career in human immunodeficiencyI virus (HIV) nursing in the United Kingdom inearly 1995—one year before the advent ofcombination antiretroviral therapy (cART), whenthe diagnosis of HIV carried a life threateningprognosis. Indeed HIV nursing in those days wasoften palliative care. The six-bed HIV ward Iworked in at Brighton was invariably full withyoung gay men dying of diseases likePneumocystis carinii pneumonia, cerebraltoxoplasmosis, lymphoma and progressivemultifocal leucoencephalopathy. Many wereblind from cytomegalovirus retinitis. It was aterrifying time, laden with appalling grief.Moving forward 20 years, HIV infection isconsidered a chronic and manageable conditionand the aforementioned acquired immunedeficiency syndrome (AIDS) defining illnesses arerarely seen now. An article published in TheLancet 1 (2008) suggests that in the present time, a25-year-old man diagnosed with HIV and needingto commence treatment could expect to live foranother 40 years. As life expectancy hasimproved, patients face an increasing burden ofco-morbidities associated with chronic HIVdisease and the ageing process. Meanwhile, since1999 the rates of new HIV diagnoses in Victoriahave continued to climb 2 .The first Australian death from an AIDS relatedillness occurred in Melbourne in 1983. That sameyear, a group from the Melbourne gay communityformed the Victorian AIDS Council Gay Men’sHealth Centre. Other states subsequently createdtheir own Councils 3 . The Centre Clinic comesunder the auspices of the Victorian AIDSCouncil/Gay Men’s Health Centre and specialisesin sexual health and HIV. It is a wholly bulkbilling general practitioner (GP) service.The service has about 2500 regular patients ayear of which approximately 400 are living withHIV. The majority of clients, approximately 95 percent, are men who have sex with men (MSM).This includes gay men, bisexual men and a smallnumber of men who identify as heterosexual butalso have sex with men. The remaining five percent includes exclusively heterosexual menand women, lesbian and bisexual women,transgendered clients, and female and malesex workers.There are four GPs operating from the Clinic:one full-time and three part-time. The Clinic alsoemploys reception staff, a practice manager anda full-time sexual health practice nurse (PN). Aswell as being vocationally qualified with the RoyalAustralian College of General Practitioners, thedoctors who work in the service are all s100prescribers. This means they are trained andaccredited to prescribe highly specialised drugsto treat HIV infection and for non-occupationalpost-exposure prophylaxis (NPEP). NPEP is usedto reduce the risk of a person becoming HIVpositive following a high risk (usually sexual)exposure to HIV. NPEP consists of a one-monthcourse of antiretroviral medication, which needsto be commenced within 72 hours of the potentialexposure to HIV 4 .I start my day by checking pathology resultswith any available doctors and attend followup activities, such as aberrant HIV relatedmonitoring tests or positive STI results. Myappointment may be either pre-booked orpatients may see me directly after a consultationwith their GP. While I work in collaboration withthe GPs, my role has a fair degree of autonomy.I see patients independently for asymptomaticsexual health checks, HIV chronic diseasemonitoring, GP HIV chronic disease managementplans, HIV medication adherence coaching andpsychosocial support.I also have a triage role in the service; oneThe key to survival in thisenvironment is to be adaptable,resourceful and self aware.which has developed over time. Receptionstaff ask anyone wishing to book a same dayappointment if the concern is urgent—ifaffirmative, then I speak with them and triageaccordingly. Many patients also share theircare between providers and I spend timeliaising with other centres to maintain accurateclinical records.Melbourne has seen a dramatic rise in thenumber of reported syphilis cases in recentyears (two cases in 1999, 375 cases in 2008) 5 .Blood testing for this infection is now routineand included every three months with routineHIV monitoring tests in MSM. For thosemen not living with HIV, the frequency oftesting is recommended as per the SexuallyTransmitted Infections in Gay Men Association(STIGMA) guidelines 6 .A collaborative approach is the modus operandiat The Centre Clinic and team members at thestart of each day will discuss patients who haveappointments. I then generate a list of recalls fromMedical Director and follow up according toprotocols. Follow up may relate to NPEP, STItreatment, syphilis serology after treatment,vaccination or HIV medication commencement.Recalls can also be for any ‘reminder reason’ that14Primary Times June 2010

Australasian Chapter of Sexual Health MedicinePRACTICE NURSEhas been requested in the patient’s file.My day moves into a less predictable phaseonce patients start to arrive. While the bulk ofmy work involves asymptomatic STI screening(including HIV pre and post test counselling),HIV monitoring and the creation of HIVManagement Plans, I often find myself in novelsituations. The key to survival in this environmentis to be adaptable, resourceful and self aware.The judicious use of humour is also a source ofself, client and collegial support.Observing and participating in the evolution ofHIV over the last 15 years has been a unique andenriching experience. My accumulated experienceis called upon during clinical consultations andassists me in providing reassurance to patients ata time of emotional upheaval.The Centre Clinic is a great place to work andhas a real sense of community. It is a place wherewe know we continue to make a real differencefor our patients.References1. Cooper D. Life and death in the cART era. The Lancet.2008;372:266–267.2. Dept of Health Victoria & Burnet Institute HIV and AIDSin Victoria, 1938 to 2008. Accessed 25 March 2010: www.health.vic.gov.au/ideas/surveillance/annual_reports3. Access Information Centre at The Alfred. Turning 21, Thehistory of HIV in Victoria: a chronology. Accessed 25March 2010: www.hivhepsti.info/fs/hivchronology.htm4. Victorian NPEP Service Guidelines, July 2007. Accessed25 March 2010: www.cgmc.org.au/Assets/Files/NPEPGuidelinesRevisedJuly2007b.pdf5. Victorian Infectious Diseases Bulletin, ISSN 1441-0575.2009;12(3). Accessed 25 March 2010: www.health.vic.gov.au/__data/assets/pdf_file/0005/407561/VIDB-12-3-web.pdf6. Sexually Transmissible Infections in Gay Men ActionGroup (STIGMA). Sexually transmitted infection testingguidelines for men who have sex with men. Accessed 25March 2010: www.stigma.net.au/resources/STIGMA_MSM_Guidelines_RACGP_updated_Feb_09.pdfSimon PowellSimon Powell has worked as: a Clinical Nurse Specialist in HIV;a Sexual Health Counsellor; an HIV Clinical Trials Co-ordinator, inBrighton, UK; an Associate Charge Nurse in the HIV inpatient unit,Alfred Hospital, Melbourne; an Advanced Practice Nurse (HIV) atMelbourne Sexual Health Centre; and, since 2008, as a SexualHealth Practice Nurse at The Centre Clinic, Gay Men’s HealthCentre in Melbourne. He has a Masters Degree in Counselling anda Diploma in Gestalt Therapy.Getting started with an STI discussionBringing the subject up opportunistically“ We are offering Chlamydia testing to all sexually active people under the age of 25,would you like to have a test while you’re here or find out more about Chlamydia?”Using a ‘hook’“ Have you heard about HBV or HPV vaccination? They protect against infections that canbe sexually transmitted, perhaps we could discuss these while you’re here?”As part of a reproductive health consultation“ Since you’re here today for a pap smear/to discuss about contraception could we also talk about some otheraspects of sexual health, such as an STI check up?”Because the patient requests a “checkup” for STIs“ I’d like to ask you some questions about your sexual activity so that we can decidewhat tests to do, is that OK?”(See Brief Sexual History ✔)Brief Sexual History ✔”I’d like to ask you some questions about your sexual activity so we can decide what tests to do, is that OK?”Are you currently in a relationship?In the last 3 months, how many sexual partners have you had? How many partners have you hadin the past 12 months?Were these casual or regular partners?Were your sexual partners male, female or both?When was the last time you had vaginal sex/oral sex/anal sex without a condom?In the past year were you ever paid for sex?Have you previously been diagnosed with an STI?Is there anything else that is concerning you?NSWSEXUALHEALTHINFOLINE1800 451 624Mon - Fri9am - 5:30pmOther risk behaviours“ I’d now like to ask about some other activities that could increase aperson’s risk of certain infections, is that OK?”Have you had any tattoos? If yes, was that here in Australia oroverseas?Have you ever injected drugs?Have you ever shared needles or injecting equipment?Have you ever been in gaol?Consent“I suggest that we test for...” eg: ChlamydiaThis will involve a urine test. Can you tell me what you understandabout Chlamydia?If the result is positive, we can also talk about recent partnersyou’ve had being tested as well.”Contact tracingContact tracing aims to reduce the transmission of infections throughearly detection and treatment of STIs“ From what you have told me today we now know there are 2or 3 people out there who might also be infected. Do you feelcomfortable talking to them or would you like some help?”“ If you would like some help, I will need the names and contactdetails of sexual partners over the last 6 months*”*These partners need to be treated, as some STIs have no symptoms.Contact Tracing manual:www.ashm.org.au/Projects/contactTracingManualThese sites can support your patients to tell their partners:www.whytest.org (MSM) www.letthemknow.org.auSupportGeneral Practitioners, Health Care Workers and patients can ask forsupport from their local Sexual Health Clinicwww.health.nsw.gov.au/PublicHealth/sexualhealth/sexual_phus.aspOR callNSW Sexual Health Infoline – 1800 451 624Red Book www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/TheRedBook/redbook_7th_edition_May_2009.pdfFor more copies of this STI Testing Tool: www.stipu.nsw.gov.auRef: Clinical Guidelines for the management of STIs among Priority populationswww.stipu.nsw.gov.au/pdf/STI_Rx_Priority_Populations.pdfJune 2010 Primary Times 15

DISEASE PROCESSThe silent chronic diseasesThere are around 160 000 people living with chronic hepatitis B, whileat least 210 000 Australians have chronic hepatitis C 1 .Many cases of hepatitis B and Cremain undiagnosed in Australia.The number of people with hepatitis Bis predicted to rapidly rise over the nextdecade and complications of chronichepatitis C are projected to triple in thenext 20 years if more people are nottreated 2,3 . Without early diagnosis,long term monitoring and appropriatetreatment, many people will be left atrisk of life-threatening complicationssuch as cirrhosis and liver cancer 2,4 .Yet, the burden of chronic hepatitis Band C seems to have eluded ourattention, media campaigns andfunding. With hepatitis clinics stretchedin meeting the demands of theseincreasing numbers, it is becomingimperative that general practice plays acritical role in screening and managingthese chronic conditions 2,5-7 .Hepatitis B virusThe prevalence of chronic hepatitis B(HBV) infection is increasing in Australia.This is predominantly related to theincrease in immigration from highlyendemic regions—Asia and thePacific, sub-Saharan Africa and theMediterranean—and over-representedin our Aboriginal Australian population 8 .Hepatitis B is transmitted through bloodand body fluids (predominantly vaginalsecretions and semen), with mostchronic hepatitis B being contractedperinatally from mother to infant orhorizontally to children (usually thoseborn in endemic countries) prior to theinitiation of vaccination programs 8 .Vaccination prevents new cases ofhepatitis B and is important in thefollow up of sexual contacts of peoplewho have chronic hepatitis B.Recommendations for screeninginclude: any person born in (or parentsborn in) an endemic country; AboriginalAustralians; people engaged inunprotected or multiple partner sex;sexual contacts of those with chronichepatitis B virus; history of hepatitis Cvirus or human immunodeficiency virus;those undergoing immunosuppressivetherapy or dialysis; those who currentlyor previously have injected drugs; and,all pregnant women 9 .Regular monitoring of hepatitis B isimportant as there are four phases ofthe disease that can be determinedthrough various tests such as bloodtesting, liver biopsy and liverultrasound 10 . Hepatitis B treatment cancontrol the virus, much like hypoglycaemicscontrol the condition andcomplications of diabetes, buttreatment is not always indicated foreveryone. This means a person withhepatitis B needs to undergo long termmonitoring to ascertain the phase of thedisease and the best time to treat.Treatment and disease progressionis determined through collaborationbetween general practice and the liverspecialist; thus referral for specialistopinion is important.Hepatitis C virusThere are 211 700 Australians withchronic Hepatitis C virus (HCV) 1 ;meaning, they have had the virus forlonger than six months and will livewith the virus for the rest of their livesunless successfully treated. HCV is aleading cause of liver transplant inAustralia and cirrhosis and liver cancerare possible outcomes of prolongedinfection 11,12 .HCV is transmitted through infectedblood and, in Australia, has a strongaffiliation with the sharing ofcontaminated injecting equipment 6 . Itis, however, important to note that notall people with HCV are injecting drugusers and that many diagnosed mayhave injected some 20 years ago andhave no affiliation now with injectingdrug use. As a possible consequenceof this association and other misconceptionsabout the virus, many peoplewith hepatitis C experience stigma anddiscrimination, making living with thecondition and accessing treatment allthe more difficult 13 . Other modes oftransmission are: unsterile medical ordental procedures; blood transfusions(prior to screening); during vaccination(that has not adhered to standardinfection control measures); unsteriletattooing and body piercing; andsharing of blood contaminatedhousehold items such as toothbrushesand razors 14 .Treatment consists of a combinationof highly specialised medications(s100), with a weekly subcutaneousinjection and twice daily tablets thatcan clear the virus successfully 15 in50–80 per cent of cases depending onthe genotype of the virus (there are sixgenotypes or strains of the HCV, withgenotype 1 and 3 being the mostcommon in Australia) 16 . Treatment isdifficult and is similar to chemotherapyin its side-effect profile. For this reason,people undergoing treatment needclose monitoring and lots of supportduring this time. General practice staffin collaboration with a liver specialistcan monitor and support peoplethrough treatment, and referral tosupport agencies should beencouraged. Sharing the care isimportant if we are to decrease thenumbers of people affected and theserious complications that can occur 5,6 .There are multiple opportunities forpractice nurses to influence the courseof these conditions and impact onpatient outcomes. These opportunitiesinclude:• creating a disease register• encouraging screening of people‘at risk’• planning care• consulting on behavioural modification• supporting and referring people tospecialists and allied healthprofessionals, and• recalling patients for follow up andregular monitoring.Undiagnosed, untreated andunmanaged hepatitis B and C cancontinue to be transmitted within thecommunity and can lead to lifethreateningcomplications such ascirrhosis and hepatocellular carcinoma.The impetus to place these silentviruses on the chronic disease agendahas never been more important.References1. HIV/AIDS, viral hepatitis and sexuallytransmissible infections in Australia annualsurveillance report. National Centre in HIVEpidemiology and Clinical Research (NCHECR),Frances Cieslak RN,DipNursing (Infectious Diseases), BA, VET, GCHPEFrances is a RN with qualifications in both nursing and education. She has worked in healtheducation for the last eight years and is currently the Victorian Viral Hepatitis Educator. This positionis funded by the Department of Health and based at St Vincent’s Hospital, with a brief to provideeducation related to hepatitis B and C to health professionals across the state. She has clinicalexperience in infectious diseases including HIV/AIDS and has worked as a remote area nursethroughout the Kimberley and south west Queensland. Frances undertaking a Primary Health CareResearch Evaluation and Development (PHCRED) fellowship exploring issues related to hepatitis B.16Primary Times June 2010

DISEASE PROCESS2009. Accessed 22 April 2010: http://www.nchecr.unsw.edu.au/NCHECRweb.nsf/page/Annual+Surveillance+Reports2. Matthews G and Robotin M. B positive: All youwanted to know about hepatitis B: A guide forprimary care providers. Australasian Society forHIV Medicine (ASHM), 2008. Accessed 22 April2010: http://www.ashm.org.au/default2.asp?active_page_id=1333. Hepatitis C Virus Projections Working Group:Estimates and projections of the hepatitis C virusepidemic in Australia 2006. Ministerial AdvisoryCommittee on AIDS, Sexual Health and Hepatitis,Hepatitis C Sub-Committee. Accessed 22 April2010: http://www.hepatitisaustralia.com/documents/estimates06.pdf4. Feller R, Strasser S, Ward J and Deakin G.Primary care management of chronic viralhepatitis. In: HIV, Viral Hepatitis and STIs: A guidefor primary care. Australasian Society for HIVMedicine, 2008. Accessed 22 April 2010: http://www.ashm.org.au/default2.asp?active_page_id=1335. Hardwick J. Review of hepatitis C treatment andcare services: Final report. Aids/InfectiousDiseases Branch, NSW Health, 2008. Accessed22 April 2010: http://www.health.nsw.gov.au/pubs/2008/pdf/080200_hep_c_report_1-2.pdf6. Hellard M and Wang Y. The role of generalpractitioners in managing and treating hepatitisC. Medical Journal of Australia.2009;191(10):523–524.7. Wallace J, McNally S and Richmond J. Nationalhepatitis B needs assessment 2007. AustralianResearch Centre in Sex, Health and Society,Latrobe University, 2007. Monograph no 64.8. Nguyen V and Dore G. Prevalence andepidemiology of hepatitis B. In: Matthews G andRobotin M (eds.) B positive: All you wanted toknow about hepatitis B: A guide for primary careproviders. ASHM, 2008. Accessed 22 April 2010:http://www.ashm.org.au/default2.asp?active_page_id=1339. Digestive Health Foundation. A guide tomanagement for health professionals: Chronichepatitis B, 2007. Accessed 22 April 2010:http://www.gesa.org.au/pdf/booklets/ChronicHepatitisB1Ed07.pdf10. Danta M. Hepatitis B virus testing andinterpreting test results. In: Matthews G andRobotin M (eds.) B positive: All you wanted toknow about hepatitis B: A guide for primary careproviders. ASHM, 2008.11. General practitioners and hepatitis C fact Sheet.ASHM, 2008. Accessed 22 April 2010: http://www.ashm.org.au/images/publications/booklets/gp%20august2008-web.pdf12. Annual surveillance report in HIV/AIDS, viralhepatitis and sexually transmissible infections inAustralia. NCHECR, 2008. Accessed 22 April2010: http://www.nchecr.unsw.edu.au/NCHECRweb.nsf/page/Annual+Surveillance+Reports13. Anti-discrimination board of NSW. C change— Report of the enquiry into hepatitis C relateddiscrimination, 2001. Accessed 22 April 2010:http://www.lawlink.nsw.gov.au/lawlink/adb/ll_adb.nsf/pages/adb_hepatitis_c_enquiry14. National hepatitis C resource manual 2ndedition, 2008. Accessed 22 April 2010: http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-hepc-manual-toc15. McHutchinson J. Management issues in hepatitisC infection handbook. Science Press London,2004.16. Digestive Health Foundation facts about hepatitisC. 3rd edition. Gastroenterological Society ofAustralia, 2007. Accessed 22 April 2010: http://www.gesa.org.au/pdf/Hep_C_3Ed_07.pdfResources1. Frances Cieslak Victorian ViralHepatitis Educator, St Vincent’sHospital FREE education andupdates for health professionals intheir workplace within Victoria.Phone: (03) 9288 3586, mobile:0407865140, email: frances.cieslak@svhm.org.au2. www.hepbhelp.org.au providesinformation and advice on theinvestigation and managementof patients with Hepatitis B andthe location of HepB clinics.3. Multicultural Health Support Service,Information, education and supporton issues of sexual health, HIV/AIDSand Blood Borne Viruses for CALDcommunities. Phone:(03) 93429700 or visit the website:www.ceh.org/mhss.aspxIf your work involves aged people, agood Companion can be invaluable.Designed for professionals who devote their efforts toproviding high quality care for older people.The revised and updated 2010 (third) edition of the AMH Drug Choice Companion: Aged Careis a widely accepted aid to quality use of medicines in aged care in Australia.In the Aged Care Companion, drug choices for treatment of specific conditions are listedalongside non-drug options, or arranged by disease severity or symptoms, with dosinginformation specifically for the older person.It contains information on more than 70 specific conditions common in older people. TheCompanion is a practical, pocket sized reference for practitioners such as doctors, nurses andpharmacists who work with older people.Recommended Retail Price $60.00 + P&H*Price current at May 1, 2010 and subject to change without noticeFor more information or to order, go to www.amh.net.auOther AMH resources for healthcare professionals:Revisedand updatedthird editionavailablenowAMH Book AMH Online AMH Handheld AMH Mobile AMH CD-ROM Emergency Care MediFlagsAMH provides independent medicines information for Australian healthcareprofessionals, to facilitate the quality use of medicines. It is jointly owned by the RoyalAustralian College of General Practitioners, the Pharmaceutical Society of Australia andthe Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists.June 2010 Primary Times 17

RESEARCHGeneral practices toACCEPt the challengeThe Australian Chlamydia Control Effectiveness Pilot(ACCEPt) was launched in rural Victoria recently.To combat the rising chlamydia rates and theresultant burden to the health system, theFederal Department of Health and Ageing hasfunded the ACCEPt project to assess thefeasibility, acceptability and effectiveness of anorganised program for chlamydia testing ingeneral practice. This exciting, world first trialaims to encourage general practitioners (GPs) andpractice nurses to provide and increase annualchlamydia testing for sexually active peopleaged 16 to 29 years.Australian GPs most commonly test forchlamydia when a patient presents withsymptoms, requests a test or has an infectedpartner 1 . Given that over 80% of infections areasymptomatic 2 , this strategy is likely to miss manyinfections. Annual testing of sexually active youngpeople aged less than 25 years is recommendedby the Royal Australian College of GeneralPractitioners 3 . However, even though 90% ofwomen and 70% of men in this high riskage-group see their GP annually 4 , this testingis infrequently performed 1 .To achieve the project aim of examiningwhether annual chlamydia testing for youngpeople is feasible and effective, GP clinics andAboriginal Community Controlled HealthServices in approximately 54 suburbs or townswill be invited to participate in the trial. Thesegeographical areas will be randomised to receiveeither the intervention or to carry out usual care.The intervention is multifaceted and includesfeedback on testing performance, education forclinic staff, incentives and multiple rounds oftesting. At the trial’s conclusion, the success of theintervention will be determined by examining thechange in chlamydia prevalence, rates of pelvicinflammatory disease, and number of chlamydiatests performed. Most importantly, ACCEPt willassist the government to decide whether to rollout a national chlamydia screening programand how it will work best.A multidisciplinary consortium of researchersled by an executive team, largely based in VictoriaChlamydia: Common. Curable. easily diagnosed.and NSW at The University of Melbourne andthe National Centre for HIV Epidemiology andClinical Research, are running the trial. The trialhas commenced in rural Victoria and may becoming to your practice soon.For further information about ACCEPt,visit: www.accept.org.au or call (03) 8344 0792.References1. Tomnay J, Gebert R and Fairley C. A survey of partnernotification practices among general practitioners andtheir use of an internet resource for partner notificationfor Chlamydia trachomatis. Sexual Health. 2006;3(4):217–220.2. Peipert J. Genital chlamydial infections. N Eng J Med.2003;30:901–904.3. Harris M, Bennett J, Del Mar C, Fasher M, Foreman L,Johnson C, Joyner B, Litt J, Mazza D, Smith J, Tomlins R,Bailey L, London J and Snowdon T. Guidelines forpreventive activities in general practice. Melbourne,Australia: Royal Australian College of GeneralPractitioners, 2009.4. Hocking J, Walker J, Regan D, Chen M and Fairley CK.Chlamydia screening- Australia should strive to achievewhat others have not. MJA. 2008;188(2):106–108.Executive Members:Dr Jane Hocking, University of MelbourneProfessor Christopher Fairley,Melbourne Sexual Health CentreProfessor Jane Gunn, University of MelbourneProfessor Basil Donovan,Sydney Sexual Health CentreProfessor John Kaldor, University of NSWDr Rebecca Guy, University of NSWAssociate Professor Matthew Law,University of NSWProfessor Nicola Low,University of Bern, SwitzerlandAssociate Professor Meredith Temple-SmithUniversity of MelbourneConsortium Members:Dr David Regan, University of New South WalesA/Professor David Wilson, University of New South WalesMr James Ward, University of New South WalesA/Professor John Imrie, University of New South WalesProfessor Rob Carter, Deakin UniversityProfessor Marian Pitts, La Trobe UniversityA/Professor Anne Mitchell, La Trobe UniversityA/Professor Marion Saville, Victorian Cytology ServiceA/Professor Dorota Gertig, Victorian Cervical CytologyRegistryDr Lena Sanci, The University of MelbourneDr Marie Pirotta, The University of MelbourneA/Professor Sepehr Tabrizi, Royal Women’s HospitalA/Professor Marcus Chen, Melbourne Sexual HealthCentreA/Professor Margaret Hellard, Burnet InstituteJune 2010 Primary Times 19

CLINICAL CAREBest practice forchronic woundsChronic wounds requirepatient centred, holistic,interdisciplinary, cost-effective andevidence-based care. Best practiceinvolves the assessment of the wholepatient, not just the ‘hole in thepatient’, and any wound that is nothealing should prompt us to lookfor unresolved underlying causes 1 .No one parameter can provideenough information to plan care orto monitor progress 2 . Wound chartscan be a useful reminder of what toassess and can assist in comprehensivedocumentation, consistency of careand communication 3 .Wound assessmentcriteriaPatient detailsIdentify the patient and ensure thatyou are using the correct patient file.Medical historyObtain a comprehensive medicalhistory. Past and current medicalhistory can assist in identifying theunderlying cause and factors thatmay delay healing 1 .MedicationsIdentify medications the patient istaking. Some medications affecthealing, including: non-steroidalanti-inflammatory drugs, cytotoxics,corticosteroids, immunosuppressants,antibiotics and nicotine 4 .LocationDocument the location of eachwound. Body diagrams showingwound position, as well as numberingof wounds, ensure that individualwounds can be easily identified 5 .Locality is also important whendetermining aetiology 5 .Wound historyKnowing which treatments havealready been used and their effectis important in avoidance of usingknown allergens 5 . The age of awound may be an indicator of thestage of healing to which it shouldhave progressed 2 .AetiologyCorrect treatment cannot be planneduntil the reason for non-healing isknown 5 . When confirming theaetiology multiple diagnostic toolsshould be used 6 , includinglaboratory tests, diagnostic tests,clinical history and wound history.It is recommended that allpatients with a lower leg ulcer have adoppler performed to determine theankle brachial pressure index (ABPI)and rule out arterial disease 7 .A biopsy would rule outmalignancy, and clinical assessment(shape, location, edges, colour andtexture of the surrounding skin) mayalso be an indication of aetiology 8 .ClassificationMost classification systems or thestage of wounds deal with a specificwound type (e.g. pressure ulcers,skin tears and diabetic foot ulcers).Classification by depth of tissueinjury (superficial, partial thickness,etc.) is often used for all wounds thatare not pressure or neuropathic ulcers.The stage of a wound could indicatean expected time frame for healing 2 .Colour or tissue-typeThe colour of a wound helps identifyviable and non-viable tissue (e.g.black, green, yellow, red and pink),as well as the phase of healing.However, Keast 8 explains that amore reliable indicator is thepercentage of tissue type thancolour. Regular re-evaluation helpsto measure progress.ExudateThe amount of exudate, and itscolour, type and odour, providesclues about the phase of healing andhelps the practitioner to choose themost appropriate dressing. Changesin exudate may be one of the firstsigns of impending infection 8 .Consistent and clear terminology,definitions, qualitative descriptionsand quantitative measures ofexudate are important 8 .DimensionsWound size is objective evidencethat the wound is improving ordeteriorating. Linear measurementsare often inaccurate, due to irregularwound shape. A tracing is moreeffective as the surface area can becalculated from this simply bycounting squares on a grid. Achange in surface area is a usefulparameter in assessing responseto treatment 9 .The Visitrak wound managementsystem is capable of estimating thearea of undermining, tunnellingand sinus tracts, as well as surfacearea, and if one is available thismeasurement should be recordedevery one to four weeks 9 .The depth may be classifiedby the thickness method, such assuperficial, partial or full thickness.It is often difficult to measure thetrue depth of a wound due todifferent parts of the wound havinga different depth 9 .EdgeThe wound edges can indicate thephase of healing, and may beanother indicator of the aetiology 10 .Edges may be attached to the woundbase or separated. If undermining ispresent, the edges are not attachedand epithelialisation cannot occur.If the edges are not advancing asexpected, the wound may have beensubjected to repetitive injury(e.g. during dressing change) 10 .Surrounding skinThe skin surrounding the woundand the whole limb may also giveclues to the aetiology or underlyingpathology. Look for texture, callus,maceration, oedema, colour,sensation, temperature, hair, nails,blisters, etc. 2PainThe type, location, pattern andintensity of pain can also assist inidentifying the aetiology of thewound. Changes in these parameterscould indicate infection, underlyingpathology or inappropriatetreatment 11 . Uncontrolled pain maylead to reduced compliance withtreatment. The clinician’s assessmentof the pain is often different to thepatient’s perception, which makes apain scale a valuable tool 12 .OdourIncreased odour may also indicateinfection 2 . Malodour is veryembarrassing for the patient andmay prevent them from performingnormal activities 2 .Prognosis and goals of therapyA baseline assessment allows theclinician with the patient todetermine the prognosis and setshort and long-term goals. Involvingpatients in care planning gives themmore control, which helps increase20Primary Times June 2010

Look at the WHOLE PERSON, not the hole in the personCLINICAL CAREWWoundPPsycho‐logicaltheir self-esteem and compliance 13 .When a goal is met, it encouragesthe patient to continue withtreatment and to participate inachieving wound healing.Dressing regimenThe dressing regimen needs to bedocumented to enable continuity ofcare. The wound should be monitoredfrequently after initiating woundtreatment to identify early signsof effectiveness and documentedappropriately.PhotographyWound photography can be anexcellent educational tool for healthprofessionals to illustrate variouswound types, staging and progressionof healing 14 . Photographs alsoprovide a permanent record of thewound condition at baseline and atregular intervals throughout care.Photographs are useful for clientswho cannot directly see the woundto motivate them to supporttreatment plans, in the case of legalissues or for acquiring servicesand funding 15 .ConclusionEElderlyHHistoryTo be of value, a wound assessmentchart needs to be completedaccurately by all staff. To achievethis, the chart should be userfriendly,quick and easy to use andRReducedvascularityOObesitySSensa5onmovementaddress relevant parameters. Chartsalso serve as an educational tool forstudent nurses and new practitioners.Using a chart encourages accurateassessment and documentation,leading to continuity of care andappropriate treatment. To ensurebest practice in wound management,it would be appropriate for allpractices to have a written woundmanagement policy and to usestandard wound assessmentguidelines, including acomprehensive wound chart.References1. Sibbald G, Orsted H, Coutts P and KeastD. Best practice recommendations forpreparing the wound bed: Update 2006.Wound Care Canada. 2006;4(1):15–29.Accessed 11 Apr 2010: www.cawc.net/images/uploads/wcc/4-1-vol4no1-BP-WBP.pdf2. Sussman C. Assessment of the skin andwound. In Sussman C and Bates-Jensen B(Eds.), Wound care: A collaborativepractice manual for physical therapistsand nurses. 3rd ed. Gaithersburg, Md:Aspen Publishers. 2007;85–122.3. Benbow M. Evidence based woundmanagement. Whurr Publishers, London.2005;61.4. Carville K. Factors that inhibit healing.Wound Care Manual. 5th ed. OsbornePark: Silver Chain Foundation.2007;40–45.5. Hess C. The art of skin and wound caredocumentation. Advances in Skin andWound Care. 2005; 18(1);43–53.6. Hess C and Trent J. Incorporatinglaboratory values in chronic woundmanagement. Advances in Skin &LListofmedica5onsOOthertherapiesEE5ologyNNutri5onWound Care. 2004; 17(7):378–386.7. Kunimoto B, Cooling M, Gulliver W,Houghton P, Orsted H and Sibbald R.Best practice recommendations for theprevention and treatment of venousleg ulcers: Update 2006. Wound CareCanada. 2006;4:45–55. Accessed 11 Apr2010: www.cawc.net/images/uploads/wcc/4-1-vol4no1-BP-VLU.pdf8. Keast D, Bowering K, Evans W, MackeanL, Burrows C and D’Souza L. MEASURE:A proposed assessment framework fordeveloping best practicerecommendations for wound assessment.Wound Repair and Regeneration.2004;12(1): S1–s17.9. Flanagan M. Wound measurement:can it help us to monitor progressionto healing? Journal of Wound Care.2003;12(5):189–194.10. Cuzzell J. Wound assessment andevaluation: Wound documentationguidelines. Dermatology Nursing.2002;14(4):265–266.11. World Union of Wound HealingSocieties. Principles of best practice:Minimising pain at wound dressingrelatedprocedures. A consensusdocument. London: MEP Ltd; 2004.Accessed 10 April 2010: www.wuwhs.org12. King B. A review of research investigatingpain and wound care. Journal of WoundCare. 2003;12( 6).13. Douglas V. Living with a chronic legulcer: an insight into patient’s experiencesand feelings. Journal of Wound Care.2001;10(9):355–360.14. Hayes S and Dodds S. Digitalphotography in wound care. NursingTimes.net. 2003;99(42):48. Accessed10 Apr 2010: www.nursingtimes.net/nursing-practice-clinical-research/digital-photography-in-woundcare/205042.article15. Buckley K, Adelson L and Hess C.Get the picture! Developing a woundphotography competency for home carenurses. The Journal of Wound, Ostomyand Continence Nursing. 2005;32(3):171–177.Resources1. Australian Wound ManagementAssociation. Standards,guidelines, research, publicationinformation and links to state andinternational wound managementassociations: www.awma.com.au2. Visitrak wound managementsystem:wound.smith-nephew.com/au/node.asp?NodeId=40023. Qld Health: Wound assessmentand management tool: www.archi.net.au/documents/e-library/qs/wound/wound.assessment.pdf4. Tissue Viability, NHS QualityImprovement Scotland:Assessment chart for woundmanagement:www.tissueviabilityonline.com/view-tool?resid=243&from=/resources/toolsBeverley YoungRN, Masters in Wound CareBeverley (Lea) has extensive nursingexperience in both the UK and Australia.Lea worked as a community healthnurse in Tasmania for 15 years beforecommencing part-time work as apractice nurse in 2009 at the Risdon ValeCommunity Health Centre and its partnerpractice, the Clarence Community HealthCentre. Lea has also worked part-time atthe Royal Hobart Hospital Wound Clinic.Lea was the winner of the Merck Sharp& Dohme Best Practice Nurse Award forInnovation in Nursing in General Practice2009 in recognition of her innovativemethods to improve wound care services.June 2010 Primary Times 21

PRACTICE NURSINGNational Practice NurseWorkforce SurveyThe Australian General Practice Network (AGPN) released the first comprehensive NationalPractice Nurse Workforce Survey Report in 2003. It has since been released biannually.In 2009 the report provides a snapshot of workforce trends to date.Key findings• Part-time employment is stillpredominant in the practice nurse(PN) workforce, showing a slightincrease of 4.1% to 79.6%. Thenumber of PNs working in at leastone other nursing job was 32.3%(30.7% in 2007).• Gender distribution has remainedstable, with 98.2% being female.• Similarly to results found in 2007,four out of five PNs are aged 40 orover. Age distribution of registerednurses (RNs) in practices hasremained relatively stable. Therehas been a slight ageing trend forthe enrolled nurse populationwith fewer nurses in their 20sand a significant boost in theproportion of nurses in their 50s.• From practice data, 49% of PNsare located in major cities ofAustralia, 19% in inner regionalAustralia, 18% in outer regionalAustralia, and the remaining14 % in remote or very remoteAustralia.Qualifications and experience• Approximately 85% of PNs areregistered. This is a similar resultto those in 2007, with only a slightincrease in the proportion of RNs.• The percentage of PNs who haveundertaken postgraduatequalifications has increasedslightly, rising 3.22% to 64.04%.Similarly to 2007, the mostpopular qualifications areAccredited Nurse Immuniser(31.27%) and Midwifery (18.48%)courses.Growth of the Australian PNworkforceSince 2007 the number of employedPNs in Australia has increased 15.3%,from 7728 to 8914. Despite this, theproportion of practices employingPNs marginally decreased to 87.7%,and the number of practices in theAustralian general practice networkhas decreased by 8.4%. This stronglyimplies that growth in the workforceis mostly due to an increase of theaverage number of PNs employed byeach practice. Statistics support this.The table below shows a markeddecrease in the proportion ofpractices employing one nurse,offset by a general increase in thenumber of practices employingmore than one nurse. This suggeststhat the value of practice nursing isbeing recognised within practicesthat employ nurses.Percentage of practices employing PNs4035302520151050Nurses employed per practice0 1 2 3 4 5 6Number of practice nurses2007 2009Membership with professionalorganisationsSimilarly to results recorded in 2007,63.7% of surveyed nurses have amembership with a professionalmedical and/or nursing%4035302520151050Royal College of Nursing Aust.College of Nursing (NSW)Australian Nursing FederationAustralian Practice Nurses Assoc.organisation. The chart above showsthe percentage of respondentsaffiliated with each organisation in2007 and 2009.With an increase of 2% of networkmembers, the Australian PracticeNurses Association is pleased tohave clearly attained the highest rateof membership growth amongstnurses in the Australian generalpractice network.Additional commentsSome of the report’s most valuableinsights can be found in surveyrespondents’ written comments.The time and costs associated withongoing training were recurringthemes. Many practice nurses highlyvalue training but are challengedwith scheduling this around workand frequently do not receiveincentives for this training.The greatest concern regardingworkforce retention is the payinequality as compared to nursesworking in hospitals; 242Membership with medical associationsAssoc. of Aus. Rural NursesAus. Diabetes Educators Assoc.Other organisations20072009respondents commented on thisissue. There was also positivefeedback about many aspects ofpractice nursing as a career, such asflexible and family-friendly workinghours, recognition from other healthprofessionals and variety of work.Last impressionsThe value of practice nursing isbeing recognised by practices thatemploy nurses. There is potentialfor growth in the practice nursingworkforce. Practices withoutemployed nurses must be made fullyaware of the benefits of nursing inthe general practice environment.Nurses in general practice benefitfrom being recognised by otherhealth professionals and often enjoya greater measure of autonomy;however, there is an enduring needto improve access to ongoing training.The full report is available on theAGPN website: http://generalpractice nursing.com.au/current-activities22Primary Times June 2010

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PRACTICE NURSINGReflecting on patientcare outcomesReflective journaling can develop critical thinking and lead to an increased awareness of thecontributing elements in an incident. Although many nurses perform reflective role analysisautomatically, some may find it challenging to move beyond dealing with the everyday issues andinto better management of chronic conditions and prevention. While reflective journaling can takeany form, Sue Jackson finds that developing a case study can give the process structure.The process of critical reflection,identification of contributingelements and increased awarenesscan lead to professional practicedevelopment. The following case studydemon strates the case review techniqueas a tool for reflective journaling. Thisprovided a review of the key elements ofnursing intervention that contributed toa positive outcome in the case of apatient with diabetes. It takes the formof a conversation, as would be expectedduring the mentoring that occurs in aclinical environment.Case history: Mr TMr T, aged 67, presented to my generalpractice to receive his annual seasonalinfluenza vaccination. The consultationprovided the opportunity to undertakechronic disease self managementsupport, and led to significantimprovements in his diabetesmanagement. I carried out a criticalreflection of the process in order tobuild on this success and maintainmy professional practice.While the consultation began as aroutine episode of care, I used theappointment to identify opportunitiesto implement additional ‘prevention’strategies.Consultation:I called Mr T into my consultation room,welcomed him, and confirmed he hadcome to see me for his ‘flu shot’.In the process of discussing hisannual flu shot, I checked his healthrecord for allergies and whether he hadreceived a pnuemoccocal vaccinationand noted his history:• A 67-year-old single man, whohad retired from school teaching.(Higher prevalence of chronicdisease in older Australians.)• Diabetes type 2 diagnosed in 2005.• BMI: overweight range.• Non smoker.• No significant family history.• Medications prescribed: Metformin500mg daily for blood glucose control;Micardis 80mg for hypertension;Crestor 20mg for hyperlipidemia.• Glycaemic control status deterioratingdue to current poor control.As I prepared Mr T’s influenzavaccination, my thoughts turned tohis diabetic history. In my routinediscussion during his vaccination,I steered the conversation towardthe topic of his health.It can be difficult to broach diabetesand poor glycaemic control, and offerassistance in a nonthreatening way,within a 10-minute appointment fora different issue. Managing theconversation in a delicate mannerwas a key technique that contributedto the success of the opportunistic selfmanagement support. For instance,I asked Mr T if he had any concernsabout his health to which he responded,by saying that managing his bloodglucose levels (BGLs) was puzzling andthat he felt he was ‘losing a battle’.I actively listened to his concerns,agreeing that achieving good glycaemiccontrol can be a perplexing andfrustrating exercise and that manydiabetic patients feel the same. I offeredto assist him if he would return to seeme for a 30-minute consultation todiscuss diabetes management.Mr T agreed and we set an appointmenttime. This opportunistic chat proved tobe the first step toward achieving asuccessful outcome in managing hisdiabetic condition.When Mr T returned, I was keen toapproach the consultation with empathy,so began by asking him what heunderstood about diabetes. My motivein approaching the consultation this waywas to: build our relationship; help himfeel comfortable in sharing his diabetesstory; assess his level of knowledge andunderstanding of his condition; and,identify the areas where I could offerassistance. When reflecting on whatmade this consultation successful,I noted that I was doing most of thelistening during this visit. I listenedcarefully to Mr T and noted his dietaryhabits and capillary BGL readings.Mr T was frustrated with his attemptsto control his condition and expressedhow it was too complex for him tounderstand and he no longer wanted totry. During our discussion he revealeda number of misunderstandings abouthis condition:• The impact of his diet, particularlycarbohydrates, on his glycaemiccontrol.• The significance of portion control offood and fat content of food, and howSue JacksonSue is a registered nurse and registeredmidwife. She has been working as apractice nurse for the past 10 years and isemployed as a Senior Nurse and ChronicDisease Specialist, by Healthscope Ltd,at Wentworth Avenue Family Practicein Kingston ACT. Sue has an interestin chronic disease management andlifestyle modification strategies. Sheis also a credentialed immuniser, andhas completed additional education indiabetes management.this affects his weight management.• A poor understanding of the benefitsof exercise and his insulin sensitivity.• No understanding of how hismedication was treating his condition.The key techniques of providing anempathic, supportive environmentfacilitated Mr T’s disclosure of hisfrustration and lack of understandingregarding self management of hisdiabetes condition. I successfullynegotiated another consultation timewith him to address his concerns.I later reflected how important it wasto provide dedicated self managementsupport time with adequateconsultation periods to patientswith chronic diseases.At the next visit, it was quicklyevident that Mr T was a highly intelligentman who asked many consideredquestions. I built on the rapportdeveloped in previous visits andassessed Mr T’s recall andunderstanding of our previousdiscussions. I did this by asking him toshare his health concerns that we talked24Primary Times June 2010

PRACTICE NURSING... he expected to be chastisedfor his poor control of hiscondition.about at our previous meeting. He wasaware of greater complications to hishealth incurred by diabetes and recalledthe effect on his kidney function andeyes, but was unsure of the reasonsfor these links.Consequently, I centred thediscussion on the issues important toMr T regarding the problems he raisedand the additional complications ofdiabetes. When Mr T revealed a poorlymaintained glucometer I suggestedinvolving a diabetes educator.Unfortunately, this suggestion increasedMr T’s anxiety and he confided that heexpected to be chastised for his poorcontrol of his condition. He conveyedthat he had felt foolish, ignorant andunsure of how to improve control of hiscondition, and in the past had negativeinteractions with a diabetes educator.I reassured Mr T that a number ofpatients with diabetes had commentedpositively about their interaction with thediabetes educator, and that it had beenvery beneficial.In order to further allay his anxiety,I phoned the diabetes educator inhis presence and discussed Mr T’sproposed plan of care, specifyingaspects which needed to be addressed.My ability to speak on his behalfreassured Mr T about his previousconcerns regarding seeing a diabeteseducator. I also sent a referral letter tothe educator to provide a more detailedmedical history.A further visit was scheduled toprepare a GP Management Plan andTeam Care Arrangement, to facilitateand subsidise the diabetes educatorvisit and allow for a podiatry review.At this visit, a GP Management Planwas drafted and prepared togetherwith Mr T in conjunction with his GP.Management goals included:• HbA1c result of 7 or

McGraw-Hill is proud to announcethe rst book written specically forAustralian practice nursesThis new book is a milestone in thedevelopment of practice nursing as aspecialty.General Practice Nursing offers practicenurses information on a range ofclinical and professional topics in aconcise, easy to read format. It offersevidence based, contextual informationsupported by case studies to assistnurses in applying theory to practice.Clinical topics such as immunisation,triage, wound management andpharmacology are coupled with generaltopics such as the role of the practicenurse, the Australian health system,evidence based practice, continuingprofessional development and nurse ledcare.By Lynne Walker, Elizabeth Patterson, William Wongand Doris YoungISBN: 9780070276949AUS$100.00/NZ$125.00Available June 2010518 pgs. Full colour design. SoftcoverTo view a sample of the book:http://www.mcgraw-hill.com.au/medical/walker/pageip.htmlTo encourage reective practice, eachchapter will include questionsthroughout the text, testimonials andreection questions.Available from your local medical bookshop or contact McGraw-HillPh: 61 2 9900 1888, Fax: 61 2 9900 1980Mail: Locked Bag 2233 North Ryde BC NSW 1670,Email: cservice_sydney@mcgraw-hill.comMcGraw-Hill Australia Pty Ltd ABN: 18 000 473 674 PRIVACY NOTICE (for our full privacy statement, please visit www.mcgraw-hill.com.au). McGraw-Hill Australia Pty Ltd recognises the importance of protecting your personal information inaccordance with the privacy amendment (Private Sector) Act 2000.

PRACTICE NURSINGBook review:General Practice NursingTitle: General Practice NursingAuthors: Lynne Walker,Elizabeth Patterson, WilliamWong and Doris YoungPublisher: McGraw-Hill Education(www.mcgraw.hill.com.au)ISBN 13: 9780070276949ISBN10: 0070276943Format: Hardback, 503 pagesPublication date: June 2010RRP: A$100Book description: General PracticeNursing is the first textbook developedspecifically for Australian practicenurses. The textbook providespractice nurses with informationon a range of clinical andprofessional topics in a conciseand easy-to-read format.This book is sectioned into fourmain parts. The first addressesprofessional issues such as theAustralian healthcare system andlegal issues pertaining to nursing ingeneral practice. The second dealswith the fundamentals of practicenursing, encompassing triage, healthpromotion, wound management andimmunisations. The third, entitled‘Clinical skills and management inpractice nursing’, delves into issuessuch as the role of nurses in chronicdisease management and the care ofyoung children in general practice.The fourth section addresses theway forward in practice nursing,with chapters dedicated to researchand the utilisation of evidence-basedpractice, leadership and ongoingprofessional development.Personal impressions: The strengthof the book comes from the fact thatthe authors and contributors havean acute understanding of generalpractice and general practicenursing. Familiar names are seenwithin—names synonymouswithin nursing circles that havestrengthened and assisted in shapingthe ongoing development of thespecialised field of nursing in generalpractice within Australia.The presentation of the bookinvites the reader to read on; and it’seasy to do so with colour photographs,clearly marked sections and brightheadings. The authors have alsocaptured honesty within the book,within included testimonials andreal life stories of nurses caring fortheir patients within their surgeries.Each chapter’s questions andreflection points encourage thereader to critically analyse their ownpractice. For those who strugglewith the concept of ‘reflectivepractice’, this book makes it effortless.The book is a ‘must-have’ fornurses new to general practice.For those who do the job daily, itprovides encouragement, ongoinglearning tools and reference sources.For undergraduate nurses, this bookmay even ignite an interest to pursuegeneral practice nursing. Studentdoctors and general practitionersmay find the book a beneficial toolin highlighting the enhanced patientcare delivery that can be embracedby utilising nurses in generalpractice to their full potential andwithin their scope of practice.This is a beautiful book and Iwholeheartedly recommend it.Ruth Mursa RN, Dip Applied Science(Nursing), MN (Nurse Practitioner)Ruth works as a Nurse Practitioner atthe Kotara Family Practice in Kotara,a suburb in Newcastle, NSW. Ruthhas worked in Australia and overseasas a surgical nurse in acute care andorthopaedics and as a Clinical NurseSpecialist in recovery. Ruth has beena practice nurse since 1997 andgraduated with a Master of Nursingdegree from Newcastle University in2009. She is studying for a secondMaster of Nursing in Child andFamily Health.June 2010 Primary Times 27

NEWSPap testprovidersin Victoriaon therisenew Victorian CervicalA Cytology Registry reportindicates that the number ofnurses in Victoria who haveundertaken Pap test training hasjumped from 185 in 2000 to 418in April 2010—a 125% increase.The most dramatic growth incervical screening by nurses hasbeen in rural areas with thepercentage of total Pap testsjumping by up to 5.1% since2007, compared to a 0.4%increase in metropolitan areas.In 2009, 14 123 Pap tests wereundertaken by general practicenurses.Under-screened, rural andolder women are among thosebenefiting from the cervicalscreenings services offeredby nurse Pap test providers,especially those working ingeneral practice. The rapidgrowth in the number of nursePap test providers and their skill intaking Pap tests can be attributedto a credentialing programadministered by PapScreenVictoria, and by nurses attendingregular professional developmentworkshops.Division 1 Registered Nursesinterested in becoming a Pap testprovider can find more informationin the Health Professionals sectionat: www.papscreen.org.auAdrenaline auto-injector now availablenew, innovative adrenalineA auto-injector device is availablefor the emergency treatment ofserious allergic reaction oranaphylaxis. Anapen® (adrenaline300μg/0.3mL) and Anapen® Junior(adrenaline 150μg/0.3mL) offerhealthcare professionals and theirpatients a long-awaited choice in thefirst-line treatment of lifethreateningallergic reactions.The user-friendly design of Anapen®may help reduce the time it takes toachieve successful adrenalineWomen experiencingoestrogen deficiency due tonatural or surgically-inducedmenopause can now accesshormone replacement therapy(HRT) patches as a first-line optionfor the symptoms of menopause.Estradot® (oestradiol), Estalis®Continuous and Sequi (oestradiol/injection and minimise the likelihoodof an unsuccessful attempt. Itfeatures a simple and distinctivered ‘firing’ button, which employs asimilar mechanism of action to thatof a retractable ball-point pen.Australian medical and consumerassociations have ensured thateducational and training resourcesthat include Anapen® instructionsare readily available to staff atschools and childcare services,healthcare professionals, parentsand patients.norethisterone acetate) areavailable as a first line option onthe PBS for women experiencinghormonal imbalance.HRT patches are used to manageshort-term symptoms associatedwith oestrogen deficiency, and toprevent postmenopausal bonedensity loss in postmenopausalResources1. LINK Pharmaceuticals. Anapen®:Education and training packs forhealthcare professionals andconsumers: www.analert.com.au2. The Australasian Society ofClinical Immunology and Allergy.Anaphylaxis resources ande-training, position papers/guidelines and action plans.Accessed 26 Apr 2010:www.allergy.org.auNew hormone replacement therapy patchesFirst Australian NationalMale Health PolicyThe Department of Health andAgeing has developed a newNational Male Health Policy,Building on the Strengths ofAustralian Males. The Policypro vides a framework for improv ingthe health of males and providespractical suggestions for actiondesigned to achieve better healthoutcomes for male popu lationgroups at risk of poor health.The Policy has nine supportingdocuments, which provide indepthanalysis of some of the issues raisedwithin the Policy. Supportingdocuments include: SocialDeterminants and Key ActionsSupporting Male Health; HealthyMinds; Healthy Routines; HealthyReproductive Behaviours; HealthyLimits; Access to Health Services;Action Males Can Take Now; andwomen who are at increased riskof osteoporotic fractures and areintolerant of, or contraindicated for,other medicinal products approvedfor the prevention of bone mineraldensity loss.For further information visit:www.menopause.org.auNational Aboriginal and TorresStrait Islander Males HealthFrame work Revised GuidingPrinciples.Further information anddownloads can be accessed at:http://www.health.gov.au/internet/main/publishing.nsf/Content/national+mens+health-128Primary Times June 2010

Changes to CTPinsurance will help moreof your patients.From April 2010, the NSWCompulsory Third Party, or GreenSlip, insurance scheme has beenexpanded so that anyone injuredin a motor vehicle accident in NSW,regardless of who was at fault,may be able to access benefits.The change relates specificallyto the Accident Notification Form(ANF) which provides for theearly payment of reasonable andnecessary medical expenses and/or lost earnings up to a maximumof $5,000.You can help your patients toaccess early treatment for theirinjuries by telling them about theANF and completing the medicalcertificate section of the form.The completed ANF includingthe medical certificate must besubmitted to the relevant CTPinsurer within 28 days of theaccident.The ANF and an information sheetfor your patients is availableat www.maa.nsw.gov.au orby calling the Motor AccidentsAuthority’s Claims Advisory Serviceon 1300 656 919

RESOURCESNew evidence paperon antioxidantsThe National Heart Foundation of Australiahas released a new scientific paper Summary ofevidence: Antioxidants in food, drinks andsupplements for cardiovascular health. Theposition statement, Antioxidants in food,drinks and supplements for cardiovascular health(2010) details the Heart Foundationrecommendations to adult Australians,Governments and food industry.The review found that a balanced diet witha wide variety of plant-based foods will providethe antioxidants beneficial for cardiovascularhealth.For further information go to:www.heartfoundation.org.au/Professional_Information/Lifestyle_Risk/Nutrition/Pages/default.aspxNew resource for bleeding disordersSeventy-five per cent of patients living with severebleeding disorders worldwide do not have accessto appropriate diagnosis and treatment.Healthcare professionals and more than 3300Australians living with inherited bleedingdisorders can now access a new educational videopodcast designed to raise awareness of the effectsof haemophilia, von Willebrand disease, rarefactor deficiencies and inherited plateletdisorders.The podcast, The many faces of bleedingdisorders—United to achieve treatment for all,was launched by Baxter in collaboration with theWorld Federation of Haemophilia (WFH).The podcast provides healthcare professionalsand patient organisations with a comprehensiveresource to simply and effectively educate patientsabout risk factors for inherited bleeding disorders,treatment options and recent researchdevelopments, and highlights the need for bettertreatment access for everyone living with theseserious conditions.The podcast is downloadable at:www.wfh.org/whd.Asthma inhaler‘how to’ videofor childrenThe National Asthma Council Australia haslaunched a simple online video to demonstratecorrect inhaler usage for children using a pufferand spacer.The new online video is an extension of aseries of videos designed to improve inhaler useamongst adults. The Using your MDI (puffer)and spacer for kids video can be viewed at:www.nationalasthma.org.au/content/view/686/109130Primary Times June 2010

idging the gapclinical auditEffectively manage your CVD patientsThe Bridging the Gap Clinical audit has been designed to enhance the clinical skills of practice nurses and supporta multidisciplinary approach widely recognised as essential to the effective management of patients with CVD.This program is endorsed by RCNA and APNA for 10 continuing nursing education (CNE) points and participatingGPs can obtain 40 RACGP Category 1 QA&CPD points.Free CAT Softwarefor your practiceImprove practicesystemsTeam-based approach• Facilitates practice accreditation• Instantly produces disease registers, e.g. CHD• Identifies outstanding Service Incentive Payments (SIP) item numbers for patients with diabetes• Identify patients at risk of chronic disease• Develop patient recall systems• Routinely implement GP Manangement Plans (GPMP) and Team Care Arrangements(TCA) for patients with chronic conditions• Access related MBS items such as:– 721 GPMP & 723 TCA– 10997 PN patient review for those on a GPMP• The program supports the partnership between practice nurses and general practitionersSign up today to bridge the gap in cardiovascular disease and earn CPD points.Spaces are limited. For more information, log on to www.bridgethetreatmentgap.com.auSponsored by PfizerDeveloped by LifebloodAdministered by Lifeblood ABN 43 926 343 251. 100 Mallet Street, Camperdown NSW 2050 Sponsored by Pfizer ABN 50 008 442 348. 38–42 Wharf Road, West Ryde NSW 211418149

NEWSGo red for womenHeart disease is the biggestcause of death in Australianwomen. In fact, it is responsible forfour times as many deaths in womenthan breast cancer—over 11 000women per year.Recent Heart Foundationresearch shows that awareness ofthis fact is low, with only one in fivewomen knowing heart disease is theleading cause of death. This researchalso highlighted that women aremisinformed about heart disease,with many assuming it only happensto older men.The risk of heart disease increasesin women after menopause, asoestrogen acts as a protective factorduring a woman’s childbearingyears. The good news is that heartdisease is largely preventable.Practice nurses can play animportant role in both raisingawareness and encouraging patientsto take steps to reduce risk factors.Smoking, poor diets and physicalinactivity are important risk factorsfor heart disease as well as age, highblood pressure, high cholesterol andfamily history.The Heart Foundation Go Red forWomen (GRFW) campaign aims toraise awareness of heart health.Tips on nutrition, new recipes,ideas on how to get physically activeand personal stories can be accessedthrough both the GRFW websiteand the free GRFW e-newsletter.For more information visit theGRFW website at: www.goredforwomen.org.au or call the HealthInformation Service on 1300 362 787.On 1 June, the Australian Instituteof Health and Welfare released thenew report Women and heartdisease: Cardiovascular profile ofwomen in Australia. To access thisreport visit: www.aihw.gov.au/publications/index.cfm/title/10748alginate gel with enzymes that kill absorbed bacteria 1Advanced technology wound care with 3 clinical benefits• Moist wound environment • Continuous auto-debridement • Broad spectrum anti-bacterial activity 1Grade 2 leg skin tear treated with Flaminal ® Hydro 2Day 0 Day 30Day 68www.flaminalaustralia.comalginate gel with enzymes thatkill absorbed bacteria 1[1] White R. ‘Flaminal: A novel approach to wound bioburden control’, Wounds UK 2006, 2 (3): 64–69. [2] Data on file at Flen Pharma. FD10019Flen Pharma NVAspen Pharmacare Australia Pty LimitedBlauwesteenstraat 87, B-2550 Kontich, BelgiumABN 51 096 236 985www.flenpharma.com34–36 Chandos Street, St Leonards NSW 2065® : Trademark of Flen Pharma Ph +61 2 8436 8300 ■ www.aspenpharma.com.au

WE’RE STILL DOING A FEW LAPS, THEN COFFEE®PBS Information: Restricted Benefit. Symptomatic treatment of osteoarthritis andrheumatoid arthritis. Refer to PBS schedule for full PBS restricted benefit information.BEFORE PRESCRIBING, PLEASE REVIEW FULL PRODUCT INFORMATION AVAILABLE FROM PFIZER AUSTRALIA PTY LTD.Minimum Product Information. CELEBREX ® (celecoxib) 100 mg and 200 mg Capsules. Indications: Symptomatic treatment of osteoarthritis (OA), rheumatoid arthritis (RA) &ankylosing spondylitis (AS). Treatment of primary dysmenorrhoea in adults.Contraindications: Hypersensitivity to ingredients; allergic-type reactions to sulphonamides; concomitantuse with other NSAIDs; aspirin/NSAID sensitive asthma; urticarial/allergic reactions to aspirin or NSAIDs; peri-operatively in CABG surgery; unstable/significant established IHD, PADor cerebrovascular disease; active peptic ulceration; GI bleeding; estimated creatinine clearance

NEWSRevised standards ofwound managementThe revised and updated 2nd edition of the Australian WoundManagement Association (AWMA) Standards for WoundManagement was launched in March.The 1st edition of the Standards, published in 2002, underwentreview at various national workshops. In addition, the AWMAStandards Sub-committee conducted an extensive literature review toidentify contemporary evidence, guidelines and consensus statements.All wound practitioners are encouraged to obtain a copy of theStandards. AWMA members will receive a free copy of the Standardsin their next edition of Wound Practice & Research. The document isalso available in hard copy from Cambridge Media for $15 (includesGST and postage).For further information and an order form go to:www.awma.com.au/publications/publications.php#standardsNew online course onBBVs and STIsnew online course on blood borneA viruses (BBVs) and sexuallytransmitted infections (STIs) is nowavailable on the APNA website. Thecourse is aimed at practice nursesproviding clinical services in primary careto patients who have, or are at risk of,BBVs and STIs.The course outlines the public healthaspects and clinical management of BBVsand STIs and it advocates a proactiveapproach to healthcare and evidencebasedpractice. It also provides anoverview of the epidemiology, testingprinciples, pathogenesis, natural historyand treatment of HIV, hepatitis B and Cand common STIs.This online course is FREE for NSWparticipants and available to otherstates and territories for a nominal fee.Visit: www.apna.asn.auAPNA PracticeNurse Shirtsand PolosPolo shirts are available in dark green with APNA logoand the words Practice Nurse underneath. Collaredshirts are either chambray (straight cut) with a breastpocket or avocado green (tailored fit). Both have APNAlogo and the words Practice Nurse underneath andcome in ladies sizes ladies 8 to 24.Cost: $35 each + $5 postage & handling (Polos),$39 each + $5 postage & handling (Shirts)See the back of the Primary Times address flysheetfor order form or call (03) 9669 7400.34Primary Times June 2010

IMMUNISATIONRemember pneumococcal vaccination this yearThe influenza season is upon us,as is the time for pneumococcalvaccination.In 2005 the pneumococcalimmunisation program for olderadults commenced in all states andterritories except Victoria, where theimmunisation program startedearlier 1 . During that year manyAustralians 65 years and older werevaccinated against pneumococcaldisease. Patients immunised in 2005are now due for their five-yearbooster doses.In addition to those over 65, theNHMRC Immunisation Guidelinesrecommend pneumococcalvaccination with Pneumovax®23 forgroups who are considered at-riskof infection from pneumococcalbacteria. This includes patients withchronic illnesses such as cardiac,renal or respiratory disease, diabetics,alcohol-related problems, those withimpaired immunity, asplenic patientsand tobacco smokers. These ‘at-risk’patients are eligible to receivePneumovax23 on the PBS with aprescription 1 .Aboriginals and Torres StraitIslanders (ATSI) over 49 yearsand those aged 15–49 with the ‘atrisk’ conditions mentioned, arealso provided the vaccine freeon the National ImmunisationProgram (NIP) 1 .When comparing vaccinationrates of the ‘at-risk’ patients andover 65s, only a small proportionof the eligible ‘at-risk’ patients aregetting vaccinated each year 2,3 .Pneumococcal disease can beserious for the ‘at-risk’ patients, withmost people who develop invasivepneumococcal disease having atleast one risk factor 1 .During influenza pandemics,including the recent H1N1 pandemic,many of those dying from influenzahad concurrent pneumococcalpneumonia 4–6 . This highlights theimportance of immunising the‘at-risk’ patients this year.The NHMRC immunisationguidelines have similarrecommendations for patients‘at-risk’ of influenza andpneumococcal infection. This yearmore ‘at-risk’ patients will be eligiblefor free influenza vaccine 1 . This givesHealthcare Professionals greateropportunity to discuss pneumococcalvaccination when patients presentfor their flu vaccine.This article was provided by CSLBiotherapies Pty Ltd ABN 66 120 398067, 45 Poplar Road, Parkville, 3052.February 2010. Pneumovax23 is aregistered trademark of Merck & Co. Inc,Whitehouse Station, NJ, USA.References1. The Australian Immunisation Handbook,NHMRC. 9th Edition, 2008, Chapter3.15.2. IMS Sales data 2005–2009.3. Roxon, N. $44 Million to protect thosemost at risk from seasonal flu [pressrelease]. Canberra: Dept of Health andAgeing; 2009 Jul 19.4. Bacterial coinfections in lung tissuespecimens from fatal cases of 2009pandemic influenza A H1N1 2009,MMWR, 29 Sept 2009;58:1–4.5. WHO Weekly Epidemiological,No. 42, 2008;83:373–384.6. Morens D, Taubenberger J and Fauci A.Predominant Role of BacterialPneumonia as a Cause of Death inPandemic Influenza: Implications forPandemic Influenza Preparedness.The Journal of Infectious Diseases.2008;198:962–970.Get your patients started with an Arginaid ® Sample KitTo order call 1800 671 682Available while stocks lastJune 2010 Primary Times 35

GUIDELINESOsteoporosis guidelinesThe Clinical guideline for theprevention and treatment ofosteoporosis in postmenopausal womenand older men was released in February2010 by the National Health andMedical Research Council (NHMRC).Osteoporosis is a diseasecharacterised by low bone mass anddeterioration of bone tissue, leading toenhanced bone fragility and increase infracture risk. It is diagnosed by a bonedensity test that usually measures thedensity at the hip and spine. Theincidence of minimal trauma fracturesin Australia is higher among womenthan men and increases with age inboth genders.The guideline outlines a best practiceapproach in: identifying, diagnosing,treating and managing, in a timely andaccurate manner, men and women whohave been diagnosed with at least oneminimal trauma fracture; reducing theprogression of such individuals to asecond fracture; and optimising patientand carer access to information,understanding of the condition andinvolvement in its management inorder to help patients improve theirhealth status.The guidelines can be accessed fromthe Royal Australian College of GeneralPractitioners (RACGP) website:www.racgp.org.au/guidelines/musculoskeletaldiseases/osteoporosisGuidelines forconstipation andimpaction managementFor the first time healthcare professionals and carers inAustralia have access to clinical best practice guidelinesto identify, assess and treat constipation and impaction inolder people.IMPACT bowel care for the older patient contains acomprehensive, practical and easy-to-use set of guidelines,assessment tools and treatment pathways.A multidisciplinary team of 10 leading experts, chairedby gastroenterologist Professor Peter Gibson of Box HillHospital, Melbourne, developed the guidelines, whichwere released in March. The team was supported by anunrestricted educational grant from Norgine Pty Ltd.To obtain a free copy call Norgine Pty Ltd on 1800 635 000.36Primary Times June 2010

Mental Health Online LearningMental disorders are becoming increasingly prevalent in oursociety. For a number of reasons many sufferers do not sharetheir concerns with health professionals. When they do seektreatment, general practice is where they present more oftenthan other settings. This online learning has been split intotwo modules that will allow you to be better prepared whendealing with patients with Mental Health issues.Module 1Will assist you by:• Providing you with background information about theprevalence of mental disorders especially in the generalpractice setting• Increasing your knowledge on the reasons that encourageand inhibit people from sharing their mental health concernswith health professionals. This will increase your index ofsuspicion and lead to improved detection of mental healthproblems,• Developing your skills in basic mental health assessment,particularly with the view to making better referrals to GPor mental health service, and• Developing your skills in basic risk assessment with clientswho have mental health problems.Duration: 2 hours Cost: FREEModule 2Focuses on the role of the various members of the mentalhealth team, mental disorders, mental health problems andwill also discuss issues of early intervention and assisting yourpatients to achieve and maintain good mental health.In this module you will learn about:• The role of the various members of the mental health team• Mental health• Mental disorders (also known as mental illnesses)• Mental health problems• Issues of early intervention – assisting your clients toachieve and maintain good mental health• The types of treatment available for mental disorders.Duration: 3 hours Cost: FREETotal of 4 APNA CPD PointsVisit APNA online learning at www.apna.asn.au or call 1300 303 184The development of this program was supported by the Australian Government,Department of Health and Ageing and enrolments to this online learning are providedat no charge through the Nursing and Allied Health Scholarship and Support Scheme.

CoaguChek ® XS systems- the smart way to test INRINR monitoring has never been made soeasy for immediate therapy adjustmentLIFE TIMEWARRANTY4Simple4Fast4Easy to use4ReliableNow even less blood needed withonly a 8µL drop of bloodWhen accuracy is vital you can feelcomfortable that the CoaguChek ® XSsystems will deliver the results for you andyour patients.CoaguChek ® XSor CoaguChek ® XS PlusThe choice is yoursWith over 2 million meters in use throughoutthe world by both patients and Health CareProfessionals, Roche is the leading providerof INR devices.Roche Diagnostics Australia Pty Ltd31 Victoria Ave Castle Hill NSW 2154Phone: 02 9860 2222ABN 29 003 001 205.