Reducing hospital associated complications in older people: Results from the CHERISH cluster randomised controlled study

Mrs Prue McRae1, Dr Merrilyn  Banks1,2, Dr Adrienne  Young1,2, Professor Ruth Hubbard3, Dr  Nancye Peel3, Professor Adrian Barnett2, Associate Professor Kwang Lim4,5, Professor Nicholas  Graves2, Professor  Susan  Kurrle6, Professor Irene Blackberry4,7, Professor  Theresa  Green2, Professor  Sharon Inouye8,9, Assoc Prof Alison  Mudge1,2

1Royal Brisbane And Women’s Hospital, Brisbane, Australia, 2QUT, Brisbane, Australia, 3University of Queensland, Brisbane, Australia, 4University of Melbourne, Melbourne, Australia, 5Royal Melbourne Hospital, Melbourne, Australia, 6University of Sydney, Sydney, Australia, 7La Trobe University, Wodonga, Australia, 8Harvard Medical School, Boston, United States of America, 9Aging Brain Center, Boston, United States of America

Background: Hospital-associated complications of older people (HAC-OP) include delirium, functional decline, incontinence, falls and pressure injuries. These are associated with longer hospital stays and new admission to aged care facilities.  This study aimed to implement “Eat Walk Engage” to reduce HAC-OP and length of stay in acute care older patients. Eat Walk Engage is a multi-component program facilitating multidisciplinary practice changes to improve mobility, nutrition care and cognitive engagement.

Methods: We used a pragmatic cluster randomized trial design to evaluate Eat Walk Engage. We enrolled inpatients aged 65 years or older, admitted for 3 days or more to eight acute medical and surgical wards in four Queensland public hospitals. Primary outcomes were length of stay and any new HAC-OP. Secondary outcomes included individual new HAC-OP and discharge home.  Analyses were adjusted for age, sex, co-morbidities, admission functional and cognitive status, elective status and hospital.

Results: Implementation commenced on the four intervention wards in January 2016. Between October 2016-March 2017 we enrolled 539 participants (265 intervention, 274 control) of whom 305 (57%) were aged 75 years or older, 269 (50%) were female. Median length of stay was 6 days in intervention (IQR 4 to 9 days) vs 7 days in control (IQR 5 to 10 days), adjusted hazard ratio 0.96 (95% CI 0.80-1.15). HAC-OP occurred in 115/248 (46%) intervention vs 129/249 (52%) control, adjusted OR 1.07 (0.71-1.61). Delirium was significantly reduced, occurring in 37 (14%) of intervention vs 69 (25%) control participants, adjusted OR 0.58 (0.36-0.94). In the intervention group, 199/259 (77%) participants were discharged home compared with 180/271 (66%) control, adjusted OR 1.46 (95% CI 0.94-2.25).

Conclusions: Eat Walk Engage showed a significant reduction in delirium and  may have improved direct discharge home, although length of stay and other HAC-OP were not significantly reduced.


Biography: 

Prue Mcrae is the Eat Walk Engage Program Manager at the Royal Brisbane and Women’s Hospital

High Level Care patients with hip fractures – does discharge destination from acute care affect outcomes?

Ms Lara Anderson1, Dr Lara Kimmel1, Dr  Chris Moran1, Associate Professor  Sue Liew1

1The Alfred Hospital, Prahran, Australia

Background:  Hospital presentations for management of hip fracture are increasing and a growing cohort are admitted from High Level Care (HLC).  Whilst international hip fracture guidelines highlight the importance of multidisciplinary rehabilitation post-operatively, the most appropriate setting for this is unknown.

Aim:  To determine the factors associated with discharge destination for patients from HLC who underwent hip fracture fixation, and to compare 12 month outcomes for those returning to HLC with those admitted to a Sub-Acute Facility (SAF).

Methods: A retrospective case series review of all patients from HLC admitted to The Alfred hospital, Melbourne, for fixation of hip fracture in 2014-2015 was undertaken. Data including demographic and hospital event details, length of stay (LOS), discharge destination and 12 month functional outcomes measured by the Glasgow Outcomes Score – Extended (GOS-E) were collected.

Results: Ninety patients from HLC were included, with 68 patients (75.6%) returning to HLC and 22 (24.2%) admitted to a SAF.  Those discharged to a SAF had an average LOS at this facility of 20.79 days (SD 8.02).  This group also had a longer acute LOS [7 days (IQR 5, 10), compared to 6 days (IQR 4,7.5) p value=0.02].  There was no difference between groups at 12 months in terms of mortality or function on the Glasgow Outcome Scale Extended (GOS-E), with 50% of all patients deceased at this time point and the other 50% reporting a poor functional outcome.

Discussion: Patients from HLC who underwent fixation of a hip fracture had poor 12 month functional outcomes and a high rate of mortality irrespective of discharge destination.  Given these results, future research should explore opportunities to provide structured multidisciplinary rehabilitation in the HLC environment.  Prospective economic modelling and a comprehensive suite of outcome measures to evaluate stakeholder satisfaction with such a model of care are essential.


Biography:

Lara is an orthopaedic physiotherapist at The Alfred Hospital in Melbourne, with an interest in elderly orthopaedic trauma and clinician education.  She is currently enrolled in postgraduate study in health professional education.

Vitality Passport: Halt frailty, spark vitality

Jeremy Carr1, Melanie  Reeves2

1Back On Track Physiotherapy, Corowa, Australia, 2Murrumbidgee Primary Health Network, Wagga Wagga, Australia

The Vitality Passport is tasked with halting or reversing fraility within community dwelling individuals.  The program uses a multi-component approach via a range of allied health therapies including dietetics, occupational therapy, and physiotherapy.  This presentation details the findings of an independent evaluation of the program.

Frail individuals are at greater risk of avoidable falls, hospital admissions, and the need for institutionalised care. In the Murrumbidgee region, falls related hospitalisations are a significant component of hospital admissions; at a rate of 3,533 per 100,000 women and 2,587 per 100,000 men.  In 2016, 19% of people in Murrumbidgee PHN were over 65 years old and by 2036, this age group is projected to grow to 44% of the population regionally.

Recent randomised controlled trials provide strong evidence that the progression of frailty can be halted or reversed through multicomponent intervention programs.

Participants of the program have access to individual exercise coaching, nutrition advice, cognitive training.  In addition eight group sessions are available to promote socialisation, exercise and health promotion content presented in a workbook resource. Eligible participants are referred to the program through general practice. The program components are delivered as face to face, telehealth and group sessions.

The University of Notre Dame Australia evaluated the program.  Quantitative and qualitative measures included: Edmonton Frailty Scores at 0, 3, 6, and 12 months, participant focus groups, collection of falls calendars, patient satisfaction survey and interviews with general practice staff, allied health staff implementing the program and GPs.

Quantitative and qualitative data suggest the program has been successful in reducing or arresting frailty. There was a significant reduction in frailty as measured using EFS score. Practice staff reported that the program is useful and worthwhile and has the potential to make a considerable difference over time. Data from the falls diaries suggest a positive trend in falls reduction. Participants who responded to the patient satisfaction survey thus far agreed that they had improved quality of life (86.6%) and overall health (85.4%), better physical function (81.4%) and were less fearful of falling as a result of the program (76.9%).

Acknowledgements: Associate Professor Catherine Harding, Dr Alexa Seal of the University of Notre Dame, Narelle Mills & Melanie Reeves of Murrumbidgee Primary Health Network.


Biography: 

Melanie Reeves is Portfolio Manager, General Practice Initiatives, Murrumbidgee Primary Health Network.

Jeremy Carr is the Director of Back On Track Physiotherapy

Cognitive impairment in a tertiary hospital: Prevalence and carer experience

Mrs Prue McRae1, Ms Elise  Treleaven1, Ms Karen Lee-Steere1, Mrs Margaret Cahill1, Dr Simon  Finnigan1,3, Associate Professor Alison Mudge1,2

1Royal Brisbane And Women’s Hospital, Brisbane, Australia, 2QUT, Brisbane, Australia, 3UQ Centre for Clinical Research, Brisbane, Australia

Introduction: Cognitive impairment (CI) is common in older hospital inpatients, and associated with poorer outcomes. High quality care requires partnership between patients, healthcare professionals and carers. Hospitalisation can be a stressful experience for people with CI and their carers. The aims of this study were to: 1) To identify the prevalence of CI in patients aged 65 and older; 2) Explore the carers’ experience of involvement in hospital care for patients identified with CI.

Methods: This observational study was conducted at Royal Brisbane and Women’s Hospital on March 14 2018. We performed a cross-sectional study of all ward inpatients (excluding intensive care, emergency department and mental health units) aged 65 years or older using the 4As test, a validated measure of cognitive impairment. We defined score ≥1 as CI, with score ≥4 likely to be delirium. For patients identified with CI, we undertook a brief structured survey of carers, in person or by telephone within 3 days of the audit date.

Results: We screened 218 older patients in 21 wards; 90 (41%) screened positive for CI, with 45 of these likely delirium.  Fifty two (58%) carers completed the survey; most were spouse or child, and 41 (79%) identified as a main carer for the participant. Most carers (44/52, 85%) strongly agreed they felt welcome on the ward (44/52, 85%) and confident leaving their family member on the ward, and 35 (67%) definitely agreed that they were listened to by staff. Only 28 (54%) had been asked about change in cognition and only 8 (15%) had received information on delirium prevention.

Conclusion: CI was prevalent across a broad range of acute and subacute wards. Understanding the carers’ experience will inform strategies to enhance their involvement in delirium prevention and management for their family member in partnership with clinical staff.


Biography: 

Prue Mcrae is the Eat Walk Engage Program Manager at the Royal Brisbane and Women’s Hospital

‘Functional Freedom for Fallers with Fractures’ – where do we invest intervention to maximise outcomes for our consumers

Mr Nicholas Davis1

1Central Coast Local Health District,

With approximately 1 in 3 Australians aged 65 and over falling every year, and up to 6% of these suffering a fracture, the resulting functional restriction can often result in devastating outcomes. Our service wanted to determine what aspects of client intervention we should be investing in.

We collated post intervention observational data from 121 consumers of the Transitional Aged Care Program (TACP) Central Coast Local Health District (CCLHD) who had fallen, suffered a fracture, and required surgical intervention, to determine the significance of measured predictors and variables on function via statistical analysis (January 2017 to June 2018). Functional outcome measures analysed included consumer identified mobility and falls specific goals, the DeMorton Mobility Index (DEMMI), the Modified Barthel Index (MBI), and exercise tolerance. We also investigated the impact of mild to moderate cognitive impairment on functional outcomes, and whether certain covariates are statistically significant (including sex, age, duration of intervention, carer and family assistance, service provider assistance and home exercise compliance). A Lightening Oral Presentation with accompanying ePoster will summarise outcomes and key learning for future practice and research.

Early results of statistical analysis, via linear and mixed effects regression modelling, have highlighted that functional improvements (via the DEMMI) for consumers with mild-moderate cognitive impairment are significantly less than consumers without cognitive impairment. Furthermore, whilst a negative association exists with identified mild-moderate cognitive impairment, this did not reach statistical significance in relation to goal attainment and the MBI. Current results show that duration of intervention, family assistance and the interaction of mild-moderate cognitive impairment and time had a significant effect on exercise tolerance, with a statistically significant difference between groups. Further analysis underway will identify significance of other covariates (carer, family, and/or service provider assistance with exercise, and exercise compliance) for presentation.


Biography: 

Nicholas Davis, Senior Physiotherapist, Transitional Aged Care Program, Central Coast Local Health District

Neuromotor and functional performance of older men with and without pre-sarcopenia

Dr Sean Horan1,2, Mr Blayne Arnold1, Dr Benjamin Weeks1,2, Dr Justin Kavanagh1,2

1School of Allied Health Sciences, Griffith University, Gold Coast, Australia, 2Menzies Health Institute Queensland, , Australia

Introduction: Skeletal muscle mass increases over the first three decades of life, declines steadily through middle age, and more rapidly in older age. Sarcopenia describes a condition of significant loss of muscle mass in conjunction with reduced strength and function. While the changes in mass, strength and function across the lifespan are well-documented, little is known of the underlying mechanisms. This work sort to examine the neuromotor mechanisms that underpin changes in muscles mass and function in older men.

Methods: Twenty-one older men (74.8 ±4.9yrs; height: 174.4 ±6.5cm; 84.3 ±11.4kg) and 10 younger men (26.4 ±4.2yrs; height: 178.8 ±7.8cm; 75.9 ±11.1kg) were recruited. Muscle and fat mass were determined by DXA (Norland XR-800, USA). Functional performance was examined with isometric knee extension, timed-up-and-go (TUG), 5-times sit-to-stand (5TSTS), and self-selected gait speed. Neuromotor measures included Level of Voluntary Activation (LoVA; 20%, 40%, 60% 80%, MVC) during a plantar flexion task, using tibial nerve stimulation. Plantar and dorsi flexor force were recorded, as well as muscle activity using EMG.

Results: Three older men were classified with pre-sarcopenia based on DXA-derived measures of appendicular lean mass (<6.8kg/m2). No differences in LoVA were observed between young men, older men, and older men with pre-sarcopenia (YM: 20%=17.6, 40%=50.7, 60%=82.9, 80%=93.8, 100%=96.7; OM: 20%=20.5, 40%=56.3, 60%=81.3, 80%=93.1, 100%=95.5; PS: 20%=23.7, 40%=58.0, 60%=81.9, 80%=93.9, 100%=96.1). Although not significant, pre-sarcopenic men achieved the lowest dorsi flexor (YM=40.5N; OM=33.0N; PS=25.1N), plantar flexor (YM=154.5N; OM=106.7.0N; PS=70.8N), and knee extensor forces (YM=841.7N; OM=509.2N; PS=361.0N). No differences in functional performance measures were observed.

Discussion: These preliminary findings suggest that older men with pre-sarcopenia maintain functional abilities and demonstrate similar levels of voluntary muscle activation to healthy men despite apparent deficits in strength. Recruitment is ongoing and further work will examine neuromotor characteristics in response to fatigue and muscle inhibition.

Acknowledgements: This work was supported by a Physiotherapy Research Fellowship from the Health Innovation, Investment, and Research Office, Queensland Health.


Biography:

Sean Horan is a Senior Lecturer at Griffith University on the Gold Coast, Queensland. Sean teaches musculoskeletal physiotherapy into both the undergraduate and postgraduate physiotherapy programs at Griffith. His key research areas of interest include the neuromotor mechanisms underlying the development of sarcopenia; the development of exercise interventions aimed at slowing or reversing the effects of osteoporosis; and the examination of the effects of surgical and physical activity interventions on paediatric muscuolskeletal conditions of the feet and lower limbs.

Adopting best practices to create an inclusive assessment service for lesbian, gay, transgender & intersex older people

Donna Bainbridge1

1S.A Health, Adelaide, Australia

Older Lesbian, Bisexual, Gay, Transgender and Intersex (LGBTI) people experience different health outcomes, consequences stemming from pervasive discrimination and unconscious prejudice. The growing numbers of LGBTI people seeking aged care services represents a complex, emerging, challenging and urgent area for health services to address.  This presentation addresses how the South Australian Northern Aged Care Assessment and Aged Care Placement Teams are addressing the absence of trained diversity sensitive workers within health services and how addressing this gap will improve outcomes for older LGBTI people.

The project measures staff understanding and knowledge of legal responsibilities, current knowledge and beliefs. Staff will undertake regular measures of knowledge using a tool developed during this project. Training delivery includes cultural and historical backgrounds, use of language that is aligned to a person’s identity, and how LGBTI sensitive practices and policies and procedures support staff to recognise and meet the unique needs of minority groups including LGBTIQ people.

Method : Improve staff knowledge and skills to improve service access through improved support of LGBTI aged care consumers. To demonstrate that a program of education support, key workers and stake holder engagement contributes to the development of skills to better recognise and promote best practice for LGBTI people.  Additionally, an increased awareness across the organisation has been measured through requests to undertake training and participate in other initiatives arising from this program.

Outcome : Staff education, stakeholder support results in an increased awareness and measurement of stakeholder outcomes is ongoing.  Organisation interest is high and is measured through requests to undertake training and participate in other initiatives arising from this program. Additionally, the teams have had contact with international partners and peak bodies who are providing support and mentoring.


Biography:

As a Social Worker across both the Modbury & Lyell McEwin Hospitals In South Australia and throughout my diverse career working in Commonwealth Aged Care Packages, Residential Aged Care and the present. I have acquired a sound knowledge base and experience to achieve the best possible outcomes for patients and families transitioning to residential aged care. During this period working with two patients and their partners who identify with the LGBTI community, has provided me with the insight to the barriers, discrimination, and prejudices of the aged care system. Story telling has been a unique tool for gaining power for this project.

Effect of manual therapy and exercise on mild chronic obstructive pulmonary disease: A randomised controlled trial

Dr Roger Engel1, Associate Professor Peter Gonski2, Associate Professor Subramanyam Vemulpad1, Dr Petra Graham1

1Macquarie University, North Ryde, Australia, 2Sutherland Hospital, Miranda, Australia

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterised by declining lung function and decreasing exercise capacity. Exercise capacity is a prognostic indicator for long-term survival. In COPD, regular physical activity is associated with increases in exercise capacity and quality of life but not lung function. Pulmonary rehabilitation programs play a key role in promoting physical activity for people with moderate to severe COPD. Recent evidence has shown that combining manual therapy (MT) with exercise delivers additional benefits in exercise capacity and quality of life compared to exercise alone over the medium-term for moderate COPD. The aim of this study was to investigate whether MT and exercise delivers additional benefits for mild COPD over the long-term.

METHODS

71 participants aged 50-65 years with stable mild COPD were randomly allocated to two groups: Exercise (n=35) and MT+Exercise (n=36). Both groups received a 16-week, progressively  intensive exercise program with the MT+Ex group also receiving eight MT sessions in weeks 5-8 of the exercise program. Exercise capacity, lung function and quality of life were measured by blinded assessors at baseline, 4, 8, 16, 24, 32 and 48 weeks.

RESULTS

There was no difference in effect between groups. However, results suggested clinically meaningful average improvements in exercise capacity (p=<0.001), lung function (p=<0.001) and four of the six quality of life measures (p= <0.003) over time for both groups.

DISCUSSION

Notwithstanding the absence of any additional benefits from MT, the improvements in exercise capacity and quality of life suggest that physical activity is beneficial for mild COPD. The sustained increases in lung function following progressively intensive exercise is worthy of further investigation as it highlights the potential of exercise to slow progression of COPD from mild to moderate.

The study received ethics approval from the South Eastern

Sydney Local Health District Human Research Ethics Committee (HREC): Approval number 13/004.


Biography:

Roger is an allied health practitioner with over 35 year’s clinical experience in both private practice and public hospitals. He currently holds appointments as a Senior Lecturer at Macquarie University, Adjunct Professional Fellow at Southern Cross University and Honorary Clinical Research Fellow at Sutherland Hospital in Sydney. Roger has a PhD in the field of chronic respiratory disease. As part of this work, he has developed a special interest in the early detection and management of chronic obstructive pulmonary disease (COPD). His research interests extend to aged care where he is currently working on a project to deliver multi-disciplinary care as a strategy to prevent the onset of frailty. Roger is a regular speaker at both national and international conferences.

Use of the Home Assessment Profile as an outcome measure to review Occupational Therapy practice within Aged Care.

Karen Kessner1, Megan Rumble1, Adam Cefai1

1Western Health, St Albans, Australia

Background:

With the rising cost of health service provision and mounting demand, occupational therapy services are increasingly required to demonstrate the effectiveness of the services they deliver. The aged care subacute service of a large metropolitan health service identified the need to understand the value and contribution of home assessments on patient outcomes.

Method:

A mixed methods approach was undertaken using the ‘Home Assessment Profile’ instrument and consumer feedback. The Home Assessment Profile is a valid and reliable, quantitative performance based instrument used to assess patient performance of representative activities within the home. Hazardous person-environment encounters were rated pre and post home assessment according to the degree of hazard together with the frequency with which the hazard is encountered. Consumer feedback is routinely sought within the Occupational Therapy Department for patient based interventions.

Results:

Twelve clinicians completed the ‘Home Assessment Profile’ with 60 patients over a three month period in 2017. Results showed an average risk reduction of 77% between pre and post scores (range between 44-100%), with a reduction in both the frequency and number of risks being observed. Use of the tool was found to be effective as a measure of reduction of hazards. Occupational therapy home assessment recommendations were comprehensive and varied and were able to be themed into six key areas of practice.

Discussion:

Findings from this research support home assessments as an effective intervention for inpatient aged care populations to reduce risk, increase patient feelings of readiness for discharge, and increase patient confidence to participate in meaningful occupations within their homes. The results identified that subacute Occupational Therapists are conducting home assessment in line with Occupational Therapy conceptual practice frameworks.


Biography:

Karen Kessner:

Karen is a senior occupational therapist for the subacute aged care service at Sunshine Hospital, Western Health. Karen is also the co-convener of the oncology and palliative care interest group for Occupational Therapy Australia- Victorian division. Karen has 24 years experience as a clinician across multiple clinical areas.

Karen has a graduate certificate in business management and palliative care, she is currently undertaking her masters in palliative care in aged care.

Adam Cefai:

Adam is a grade 2 occupational therapist with the subacute aged care service at Sunshine Hospital, Western Health. Adam is a strong advocate for allied health within aged care, holding a ward-based allied health leadership role, as well as sitting on the Western Health Falls Committee. Adam has 4 years of clinical experience as an occupational therapist, which has included work within acute, community and subacute rehabilitation settings.

Does Occupational Therapist led home environmental assessment and modification reduce falls among high risk older people? The Occupational Therapist Intervention Study (OTIS)

Associate Professor Alison Pighills1,2, Professor Avril Drummond3, Ms Shelley Crossland4, Ms Sarah Cockayne5, Professor David  Torgerson5

1Mackay Hospital And Health Service, Mackay, Australia, 2James Cook University, Townsville, Australia, 3School of Health Sciences, University of Nottingham, , Nottingham, UK, 4Community Mental Health Team, Leicestershire Partnership NHS Trust, Leicester, UK, 5York Trials Unit, Department of Health Sciences, University of York, York, UK

Background:Accidental falls are one of the leading causes of injury induced morbidity and mortality in older people, affecting around 30% of people over the age of 65 and 50% of those over 80. Environmental hazards are attributed as causal risk factors in 30-50% of falls,[1] thus, environmental assessment and modification (EAM) to prevent falls is intuitively sensible. National and international guidelines recommend interventions to reduce environmental hazards for older people at risk of falling. However, it remains uncertain whether EAM reduces falls in high risk older people and who can most effectively provide it.

The OTIS trial aims to determine whether Occupational Therapist (OT) led EAM leads to a reduction in falls among community dwelling people at high falls risk.[2]

Method: A pragmatic 2-arm, randomised controlled trial including a health economic evaluation. Intervention: A minimum of one home visit (1.5hrs) was provided by OTs, who used the Westmead Home Safety assessment tool to identify fall related hazards. Control: Usual care plus a falls prevention leaflet. The primary outcome was the rate of falls (falls/person/time) over 12 months. Secondary self-reported outcome measures included: the proportion single and multiple fallers, time to first fall over a 12-month period; quality of life (EuroQoL EQ-5D-5L), and health service utilisation at 4, 8 and 12 months.

Results: To date, 1331 community dwelling participants aged 65 and above, who are at an increased risk of falls have been randomised to receive either intervention or usual care.  Participants are currently in follow-up, so whilst baseline data is available, outcome data are still being collected. The final outcome of the trial will be reported in spring 2020.

Discussion: This study is the largest ever conducted evaluating the clinical effectiveness of OT led EAM. The outcome will influence international guidelines and an upcoming Cochrane Systematic Review.

References

  1. Rubenstein, L.Z., Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing, 2006. 35(Supplement 2): p. ii37-ii41.
  2. Cockayne, S., et al., Can occupational therapist-led home environmental assessment prevent falls in older people? A modified cohort randomised controlled trial protocol. BMJ Open, 2018. 8(9).

Biography:

Alison completed her PhD in 2008 at the University of York, UK, which involved a RCT (n=238), to evaluate the clinical effectiveness of environmental assessment and modification to prevent falls in older people. She was awarded the University of York K M Stott prize for the best PhD thesis. She is currently a co-investigator on a multi-centre RCT in the UK (n=1333) which replicates her PhD research on a larger scale. Her research interests include: falls prevention, rural and remote models of care, professional skill sharing and delegation; and, research capacity development.

12

NAHC Conferences

2007, Hobart (7th NAHC)

2009, Canberra (8th NAHC)

2012, Canberra (9th NAHC)

2013, Brisbane (10th NAHC)

2015, Melbourne (11th NAHC)

2017, Sydney (12th NAHC)

2019, Brisbane (13th NAHC)

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