Central Coast Local Health District Research Articles

Improving Palliative and End of Life Care on the Central Coast, Australia: Results from Two Clinically-Led Mixed-Methods Research Projects

In 2019, New South Wales Regional Health Partners commissioned the Central Coast Local Health District to undertake clinician-driven research that would lead to the implementation of new service models designed to improve palliative and end-of-life care to the Central Coast community.
 During 2020, a series of five stakeholder workshops with clinicians, healthcare managers, consumers and other local stakeholders involved in palliative and end of life care led to the development of two translational research projects: palliative and end of life care for people with advanced dementia; and the experiences of people who access emergency care towards the end of life. The subsequent clinically-led research programs were undertaken between January 2021 and September 2022. In this presentation, we discuss the results of these two mixed-methods research projects.
 To understand the patient journey, both projects undertook audits. For people who died with dementia, a retrospective case notes audit of 705 people who died between January 2015 and December 2019 found half died in public hospitals, and the other half in other settings. Less than one in five patients dying in public hospitals had an advanced care directive recorded, and fewer than one in 13 had an advanced care plan. The second audit of 1730 Central Coast residents who died between August 2020 and July 2021 found nearly half had 1 (45%) emergency department presentation in the 90 days before their death, and more than one in four had 2 presentations. There was a significant difference in the number of emergency department presentations and hospital admissions when comparing patient age and place of death.
 Across both projects, a total of 303 bereaved carers completed a postal survey. Respondents reported high levels of satisfaction with end of life care across settings. Most people receiving care were always treated with respect and dignity. Pain was managed best in hospital, compared to residential aged care and home settings. Less than half of carers said the person cared for had enough choice about where they died, but on balance, more than four in five said the person died in the right place. 
 Thematic analysis of 19 in-depth interviews with bereaved carers found three themes were common across projects: 1) There is a lack of acknowledgement of end of life, and discussions about death usually happen in the final days; 2) Services and supports are complex and fragmented, knowledge is needed to navigate them and experiences vary; and 3) End of life caring is challenging and there is limited support for carers to care.
 Drawing on previous evidence that was presented during ICIC22, we examine the lessons learned from these research projects on the importance of clinically-led research and how this is translating into the implementation of an integrated model of end of life care on the Central Coast. Key lessons for international colleagues from this research are considered.

Finding a way towards Population Health Management on the Central Coast, Australia

Background: To improve the health and wellbeing of the community members on the Central Coast, New South Wales, Australia, this project undertook an assessment of readiness for a Population Health Management (PHM) and neighbourhood based initiative. To do so, it focussed on community needs and strengths and weaknesses of local management on the Central Coast. The Central Coast Local Health District (CCLHD) and Hunter New England and Central Coast Primary Health Network (HNECCPHN) commissioned a joint strategic needs assessment (JSNA). During the project local managers, health professionals, and community members were consulted to gain insight in the readiness and needs of the region. 
 Methods: The JSNA carried out a data driven deep-dive of the health and care needs at a neighbourhood-level with the intent to drive a co-designed intensive place-based population health improvement initiative that optimizes health outcomes, improves access to care and care equity, and reduces total costs to the health system. Supported by the PHM Maturity Index (PHM-MI), the capability across the Central Coast to enable the implementation of PHM was mapped. This allowed gaining insight in the readiness of local management for this pro-active approach. 
 Results: This project is still running and aims to be completed in 2023. Preliminary results of the PHM-MI demonstrate an overall low occurrence of items that support the implementation of PHM. Participants recognized the need and voiced the willingness to work collaboratively. However, they confirmed the absence of a guiding coalition and visionary leadership leading to cross domain collaboration. The major weakness of the Central Coast is the high level bureaucracy and political influence in the health system. This hinders top-level collaboration between multiple organizations, and limits the possibilities of financial changes, the building of an integrated data-infrastructure, and the probability for community ideas to become sustainable. The major strengths of the Central Coast are the strong identity of the community members to the region, the willingness of local managers to focus on the community needs and the availability of data. The project shows that the Central Coast is a region with a lot of hidden potential for a neighbourhood based PHM initiative. 
 Discussion: Using the PHM-MI to map the capability of the Central Coast started the conversation about prerequisites that support a neighbourhood based initiative. Bringing several stakeholders together to participate in the project was challenging, but resulted in new connections between organizations. A next step for the Central Coast is to gain an overview of the most prominent processes in organizational governance, payment streams and budgets, involvement and consultation of community members, and availability of datasets. Therefore, inter- and intraorganizational collaboration is important to bring the hidden strengths on the Central Coast together and build a strong enabling environment to support the growth of the health and wellbeing of the community members on the Central Coast.

Development of Behavioural and Psychological Symptoms of Dementia(BPSD) App for use in a hospital setting

AbstractIntroductionPrevious quantitative audits at Wyong Hospital, a 300 bed regional and teaching hospital in the Central Coast Local Health District (CCLHD) showed that the majority of Clinical Aggression Response Team (CART) calls occurred in the geriatric population.Results suggested that often BPSD guidelines which were on the CCLHD intranet were not adhered to. It was suggested that medical officers need ready access to local guidelines and more education. Interviews with staff who were participating in CART calls found that medical staff were not confident in when to and what to prescribe and what was the most appropriate management.These audits, which involved interviewing participants of CART calls, plus evidence about implementing practice change, suggests that mobile phone apps are used more frequently and are more effective than intranet documents.ObjectiveDevelop a BPSD app with the potential to make evidence based recommendations and local guidelines accessible to the user at the bedside using a mobile device particularly during CART calls and enables the user to manage BPSD with ease.Methods1. Content of the app is based on BPSD guidelines published on the CCLHD intranet geriatric medicine webpages.2. A prototype of the app was developed on Marvel designs and provided to the IT and e‐health New South Wales department who provided suggestions, guidance on the app development and integration of the app onto the hospital IT system. Training sessions were provided via drop in sessions and online videos using Microsoft teams. Targeted education sessions on app usage was provided to medical personnel. Costs for the development of the app was funded by the Department of Geriatric medicine, Wyong and Gosford Hospital.3. Ethics approval was obtained from the Central Coast Local Health District Human Research Ethics Committee.ResultsThere has been more than 100 downloads of the app with levels of usage ranging from 1 to 38 on a daily basis.ConclusionThe development of the app allows ease of access to concise evidenced based information and supports clinicians in their role in managing BPSD.

Procedure videos to support rare clinical procedures in acute cardiac nursing, an implementation evaluation

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Central Coast Local Health District Research Grant. Background Cardiology procedures are often lifesaving and time-critical, but some are so infrequent that nurses may have rarely encountered them in practice. Videos demonstrating rare procedures can potentially support clinicians performing rare clinical procedures. We evaluated using locally created nursing clinical procedure videos as an adjunct to traditional written procedures. Purposes This study evaluated the implementation of 7 newly created clinical procedure videos on temporary cardiac pacing (n=3), non-invasive ventilation (NIV) (n=2) and pericardiocentesis (n=2). Methods A pre/ post -implementation Survey based on the Theoretical Domains Framework (TDF), Clinical Reasoning Cycle and the Spielberger State-Trait Anxiety Inventory (STAI) was distributed via email and Facebook groups to over 500 eligible nurses in the implementation sites. In addition, data from the hosting platform Vimeo for the implementation period and procedure numbers (15 October 2020 to 15 March 2021) were analysed. Results 122 respondents, 86% female, viewed the videos, mean age of 40.75 years (20 to 71 years). The most common procedure during the implementation period was NIV (n=170), followed by Pericardiocentesis (n=7) and Temporary Cardiac Pacing (n=5). The total number of video views over the 6 months was 598, temporary pacing-preparation (n=152), NIV Mask why and when (n=137), NIV Set up and Patient Care (n=89), Pacing: Procedure (n=62), Cardiac Tamponade (n=52), Pacing: Threshold testing and Pericardiocentesis Procedure (n=51 each). Participants agreed /strongly agreed that video procedures increased their recall (93.8%), made learning a better experience (98.3%), and was time-saving (88.0%) (Figure 2). Participants preferred videos to be an adjunct to existing written procedures and not a replacement (78%). Major themes from qualitative feedback included participants describing them as "clear and easy to understand" and the benefits of videos for rare procedures "Rarely seen in ED easy to follow and fast refresher when the procedure is time critical". Prior to implementation, the mean score for state anxiety before a rare procedure was 41.43 (SD= 9.307) with scores over 40 indicating clinically significant levels of anxiety. Older age and a higher number of years in the role were significantly correlated with lower anxiety levels (r = -0.144 p = .037; and r = 0.532 p = .000) perceived anxiety related to rare procedures did not significantly change from pre- to post-implementation. Conclusion Clinical procedure videos at the point of care are acceptable and valued. Findings suggest videos are a useful adjunct to written procedures for time-critical or rare procedures.Figure 2:Experience with video.

Community Heart Failure Service Referral Patterns in the Central Coast Local Health District (CCLHD) Throughout the COVID-19 Pandemic

Community Heart Failure Service Referral Patterns in the Central Coast Local Health District (CCLHD) Throughout the COVID-19 Pandemic

A monitoring and site visit intervention to reduce sales to minors at packaged liquor outlets.

Selling alcohol to a minor is a serious offence in the New South Wales Liquor Act. However, minors report they can purchase alcohol easily. This study used an intersectoral partnership between the Central Coast Local Health District (CCLHD) Health Promotion Service, and Liquor & Gaming NSW (L&GNSW) Compliance Operations to test a site visit intervention to increase ID checks at packaged liquor outlets (PLOs). As the current legislative framework does not allow minors to attempt to purchase alcohol from PLOs, even under compliance operations, this study employed pseudo-minors aged 18-19 years. Pseudo-minors visited all PLOs on the Central Coast, NSW in four survey rounds, attempting to purchase alcohol without ID. If a PLO sold alcohol to the pseudo-minor, they received a visit from a Health Promotion Officer and L&GNSW Inspector to inform them of the sale and that they are at risk of selling alcohol to a minor. Site visits were an effective intervention to increase the rates of ID checking. Alcohol sales to pseudo-minors without ID decreased from 34% in Round 1 to 7% in Round 4. Young sales staff and independent stores were less likely to check ID. This intervention was associated with some of the lowest rates of underage alcohol purchasing reported to date. However, it may not be sustainable in the long term. It is recommended that: future studies randomise site visits to investigate their contribution to the observed reduction, cost effectiveness of the intervention is explored and legislative change to allow controlled purchase operations for alcohol is considered. SO WHAT?: Young people under 18 years of age should not be able to purchase alcohol from liquor licence outlets, and strong laws apply if a sale is detected. However, despite these rules, young people still report they can access alcohol in this manner. Whilst our intervention of site visits with the regulatory body saw decreases in sales to our pseudo-minors, we advocate for controlled purchase operations (similar to tobacco control) as a more sustainable and effective intervention to reduce sales to minors - while this is not yet legislated for packaged liquor outlets in Australia, it is deemed best practice in other countries.

Good Clinical Outcomes Following Minor Foot Amputations in People with Diabetes: A Retrospective Clinical Audit of Associated Factors

Abstract Background: The purpose of this retrospective audit was to compare patient based clinical outcomes to amputation healing outcomes twelve months after a minor foot amputation in people with diabetes. Methods: Hospital admission and community outpatient data were extracted for all minor foot amputations in people with diabetes in 2017 in the Central Coast Local Health District. Results: A total 85 minor foot amputations involving 74 people were identified. At the twelve-month follow-up 74% (n=56) of the minor foot amputations healed, 63% (n=41) of the participants achieved a good clinical outcome (healed, no more proximal amputations, or death within the 12 month follow up period), and the mortality rate was 18%. Poor clinical outcomes were associated with those aged greater than 60 (RR 5.75, 95% CI: 0.85 to 38.7, p=0.013), those undergoing a further surgical debridement procedure during their hospital stay (RR 2.42, 95% CI: 1.3 to 4.4, p=0.005) and those who did not attend CCLHD Podiatry clinics post-amputation (RR 2.3, 95% CI: 1.2 to 4.1, p=0.010). Conclusions: To improve patient based clinical outcomes post-minor foot amputation, targeted follow-up in a high-risk foot clinic, and tailored discharge treatment plans for people aged over 60 or those undergoing a debridement procedure may be considered.

\u201cAntibiotic hardstop\u201d on electronic prescribing: impact on antimicrobial stewardship initiatives in patients with community acquired pneumonia (CAP) and infective exacerbations of chronic obstructive pulmonary disease (IECOPD)

BackgroundAntimicrobial resistance (AMR) remains a major public health threat and the exploration of interventions which may reduce inappropriate antimicrobial use are of particular interest. An Antibiotic Hardstop (AH) was included within the eMeds system introduced to the Central Coast Local Health District (CCLHD) in 2018. The function allows prescribers to set a predetermined time at which antibiotic orders would cease. By default, the function set prescribed length to 5 days with a view to encourage prescribers to review existing antimicrobial orders and reduce inappropriate use.MethodsRecords of adult inpatients prescribed broad spectrum antimicrobials with a registered indication of community acquired pneumonia (CAP) or an infective exacerbation of chronic obstructive pulmonary disease (IECOPD) between the 1st of March 2017 and 31st May 2017 for the pre eMeds cohort and 1st March 2019 and 31st May 2019 for the post eMeds cohort were randomly selected from our local health network’s Guidance MS® system. Baseline demographics, antimicrobial prescribing records and documented adverse events related to the AH function were collated/analysed. The days of therapy (DOT) and length of therapy (LOT) for each encounter were calculated manually and results analysed using a two-tailed t-test or Mann–Whitney U test.ResultsOf patients eligible to have the AH function activated during their admission, 34% (n = 34) had the function deployed at least once. Following the introduction of eMeds mean DOT for the pooled indications cohort was reduced by 3.02 days (CI 95% 0.41–5.63, p < 0.05) and mean LOT by 1.97 days (CI 95% 0.39–3.55, p < 0.05). The hardstop function resulted in 2 cases of delayed or unintentionally ceased therapies.ConclusionsFollowing the introduction of electronic prescribing and AH, a significant reduction was observed in the DOT and LOT for antimicrobial use for inpatients with CAP and IECOPD without a significant increase in adverse events. Further research is required to determine the extent to which the AH functionality directly contributed to this effect and if the effect is present across a broader range of indications.

Benign paroxysmal positional vertigo in the emergency department: An observational study of an Australian regional hospital's acute clinical practice.

To analyse adherence to evidence based practice in the diagnosis and treatment of benign paroxysmal positional vertigo (BPPV) in a regional ED. Retrospective observational population study. Wyong Hospital's ED, Central Coast Local Health District, New South Wales, Australia. Medical records of patients with an ED diagnosis of BPPV (n=101) between 2017 and 2018 were included for auditing. Adherence to clinical practice guidelines for BPPV4 statements 1a, 3a, 4a and 6 were reviewed as primary outcomes using a de-identified binary data excel tool. These outcomes were compared to available data from metropolitan tertiary EDs both in Australia and the USA. General compliance to best practice standards was low. Of patients diagnosed with BPPV in the ED only 45% (95% CI 35-54%) were diagnosed with the recommended Hallpike-Dix positional test. Of those patients who did receive diagnosis via the Hallpike-Dix test only 41% (95% CI 28-56%) went on to receive gold standard recommended treatment of a canalith repositioning manoeuvre/technique. In regards to the recommendations against practice, 36% (95% CI 28-46%) had neuroimaging performed in the ED and 58% (95% CI 48-68%) received vestibular suppressant medication as their only treatment prior to discharge. Adherence to best practice diagnosis and management of BPPV was low in Wyong Hospital's ED. Although low, Wyong Hospital's ED appeared to perform better in compliance to the clinical guidelines to its metropolitan Australian peer. There is opportunity to improve the efficiency and effectiveness in the management of acute peripheral dizziness in EDs.

A nurse practitioner model of care in the era of direct acting antiviral therapy for hepatitis C virus infection.

Background and AimDirect‐acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection has resulted in high rates of successful disease cure; however, not enough healthcare providers are available to deliver treatment to the population living with chronic HCV. To demonstrate that a nurse practitioner (NP) model of care is non‐inferior to specialist gastroenterologist (SG) management of HCV infection, as measured by sustained viral response at 12 weeks (SVR12) after initiation of DAA therapy.DesignRetrospective cohort database study.SettingSingle‐center outpatient study, Central Coast Local Health District (CCLHD).ParticipantsAll patients with chronic HCV treated in the CCLHD Liver Clinic in the period 3rd March 2016 to 31st May 2019 were retrospectively analyzed. In this time period, a total of 1638 patients with chronic HCV had completed treatment. Seven hundred and thirty‐four patients were excluded (733 pre‐PBS listing for DAAs and 1 not treated with DAA). Nine hundred and four patients were eligible for the study, of which 541 were managed by an SG, and 363 managed by an NP.Main outcome measuresData were collected on patient demographics, genotype, fibrosis score, and presence of cirrhosis. Primary end point was number of patients achieving SVR12.ResultsOf the 904 patients treated with DAA, 764 (84.5%) achieved SVR12. There was no statistical difference (P > 0.05) in achieving SVR12 between patients treated by an SP (n = 481, 88.9%) and those treated by an NP (n = 281, 77.4%).ConclusionAn NP model of care is non‐inferior to SG management of HCV infection, as evidenced by equivocal success in achieving SVR12 between the two treatment groups. Therefore, an NP model of care is a viable option in the era of DAA therapy for HCV infection. Ongoing investment into the delivery of NP care could increase treatment uptake of HCV, with the aim of decreasing overall burden of disease.

Nature and extent of outpatient podiatry service utilisation in people with diabetes undergoing minor foot amputations: a retrospective clinical audit

BackgroundPeople with diabetes are at high risk of foot complications that can lead to lower extremity amputations. National standards suggest that early assessment and management by a podiatry led multidisciplinary high-risk foot clinic (HRFC) helps to reduce complications. This review is a retrospective audit of the Central Coast Local Health District (CCLHD) podiatry department service utilisation in people with diabetes who had undergone a minor foot amputation.MethodsAll people with diabetes who had minor foot amputations in the calendar year 2017 in the CCLHD in New South Wales were identified. Podiatry occasions of service from all podiatry service clinics (e.g. general, orthoses, wound, HRFC) and hospital stays for 12 months prior to, and 12 months, post the minor foot amputation were extracted.ResultsData on 74 people with diabetes who underwent 85 minor foot amputations were collected. In the 12-month period leading up to their minor foot amputation less than half, 42% (n=31), of the patients had attended any of the available podiatry service clinics within the CCLHD system. Post-amputation and discharge from hospital there was an overall rise of 26% in numbers attending all CCLHD podiatry- led clinics bringing the total to 68% (51). However, attendance at the HRFC rose by only 2% from 16% (n=12) to 18% n= (13).ConclusionThis study shows that there was underutilisation of Podiatry Services in the CCLHD in 2017 with some participants not meeting national treatment guidelines for foot health services. Revision of current referral pathways both prior to, during and following hospitalisation and expanding the multidisciplinary HRFC to accommodate the population by providing more accessible locations has since been undertaken to increase service access. Further provision of education to those highlighted to be at high risk has also been implemented.

Supporting visitor compliance with a smoke-free policy at hospital using a nicotine replacement therapy vending machine.

Issue addressedTo support visitors to comply with Central Coast Local Health District's (CCLHD) smoke‐free hospital grounds policy, a need was identified for round‐the‐clock availability of nicotine replacement therapy (NRT). Providing NRT through a vending machine was identified as a possible solution. This initiative complemented other strategies that provide staff and patients who smoke with NRT.MethodsNRT was originally provided through a snack vending machine; however, there were commercial and regulatory concerns with this method.In 2015, dedicated NRT vending machines were installed at Gosford and Wyong Hospitals, and were operated by the Health Promotion Service. The appropriate regulatory permission was gained to supply a specific brand of NRT. Sales and incident data were recorded, and ongoing smoking counts were performed both before and after installation.ResultsIn all, 247 sales of NRT gum were made through the vending machines from early 2017 to late 2019. Smoking counts show that there are very low rates of visitor smoking (<1%) in the approximately 4.5 years pre‐ and post‐installation of dedicated vending machines. There was no statistically significant change in the smoking rate of visitors since the vending machine was installed at Wyong Hospital.ConclusionsWhile NRT is generally provided to patients and staff within health settings to support compliance with smoke‐free policies, alternatives to smoking for visitors are typically overlooked. A NRT vending machine achieves this. However, because there are few purchases made, the vending machines as currently operating are unlikely to make any significant impact on smoke‐free policy compliance at these hospitals.So what?While vending machines have limited effectiveness on overall smoke‐free policy compliance, this strategy may have applicability to all sectors with smoke‐free policies, especially those operating 24 hours a day, as a means of providing an alternative to smoking for visitors.

Using the Tailoring Immunization Programmes guide to improve child immunisation in Umina, New South Wales: we could still do better.

In the Central Coast Local Health District of New South Wales, Australia, childhood immunisation (CI) rates are around 95%, but pockets of underimmunisation exist. Using the World Health Organization's Tailoring Immunization Programmes, we identified areas of potential low vaccine coverage using Australian Immunisation Register (AIR) data (2016-18) and investigated factors that influence CI. Individual and group interviews with carers, community members and service providers (n=52 participants) were conducted. Data were analysed thematically and the themes presented to stakeholders for feedback before finalisation. During 2018, Umina had 218 children at least 1 month overdue for at least one vaccination. Five themes emerged: (1) broader socioeconomic factors may apply pressures that influence CI; (2) parents largely supported immunisation and knew of its benefits to their children and the community; (3) immunisation service providers are committed, experienced and collaborate with community partners; (4) there is potential to increase access to free immunisation services in Umina; and (5) AIR data and reminder systems could be better used to inform service delivery and prompt parents before immunisations are due. This study identified opportunities to improve CI coverage in Umina and new information useful in developing a tailored immunisation strategy. Awareness of the pressures socioeconomic factors may have on families could help plan and deliver supportive primary health care that includes equitable access to immunisation.

426 Use of Coronary Computed Tomographic Angiography (CCTA) for Absolute Risk Reduction in a Rapid Access Cardiology Clinic (RACC)

The RACC service within the Central Coast Local Health District utilises CCTA for quick and accurate investigation of patients discharged from the Emergency Department with low- intermediate risk chest pain. As demonstrated in the SCOT-HEART trial, CCTA identifies Coronary Artery Disease (CAD) in patients with chest pain, and facilitates appropriate and timely use of medical therapy, and supports more judicious use of invasive angiography1. A cross sectional analysis of all patients referred to the RACC was performed. We identified those who proceeded to CCTA, and compared changes to medical management, including addition or titration of statin as well as proceeding to angiography. Over the 6 month period 202 patients were seen in the RACC, of these 137 (68%) underwent CCTA, with 83 (61%) having newly diagnosed non obstructive CAD and 51 (37%) resulted in no CAD. Obstructive CAD was found in 1 of these patients, resulting in angiography and revascularisation. With a new diagnosis of non obstructive CAD and LDL-C >1.8, statin therapy was commenced in 45 (54%) of patients, where there was evidence of suboptimal lipid control, statin therapy was increased in 24 (29%)3.Aspirin was commenced for 42 (51%) of these patients. For support with lifestyle modifications such as smoking cessation, diet and exercise, 45 (54%) patients were referred to Cardiac Rehabilitation. Utilising CCTA to diagnose CAD within our RACC model facilitates timely implementation of primary and secondary preventative therapies supporting a reduced absolute risk for CVD events in 5 years2.

Improving the identification of cancer patients’ caring relationships

The Carer Support Unit of the Central Coast Local Health District (New South Wales, Australia) is working with the District’s inpatient cancer services to improve the identification of caring relationships for cancer inpatients. The first stage of the project was to do a literature review and environmental scan to assess the extent of the issue. We found significant barriers to carer identification, including: carer self-identification issues; definitional issues around the label ‘carer’; system and process issues; and health workforce issues. This article outlines the findings of the literature review and environmental scan, supported by quotes from carers and health professionals. It incorporates recommendations for increasing the rate of carer identification for cancer inpatients at Central Coast Local Health District.

Formative Evaluation of the Central Coast Integrated Care Program (CCICP), NSW Australia

Introduction:Integrated care has been posited as an important strategy for overcoming service fragmentation problems and achieving the Quadruple Aim of health care. This paper describes the Central Coast Integrative Care Program (CCICP) a complex, multi-component intervention addressing 3 target populations and more than 40 sub-projects of different scale, priority and maturity. Details are provided of the implementation including activities undertaken for each target population, in the context of the Central Coast Local Health District (CCLHD) strategies and priorities. Key lessons are drawn from the formative evaluation.Methods:A mixed methods approach to the formative evaluation was taken. Key stakeholders, professional staff with an in-depth knowledge of the program, were invited to complete surveys (n = 27) and semi-structured interviews (n = 23). The evaluation employed co-design principles with dialogue between CCICP partners and researchers throughout the process and sought to achieve a shared understanding of the dynamic context of the program, and the barriers and enablers for the various interventions.Key lessons and conclusion:Seven interdependent key lessons have been identified. These distil down to the setting of clear objectives aligning with all the goals of partners, developing strong relationships, leadership at multiple levels and communication and the building of a common language.

Implementing and enforcing a smoke-free policy and by-law on hospital grounds at Central Coast Local Health District.

Smoking by patients, staff and visitors on the grounds of Central Coast Local Health District (CCLHD). NSW Health introduced a smoke-free buildings and vehicles policy in 1988. A smoke-free grounds policy was implemented in 1999, and a smoke-free by-law adopted by CCLHD in 2013, making smoking on CCLHD grounds an offence. Smoking in high-profile areas near hospital entrances was counted regularly since 2000. Several methods for communicating, monitoring and enforcing these smoke-free interventions have been adopted, including signage, Public Address announcements and enforcement patrols to ensure by-law compliance and to issue fines where required. Compliance with the smoke-free interventions has been supported with the availability of Nicotine Replacement Therapy for patients and visitors. When monitoring counts first commenced in 2000, smoking rates in high-profile areas were 8.1% at Gosford Hospital and 11.1% at Wyong Hospital. Counts conducted in 2018 indicated a substantial improvement, with the smoking rate in high-profile areas reducing to 0.25% at Gosford Hospital and 0.5% at Wyong Hospital. Smoking rates in high-profile areas have held steady at approximately 0.3% since 2014, after the by-law was implemented. The introduction of the smoke-free by-law added extra impetus to efforts to reduce smoking on CCLHD hospital grounds by providing the option to fine people who breach the by-law. Smoking in high-profile areas has declined substantially since 2011, and is minimal since the establishment of the smoke-free by-law. SO WHAT?: The experiences of CCLHD in implementing the smoke-free by-law may provide insights for other health services looking to use a similar intervention at their facilities. There are also methodological lessons for other organisations looking to communicate, monitor and enforce smoke-free policies, without enforcing fines.

Predicting the need for transfer and interventional angiography for patients with acute colonic haemorrhage in a regional setting.

Radiological angioembolization is an important strategy in management of acute colonic bleeding. Due to requirement for specialized interventional radiology, many hospitals rely on transfer for this service. This study aimed to identify patient and clinical factors associated with positive (blush) computed tomography mesenteric angiogram (CTMA) or need for invasive angiography. The secondary aim was to identify a patient population who may forego transfer and be safely managed in a regional centre. All presentations to Central Coast Local Health District with colonic bleeding from June 2013-June 2017 were included. A guideline for transfer of patients with positive CTMA from Central Coast Local Health District to Royal North Shore Hospital had been established prior to the study period. Demographics, medical background, transfusion requirement, presentation details and mortality data were collected on all patients. Of 2378 patients presenting with colonic bleeding, 71 of 247 patients investigated with CTMA had a blush. Forty-six patients were transferred to Royal North Shore Hospital. Of these, 28 proceeded to interventional angiography with 19 undergoing angioembolization. Acute transfusion ≥5 units (odds ratio 6.78, P < 0.01) was the only significant predictor of needing interventional angiography. There was no association between age, bleeding site (right or left), use of antiplatelet or anticoagulation, diverticular disease or chronic kidney disease and identification of arterial bleeding on interventional angiography. There was no mortality or significant procedure-related morbidity. A patient's medical background demonstrates a lack of correlation to identification of active bleeding on interventional angiography. Patients requiring ≥5 units blood transfusion should be considered for transfer and interventional angiography.

Using the Project Integrate Framework for assessing progress towards care integration: results from a formative evaluation of a complex intervention in Central Coast Local Health District, NSW Australia

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Use of the Project Integrate Framework for situational analysis and benchmarking of progress towards care integration in the Central Coast NSW

Background: The Project Integrate[i] conceptual framework began with a literature review on conceptual frameworks and relevant aspects of integrated care, from which a new conceptual framework, was built iteratively. This framework provides a standard set of dimensions and sub-elements which can be used to describe any integrated care initiative. As part of the formative evaluation of the Central Coast Integrated Care Program (CCICP), we have employed the Project Integrate Framework to map the integration efforts of the program, provide a consistent and common language, to enable supported self-assessment of progress towards integrated care and to allow for international benchmarking. Methods: An online survey of key stakeholders was undertaken mapping the degree of agreement on progress towards the Project Integrate dimensions. The survey results were used as a support tool in a workshop to assist CCICP team reflection and assessment and build a situational analysis of care integration progress within the program. This exercise was used as the basis to support agreement of future priorities and strategies within the program. Results: The survey results indicated where progress towards care integration had been achieved in the Central Coast. It was then used as a support tool in a workshop setting to assist the CCICP team to reflect and self-assess progress towards integrated care. Reflections regarding international comparators were made, stimulating further discussion, this led to the recognition of progress made to date and a realistic review of where progress should be given the maturity of the intervention. Achievements and opportunities were identified, with priority areas mapped out. A key priority was communication, in particular, building a common and consistent language for integrated care. Workforce and upskilling regarding data warehousing and analysis was also identified as an opportunity for future work. Discussion: The survey tool alone was inadequate since many answers reflected uncertainty regarding progress (Neither Disagree nor Agree), thus the data required review and further consideration by the team to contextualise the uncertainty, particularly given the formative stage of assessment. The power of the survey results was in the group analysis and the contextualized discussion which ensued and added greatly to the understanding of progress in care integration on the Central Coast. The Project Integrate Framework and its nomenclature was identified by the CCICP team as a key communication tool, to build a consistent terminology for integrated care and its use in reporting, communication and stakeholder engagement. As with international case studies, progress towards system integration was regarded as poor, with substantial structural barriers beyond the control of the CCICP team. However, the intervention appears to be tracking more favourably in the dimension of patient-centred care. Conclusion: Use of the Project Integrate framework has enabled the CCICP team to reflect on progress and spread of integrated care within the Central Coast Local Health District and where their next steps should be for spreading and building sustainability.