Australian Metropolitan Hospital Research Articles

Prospective cohort study of rotational thromboelastometry in established biliary obstruction: dispelling the myth of auto-anticoagulation

BackgroundPatients with obstructive jaundice are conventionally described as hypocoagulable due to vitamin K malabsorption. However, associated underlying malignancy and synthetic liver dysfunction are mediators of hypercoagulability. The actual effect of biliary obstruction on the coagulation profile is not well characterised. This study aimed to define the coagulation status of patients with established biliary obstruction using rotational thromboelastometry (ROTEM). MethodsThis prospective cohort study, conducted in an Australian metropolitan hospital, included patients with a total bilirubin level of >150 umol/L and biliary obstruction on imaging. The primary outcome was the coagulation profile assessed using ROTEM. Results20 patients were included (median age 74.5 years), 15 were male and 17 had a malignant cause for biliary obstruction. The median bilirubin level was 209 umol/L (IQR: 175.0 umol/L – 255.8 umol/L). On ROTEM, all patients had normal or reduced clot formation times, and normal or increased maximum clot firmness. This confirmed all patients had a normal or hypercoagulable clotting profile, and none were auto-anticoagulated. Vitamin K administration before ROTEM did not vary the coagulation profile. DiscussionPatients with established biliary obstruction and jaundice, predominantly due to malignancy, were normo or hypercoagulable. The belief that obstructive jaundice is associated with a hypocoagulable state should be questioned.

Acute care nurses' decisions to recognise and respond to patient improvement: A qualitative study.

To explore and describe acute care nurses' decisions to recognise and respond to improvement in patients' clinical states as they occurred in the real-world clinical environment. A descriptive study. Nine medical and eleven surgical nurses in a large Australian metropolitan hospital were individually observed during nurse-patient interactions and followed up in interview to describe their reasoning and clinical judgements behind observed decisions. Verbal description of observations and interviews were recorded and transcribed. Reflexive thematic analysis was used to analyse the data. The three themes constructed from the data were as follows: nurses checking in; nurses reaching judgements about improvements; and nurses deciding on the best person to respond. Acute care nurses made targeted assessment decisions based on predicted safety risks related to improvement in clinical states. Subjective and objective cues were used to assess for and make judgements about patient improvement. Acute care nurses' judgment of patient safety and a desire to promote patient centred care guided their decisions to select the appropriate person to manage improvement. The outcomes of this research have demonstrated that the proven safety benefits of acute care nurses' decision making in response to deterioration extend to improvement in patients' clinical states. In response to improvement, acute care nurses' decisions protect patients from harm and promote recovery. Early recognition and response to improvement enable acute care nurses to protect patients from risks of unnecessary treatment and promote recovery. This study makes explicit nurses' essential safety role in recognising and responding to improvement in patients' clinical states. Healthcare policy and education must reflect the equal importance of assessment for and management of deterioration and improvement to ensure patients are protected and provided with safe care.

Experience of care from the perspectives of inpatients with palliative care needs: a cross-sectional study using a patient reported experience measure (PREM)

BackgroundImproving palliative care for inpatients is urgently needed. Data from patient-reported experience measures (PREM) can assist in identifying areas for focused improvement. This study aimed to describe patient reported experience of care in inpatients with palliative care needs, to inform a baseline understanding of care experience and identify key areas for improvement.MethodsCross-sectional study design where inpatients with palliative care needs were invited to complete ‘consideRATE,’ a patient reported experience measure of care, over six months in 2022. Inpatients with palliative care needs receiving care on an oncology, general medicine/renal and general medicine/respiratory ward (n = 3) at an Australian metropolitan hospital were screened for eligibility. Carers could provide proxy responses where inpatients were unable to participate. Descriptive statistics were used to analyse quantitative ratings, whilst free text responses were analysed using integrated thematic analysis.ResultsOne-hundred and twenty participants (108 patients and 12 carers) completed consideRATE. The questions with the highest number of ‘very good’ responses were attention to symptoms, attention to feelings and attention to what matters most; the questions with the lowest number of ‘very good’ responses was attention to patients’ affairs, what to expect, and the environment of care. Almost half (n = 57, 48%) indicated that attention to patients’ affairs ‘did not apply’ to their inpatient stay. Analysis of 532 free text responses across 8 questions highlighted the importance of feeling supported, feeling informed, feeling heard and navigating the clinical environment.ConclusionEnabling inpatients with palliative care needs to provide feedback about their experience of care is one method of ensuring improvements matter to patients. Supporting clinical teams to understand and use these data to make tailored improvements is the next step in this multi-phase research.

A survey of obstetric and gynaecology doctors at an Australian metropolitan tertiary hospital to understand their views, training and confidence in abortion care.

The barriers to comprehensive abortion care in Australian metropolitan tertiary hospitals are under-researched. Previous work has suggested that negative practitioner attitudes and lack of training may play a large role; however, this remains poorly understood. The aim was to survey doctors practicing obstetrics and gynaecology to better understand their views, training experience and confidence in abortion care. The method involved a cross-sectional study via an anonymous survey at a single metropolitan tertiary hospital not providing substantive abortion services in Melbourne, Australia. Inclusion criterion was obstetric and gynaecology medical staff working at that hospital. Data were collected regarding views, training experiences and confidence in first-trimester medical and surgical abortion, and second-trimester surgical abortion. Data were analysed according to levels of training, categorised as RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynaecologists) Fellows, prevocational/vocational trainees and general practitioner specialists. Sixty-one valid responses were received from 90 eligible participants (response rate 68%). An overwhelming majority (96%) supported abortion services. The majority of RANZCOG Fellows felt confident performing first-trimester surgical abortion (89%) and first-trimester medical abortion (71%); however, only half felt confident performing second-trimester surgical abortion (50%). Prevocational/vocational trainees were overall less confident but overwhelmingly expressed interest in gaining further experience in abortion. Doctors are generally confident in providing first-trimester abortion services (medical or surgical) in the metropolitan tertiary setting. However, further work is required to understand ongoing barriers to comprehensive abortion care. There may also be a skills shortage for second-trimester surgical abortion, requiring significant improvements in abortion training.

Exploring patient ideas, concerns, and expectations in surgeon-patient consultations

ObjectivesThis study explores patient perspectives (ideas, concerns, and expectations) in surgeon-patient consultations. MethodsWe examined 54 video-recorded consultations using applied conversation analysis. Consultations took place from 2012 to 2017 in an Australian metropolitan hospital clinic centre and involved seven surgeons across six specialties. ResultsPatient perspectives emerged in less than one third of consultations. We describe the initiation of and response to potential perspectives sequences, demonstrating how patients and surgeons co-construct these sequences when they do occur. ConclusionsFindings suggest a need for greater attention to supporting patient agency through explicit pursuit of patient perspectives. The implications extend to the Calgary-Cambridge Guide, suggesting that it may benefit from a focus on active pursuit and appropriate responsiveness to patient perspectives. Practice implicationsThis study highlights the need for surgeons to actively engage with the patient perspective offered in consultations, emphasising the importance of respect for the patient’s knowledge and expectations to improve patient satisfaction and healthcare outcomes.

Cultivating optimal analgesic prescribing practices in a metropolitan hospital network: evaluating an analgesic stewardship program

AbstractBackgroundThe increasing incidence of opioid‐related harm associated with inappropriate opioid prescription underscores the need for effective interventions directed at enhancing analgesic prescribing practices. Analgesic stewardship (AGS) programs have emerged to facilitate appropriate analgesic use, reducing analgesic‐related harm and optimising patient outcomes.AimThis study aimed to assess the impact of an AGS program on the appropriateness of opioid analgesia prescribing for adult inpatients within a metropolitan health network during the initial two months following program implementation.MethodThis retrospective audit examined de‐identified aggregate data of 100 adult inpatients of a major Australian metropolitan hospital network between August–September 2022. The multidisciplinary AGS program involving pharmacy, nursing, and medical staff provided clinical interventions and recommendations for patients, supported by organisational interventions, including education and guideline reinforcement. Data collection included patient demographics, clinical data, and AGS program recommendations documented in patient medical records. Ethical approval was granted by the Eastern Health Office of Research and Ethics (Reference no: QA23‐015‐91886) and the study confirms to the Australian Statement on Ethical Conduct in Human Research.ResultsIt was found that 51% of opioid‐naïve patients were prescribed modified‐release opioids for acute non‐cancer pain, contrary to local guidelines. The AGS program recommendations resulted in an 89.7% cessation of these prescriptions. For non‐opioid‐naïve patients, there was a statistically significant reduction in mean Oral Morphine Equivalent Daily Dose of 19.85 mg (95% confidence interval [CI] 10.3–29.4 mg, p < 0.05). AGS recommendations were predominantly adhered to, with 82% showing full or partial compliance.ConclusionThis study highlights the positive impact of an AGS program on the appropriateness of opioid analgesic prescribing for adult inpatients. These findings support the implementation of AGS programs into healthcare systems to mitigate opioid‐related harm and improve patient outcomes.

Applying a human factors approach to proning pillows in the ICU: Opportunities for redesign

AbstractProning, or turning a patient face down, is a technique used to manage patients with acute respiratory distress in intensive care units (ICUs). Research suggests that the type of pillow used in proning may have a significant impact on patient outcomes and increase the risk of disfiguring pressure injuries to the face. However, there is little evidence surrounding the usability of these pillows in the ICU. The aim of this study was to identify redesign opportunities by understanding how the tools, tasks, people, environment, and organization all interact during proning in the ICU. Thirty‐six ICU clinicians from two Australian public metropolitan hospitals completed an online questionnaire regarding their opinions and experiences with proned patients and the prevention of pressure injuries. Seven ICU clinicians then completed journey mapping activities to document the key workflows, critical incidents, considerations, and personnel involved in managing proned patients in the ICU. Several barriers and facilitators to pressure injury prevention were identified, including interactions between the various tools (e.g., proning pillows with one opening limits the management of several medical devices), the tasks (e.g., high frequency of repositioning), the people (e.g., clinical inexperience, patient features), the environment (e.g., limited availability of tools), and the organization (e.g., limited number of staff to support tasks). This holistic approach revealed several opportunities for the redesign of proning pillows and associated systems. Key takeaways include the limitations of a one‐size‐fits‐all approach to proning in the ICU context, and the need for flexibility and customization to improve proning pillows, associated medical devices, prophylactic dressings, aids, and processes.

Perspectives of inpatients with palliative care needs, their families, clinicians and key stakeholders on measuring quality of hospital care via patient experience measures: A qualitative study.

Globally there are high numbers of patients with palliative care needs receiving care in hospitals. Patient reported experience measures (PREMs) provide useful data to guide improvement work. How to implement PREMs within palliative care populations is unclear. To explore the perspectives of inpatients with palliative care needs, their family members, and the clinical team regarding the use of a generic PREM as compared with a PREM designed for people with palliative care needs and related implementation factors. A qualitative study was undertaken using semi-structured interviews and focus groups and integrated thematic analysis. Inpatients with palliative care needs, their family members, and clinical team members were recruited from three wards in an Australian metropolitan hospital. Twenty-seven interviews and three focus groups were conducted. Six themes emerged: (1) PREMs for people with palliative care needs ought to be tailored to the needs of this population; (2) PREMs should appraise whether the needs of families have been met in addition to those of patients; (3) PREMs for inpatients with palliative care needs ought to be easy to use, brief and incorporate space for free text alongside each question; (4) Implementation of PREMs for people with palliative care needs ought to consider who administers these, when and how often; (5) PREM data need to be specific enough to inform process change and/or care provision; (6) Patients and families require meaningful feedback to encourage PREM completion. This study provides practical guidance for PREM selection and implementation to inform improvements to care for inpatients with palliative care needs.

Modified Intravenous Cannula Ventilation Tubes for Otic Barotrauma Prevention.

Objectives: Middle ear barotrauma is a common complication of hyperbaric oxygen therapy (HBOT). Tympanostomy tube placement prevents barotrauma by facilitating middle ear equalization. We describe variations on techniques published by Mooney et al and Zhang et al for placing modified peripheral intravenous cannula (PIVC) ventilation tubes, which can be performed at the bedside under topical anesthesia. We aim to evaluate the safety and efficacy of this technique when performed to prevent otic barotrauma in patients undergoing HBOT. Methods: We performed an analytical observational study at a tertiary metropolitan Australian hospital with a state-wide adult hyperbaric service between 2018 and 2022. Patients were identified via unit audits. Patient, HBOT, and procedural factors were analyzed against complications using Fisher's exact test with Bonferroni correction and simple logistic regression. Results: Over 4 years, 112 patients (220 ears) underwent modified PIVC ventilation tube insertion. Mean age was 58.6 years (95% CI: 55.7-61.6, SD: 15.9). Thirty-eight patients (33.9%) were female, 74 (66.1%) were male. Thirty-four ears (15.5%) had preexisting barotrauma at the time of tympanostomy tube insertion. Patients underwent a mean of 11.5 dives (95% CI: 9.0-14.0, SD: 13.4), with ventilation tubes being required for a mean of 15.0 days (95% CI: 9.0-14.0, SD: 24.0) to complete HBOT. Fourteen ventilation tubes (6.4%) developed blockage during HBOT, and 12 (5.5%) prematurely extruded. Sixteen ears (7.3%) required reinsertion of ventilation tubes. Nine ears (4.1%) suffered barotrauma despite ventilation tube insertion. Conclusions: Otic barotrauma prophylaxis is paramount for safety during HBOT. We describe a safe, effective, and convenient technique for barotrauma prevention using modified PIVCs.

FeBRILe3: Safety Evaluation of Febrile Infant Guidelines Through Prospective Bayesian Monitoring.

Despite evidence supporting earlier discharge of well-appearing febrile infants at low risk of serious bacterial infection (SBI), admissions for ≥48 hours remain common. Prospective safety monitoring may support broader guideline implementation. A sequential Bayesian safety monitoring framework was used to evaluate a new hospital guideline recommending early discharge of low-risk infants. Hospital readmissions within 7 days of discharge were regularly assessed against safety thresholds, derived from historic rates and expert opinion, and specified a priori (8 per 100 infants). Infants aged under 3 months admitted to 2 Western Australian metropolitan hospitals for management of fever without source were enrolled (August 2019-December 2021), to a prespecified maximum 500 enrolments. Readmission rates remained below the prespecified threshold at all scheduled analyses. Median corrected age was 34 days, and 14% met low-risk criteria (n = 71). SBI was diagnosed in 159 infants (32%), including urinary tract infection (n = 140) and bacteraemia (n = 18). Discharge occurred before 48 hours for 192 infants (38%), including 52% deemed low-risk. At study completion, 1 of 37 low-risk infants discharged before 48 hours had been readmitted (3%), for issues unrelated to SBI diagnosis. In total, 20 readmissions were identified (4 per 100 infants; 95% credible interval 3, 6), with >0.99 posterior probability of being below the prespecified noninferiority threshold, indicating acceptable safety. A Bayesian monitoring approach supported safe early discharge for many infants, without increased risk of readmission. This framework may be used to embed safety evaluations within future guideline implementation programs to further reduce low-value care.

Family presence during resuscitation: Perceptions and confidence of intensive care nurses in an Australian metropolitan hospital

BackgroundWhile literature supporting family presence during resuscitation (FPDR) was first published over three decades ago, the practice remains controversial. Benefits have been confirmed, and barriers to practice identified through international research. The extent that FPDR is practised in Australian intensive care units (ICUs) is currently unknown. ObjectivesTo examine ICU nurses’ previous exposure and experiences with FPDR To establish their perceptions of the risks and benefits of the practice, as well as their confidence participating. MethodsA descriptive, cross-sectional study design, using validated FPDR risk–benefits and confidence scales, was distributed electronically to registered nurses working within a single adult ICU in Australia. ResultsFifty-six percent (n = 45) of respondents had never witnessed FPDR. Respondents were divided on whether families had the right to be present or should be given the option. ICU nurses perceived benefits for families but not for the patients involved or for the nurses participating. Nurses indicated they felt conflicted between the needs of the family, preserving the quality of the care delivered to a deteriorating patient, and protecting the safety of all stakeholders. Support for FPDR was often dependent on the availability of resources such as a family-support person. ConclusionThis research establishes that ICU nurses lacked exposure to FPDR but were confident in their ability to perform, be observed, and support families during a resuscitation event. Therefore, confidence is likely not a factor in a decision to reject the practice. Further education is indicated as there remained a reluctance to adopt FPDR practice, despite many of the barriers reported having already been largely disproven by the available literature. Institutions have a role in policy development, ensuring adequate resources, and education.

Learning and development needs for successful staff and consumer partnerships on healthcare quality improvement committees: a co-produced cross-sectional online survey.

Objectives This study aimed to conduct a learning and development needs analysis of quality improvement partnership capabilities of staff and consumers on partnership committees at an Australian metropolitan hospital and health service. Objectives were to compare consumer and staff self-rated capability importance, performance, and learning needs; to investigate if years of partnership experience influenced ratings; and to ascertain staff and consumer preferred learning strategies. Methods An online cross-sectional survey was adapted from the Hennessy-Hicks Training Needs Analysis questionnaire. Participants self-rated the importance of, and their performance on, 10 capabilities, across four domains, of an internationally validated co-produced capability development framework. They also rated preferences regarding learning approaches and media. Results A total of 199 members from 41 committees (174 staff; 25 consumers; response rate 35.38%) participated. There was a statistically significant learning and development need across all capabilities (P < 0.01). The highest learning need was for influencing organisational systems and policy (mean = -0.96; s.d. = 1.23), followed by equalising power and leadership (mean = -0.91; s.d. = 1.22), and then implementing partnership best practices (mean = -0.89; s.d. = 1.22). There were no statistically significant differences between consumers and staff on ratings, or correlations between years of partnership experience and ratings (P < 0.01). A combination of learning approaches was preferred, followed by learning through experience. Self-reflection was least preferred, which is concerning given it may promote equalising power and leadership. Face-to-face then videoconferencing were the preferred learning media. Conclusions Continuous co-learning for staff and consumers about QI partnerships is essential. Committee members needed more feedback regarding their influence and to be engaged in innovative co-design practices.

Remote blood pressure monitoring in high risk pregnancy — study protocol for a randomised controlled trial (REMOTE CONTROL trial)

BackgroundPregnant women at high risk for developing a hypertensive disorder of pregnancy require frequent antenatal assessments, especially of their blood pressure. This expends significant resources for both the patient and healthcare system. An alternative to in-clinic assessments is a remote blood pressure monitoring strategy, in which patients self-record their blood pressure at home using a validated blood pressure machine. This has the potential to be cost-effective, increase patient satisfaction, and reduce outpatient visits, and has had widespread uptake recently given the increased need for remote care during the ongoing COVID-19 pandemic. However robust evidence supporting this approach over a traditional face-to-face approach is lacking, and the impact on maternal and foetal outcomes has not yet been reported. Thus, there is an urgent need to assess the efficacy of remote monitoring in pregnant women at high risk of developing a hypertensive disorder of pregnancy.MethodsThe REMOTE CONTROL trial is a pragmatic, unblinded, randomised controlled trial, which aims to compare remote blood pressure monitoring in high-risk pregnant women with conventional face-to-face clinic monitoring, in a 1:1 allocation ratio. The study will recruit patients across 3 metropolitan Australian teaching hospitals and will evaluate the safety, cost-effectiveness, impact on healthcare utilisation and end-user satisfaction of remote blood pressure monitoring.DiscussionRemote blood pressure monitoring is garnering interest worldwide and has been increasingly implemented following the COVID-19 pandemic. However, robust data regarding its safety for maternofoetal outcomes is lacking. The REMOTE CONTROL trial is amongst the first randomised controlled trials currently underway, powered to evaluate maternal and foetal outcomes. If proven to be as safe as conventional clinic monitoring, major potential benefits include reducing clinic visits, waiting times, travel costs, and improving delivery of care to vulnerable populations in rural and remote communities.Trial registrationThe trial has been prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12620001049965p, on October 11th, 2020).

Feasibility and acceptability of a virtual clinical pharmacy service for elective orthopaedic inpatients in an Australian metropolitan hospital

AbstractBackgroundVirtual healthcare services are usually provided from urban centres to outpatient clinics or underserved rural areas. This study utilises virtual pharmacy as an innovative model to provide services to a metropolitan hospital from a rural area.AimThis study assesses the feasibility, and patient and staff acceptability of a Virtual Clinical Pharmacy Service (VCPS) in a tertiary metropolitan hospital ward with limited on‐site clinical pharmacy services.MethodPharmacists from a rural health district provided telepharmacy services for nine weeks. Data on service provision and detection of medication‐related issues were captured in the electronic health record. Service acceptability was assessed through a staff focus group and patient acceptability by a patient‐reported experience measures (PREM) survey. Ethical approval was granted by the Greater Western Human Research Ethics Committee (Reference no: 2021/ETH00097).ResultsThe VCPS demonstrated high utilisation, with 535 clinical and medication reviews provided for 225 patients. Virtual medication reviews identified 151 medication‐related issues or recommendations. PREM surveys (n = 22) were supportive of the VCPS model. Staff valued the service and reported ease of access to specialist medication advice and confidence that patient medications were correct. Staff raised patient confidentiality in open wards and lack of experience using virtual healthcare as barriers to the implementation.ConclusionFeasibility was demonstrated by high service utilisation, detection of medication‐related issues, and measures of acceptability from patients and staff. The VCPS offers a solution to enhance sustainability and service agility by delivery of clinical services when face‐to‐face is not practicable or available. Further research is required to demonstrate efficacy and to confirm patient acceptability.

Use of Temporary Abdominal Closure in Non-Trauma Surgery: A Cohort Study.

Damage control surgery in trauma is widely used but the evidence for the use of laparostomy in non-trauma abdominal emergencies is limited. This study aimed to characterise outcomes in emergency abdominal surgery by comparing laparostomy to one-stage laparotomy for patients of similar illness severity. A retrospective study of adult patients requiring emergency abdominal surgery and post-operative intensive care stay was performed between 2016 and 2020 at a major Australian metropolitan hospital. Case selection was from a prospectively maintained database, and case notes were reviewed. Patients having delayed abdominal closure were compared with those having one-stage abdominal closure. The primary outcome was odds of in-hospital mortality. The secondary outcomes included intensive care unit length of stay (LOS), overall hospital LOS, definitive stoma rate and discharge destination. Multivariable logistic regression analysis was performed to adjust for potentially confounding variables. Two hundred and eighteen patients met inclusion criteria (80 laparostomy and 138 non-laparostomy). The most common indications for laparostomy were bowel ischaemia (41.3%), sepsis (26.3%) and physiological instability (22.5%). There was no evidence of difference in odds of in-hospital mortality between groups (adjusted OR = 1.67, CI: 0.85-3.28; p = 0.138). Patients requiring laparostomy had a slightly longer median ICU LOS (4 vs. 3days; p < 0.001), similar median hospital LOS (19 vs. 14days, p = 0.245) and similar discharge destination. There was no difference in stoma rate (35.0% vs. 35.5%). Compared with standard one-stage laparotomy, laparostomy resulted in similar odds of in-hospital mortality in emergency abdominal surgery patients requiring intensive care.

The Complexities of Managing Gestational Diabetes in Women of Culturally and Linguistically Diverse Backgrounds: A Qualitative Study of Women’s Experiences

This study aimed to explore women's perspectives and experiences concerning how culture impacts the lifestyle management of gestational diabetes mellitus (GDM) in women of culturally and linguistically diverse (CALD) backgrounds. Women of any cultural background diagnosed with GDM within the previous 12 months were purposively recruited from two Australian metropolitan hospitals. Data collected using semi-structured interviews (n = 18) and focus groups (n = 15 women in three groups) were analysed using reflexive thematic analysis. Three themes were generated: "cultural beliefs and obligations impact lifestyle management of gestational diabetes", which describes how some cultures lack awareness about GDM, and modifications or restrictions were viewed as depriving the infant, but sometimes adaptions could be made so that a culturally appropriate meal was suitable for GDM management; "the relationship between cultural foods and gestational diabetes management", which discusses how important cultural foods may be incompatible with appropriate GDM management, so women worked to find solutions; "gestational diabetes education lacks cultural awareness and sensitivity", which illustrates how current education fails to address differences in cultural beliefs, language and eating practices. Cultural beliefs, obligations and food practices must be considered when assisting women of CALD backgrounds using lifestyle modification to manage GDM. GDM education must be culturally sensitive and competent and, where possible, be delivered by health professionals of a shared cultural group.

The experiences of health workers using telehealth services for diabetes-related foot complications: a qualitative exploration

BackgroundDiabetes-related foot disease (DFD) accounts for up to 75% of lower-extremity amputations globally. Rural and remote communities are disproportionately affected by DFD. Telehealth has been advocated as a strategy to improve equity of access to health care in rural and remote communities. Current literature suggests that successful implementation of telehealth requires access to adequate reliable equipment, staff training, and support. A real-time video-based telehealth foot service (TFS) for delivering DFD management has recently been established in a Vascular Surgery and Podiatry clinic within a large South Australian metropolitan hospital. The purpose of this study was to gain insights into the experiences of rural and remote health professionals utilising the TFS, as this could be invaluable in optimising the uptake of telehealth use in DFD.MethodsThis exploratory, descriptive qualitative study employed one-on-one, semi-structured interviews with health professionals who utilised the service. Thematic analysis using an essentialist inductive approach was employed.ResultsParticipants included 14 rural and remote health professionals; 2 general practitioners, 2 nurses, 1 Aboriginal Health Practitioner, and 9 podiatrists. In addition, 2 metropolitan-based TFS staff were interviewed. Five key themes were identified. ‘Patients have reduced travel burden’ included that telehealth enabled Indigenous patients to stay on country. ‘Patients had increased psychosocial support’ covered the benefits of having health professionals who knew the patient present in consults. ‘Improved access’ incorporated how telehealth improved interprofessional relationship building and communication.‘Technological and equipment challenges’ highlighted that poor network connectivity and poor access to equipment to conduct telehealth consults in rural areas were barriers. The last theme,’Lack of service communication to rural health professionals’, highlighted the need for communication around service details.ConclusionTelehealth is a valuable tool that can improve access to treatment for rural and remote Indigenous DFD patients. While this has the potential to improve DFD outcomes, empirical data is required to confirm outcomes. Considering the advantages of telehealth and rural staff shortages, there is an urgent need for investment in improved equipment and processes and an understanding of the training needs of the health care workforce to support the use of telehealth in DFD management.

A thematic analysis of hospital medical records of patients with advanced illness experiencing incarceration in the last 3 months of life

Background: The constraining prison culture is not, for the most part, conducive to the provision of palliative care for people in prison. Aim: This study aimed to explore patterns of palliative and end-of-life care provision for hospitalised prison patients. Design: A retrospective qualitative review of hospital medical records to explore the quality of end-of-life care provision for patients experiencing incarceration who died within hospital. Qualitative inductive analysis of record extracts of each patients final 3-months of life was undertaken. Setting/participants: An Australian metropolitan hospital responsible for providing secondary and tertiary health services for people experiencing incarceration. This study included a systematic sample of male patients experiencing incarceration who died in hospital between 2009 and 2019. Results: Medical record extracts of 15 male patients revealed two broad themes: (1) barriers to equitable access to palliative care for incarcerated hospitalised patients; and (2) factors that facilitated quality end-of-life care for patients and families. Barriers included: tensions between balancing risk and humanity; and limited agency over place and death. Conversely, early recognition of deterioration and anticipated dying provided patients and families opportunity to focus on end-of-life goals. Conclusions: Institutional influences of security and control challenged the provision of equitable end-of-life care for people experiencing incarceration. Further research is required to inform, and incorporate, best approaches to identifying patient wishes and advance planning into care within, or despite, the constrains of incarceration. Policy reform and a coordinated, best practice approach to the management of end-of-life care for people experiencing incarceration is needed.

Patients’ perceptions and knowledge of source isolation for multi-resistant organisms in an Australian metropolitan hospital: A bedside interview with questionnaire study

The aim of this study was to explore perceptions and knowledge of source isolation among hospitalised patients colonised or infected with multi-resistant organisms, to identify if information provided and delivery method are helpful and appropriate, and to identify areas for practice improvements. Purposive sampling was conducted. Between November 2019 and January 2020, bedside interviews with structured questionnaires (combining multiple-choice and free-text questions) were conducted with adult in-patients requiring isolation for multi-resistant organisms in a 180-bed metropolitan hospital in Brisbane, Australia. Data analysis included quantifying multiple-choice responses and thematic analysis of free-text responses. Thirty participants completed the interview questionnaire. Lack of awareness and understanding of multi-resistant organisms was evident. Participants reported a preference for face-to-face education (96.7%) and information brochures (86.7%), rather than phone call (33.3%) or informative video (0%). Qualitative responses revealed communication and information deficits exacerbated patients’ negative psychological impacts including embarrassment, loneliness, abandonment, confusion and fear. Participants identified that clinicians need better communication skills and knowledge of multi-resistant organisms to recognise and ameliorate the effect of source isolation on patients. In conclusion, patients in source isolation reported that they do not receive adequate information. Enhancing clinician knowledge of multi-resistant organisms and improving communication skills may help address the psychological needs of these patients.

Overemployed and Underappreciated: Magnetic Resonance Cholangiopancreatography Use in an Acute Surgical Unit Rarely Changes Management, Delays Discharge, and Compounds Hospital Cost

Introduction: Most acute biliary presentations involve gallstones and cholecystectomy is common. Concern regarding obstructive biliopathy occasionally warrants magnetic resonance cholangiopancreatography (MRCP). However, this delays time to intervention and increases length of hospital stay. Given operative cholangiography is within the skills of general surgeons, can MRCP be justified? This study examines MRCP indications in acute surgical patients. Patients with biliary colic/cholecystitis forms an interest group. Outcomes are analyzed to identify if MRCP led to a change in management. Methods: A 12-month retrospective review of all acute surgical admissions undergoing inpatient MRCP at an Australian metropolitan hospital was undertaken. Clinical and MRCP details (Indication; Time to MRCP; MRCP change in management) were collated. Delay to intervention, wasted bed days and a cost analysis of unnecessary MRCP expenditure was calculated. Results: A total of 64 patients qualified for analysis. Lead admission diagnoses were biliary colic (34.4%), cholecystitis (20.3%) and pancreatitis (17.2%). MRCP was indicated for choledocholithiasis in 68.8%. Time to MRCP was a mean of 21hrs (+/-20.58) with a range of 2-96hrs. MRCP was deemed to have changed management in 17.2% of all cases and only 11.4% in patients with biliary colic/cholecystitis specifically. The potential savings owing to MRCP that didn’t change management was $146,900AUD overall. Conclusion: In an environment where cholecystectomy and operative cholangiogram are common, MRCP rarely changes management. The potential improvements in clinical efficiency are significant with cost savings. MRCP should be considered carefully, particularly when cholecystectomy with cholangiogram is already indicated. There remains small subset of patients in whom MRCP can be of great utility.