Death In Australia Research Articles

Creutzfeldt-Jakob disease surveillance in Australia: update to 31 December 2020.

Nationwide surveillance of Creutzfeldt-Jakob disease and other human prion diseases is performed by the Australian National Creutzfeldt-Jakob Disease Registry (ANCJDR). National surveillance encompasses the period since 1 January 1970, with prospective surveillance occurring from 1 October 1993. Over this prospective surveillance period, considerable developments have occurred in pre-mortem diagnostics; in the delineation of new disease subtypes; and in a heightened awareness of prion diseases in healthcare settings. Surveillance practices of the ANCJDR have evolved and adapted accordingly. This report summarises the activities of the ANCJDR during 2020. Since the ANCJDR began offering diagnostic cerebrospinal fluid (CSF) 14-3-3 protein testing in Australia in September 1997, the annual number of referrals has steadily increased. In 2020, 510 domestic CSF specimens were referred for 14-3-3 protein testing and 85 persons with suspected human prion disease were formally added to the national register. As of 31 December 2020, just over half (44 cases) of the 85 suspect case notifications remain classified as 'incomplete'; 27 cases were excluded through either detailed clinical follow-up (9 cases) or neuropathological examination (18 cases); 18 cases were classified as 'definite' and eleven as 'probable' prion disease. For 2020, sixty percent of all suspected human-prion-disease-related deaths in Australia underwent neuropathological examination. No cases of variant or iatrogenic CJD were identified. The SARS-CoV-2 pandemic did not affect prion disease surveillance outcomes in Australia.

Complex and underreported? A study into the prevalence of suicide by motor vehicle in the state of Queensland

While suicide is recognised as one of the leading causes of death in Australia, it is often presumed that fatal road crashes are primarily accidental in nature. However, international research has indicated that deliberate attempts at self-harm while driving may account for between 1.1% and 7.4% of road crashes. Despite the personal and financial costs associated with such events, few studies have examined the extent of motor vehicle suicides (MVS) or the circumstances surrounding such incidents in Australia. Given this, the current study reviewed coronial, police and toxicology findings of 762 motor vehicle fatalities in Queensland (Australia) during the period 2011 to 2015 to determine the frequency of confirmed cases and explore the prevalence (and characteristics) of possible MVS that remain undetected. In total, 22 confirmed cases were identified, and such events shared significant similarities with 14 possible events, including evidence of recent emotional upset, adversity and mental health diagnoses. In contrast, differences between the groups were limited to confirmed cases being more likely to involve males and contain a suicide note or evidence of past suicidality, while possible cases were more likely to involve a multiple vehicle impact with a truck. Importantly, crucial information regarding the deceased’s psychological state and life circumstances (e.g., psychological autopsy) was not reported in many cases. Corresponding qualitative analysis of the coroners final determination (between the two groups) revealed the occurrence of the word suicide to occur seven times (31.8%) among confirmed cases and five times (35.7%) for possible casers. Furthermore, the coroners final determination of intent to suicide was open or undetermined in six of the possible cases (43%), which further suggests a reluctance (or procedural uncertainty) to categorically identify MVS. The paper further reviews the main findings, illuminates core challenges associated with identifying MVS and proposes a need for future investigations to incorporate a more standardised and evidence-based approach in order to effectively identify such events.

Field-Deployable Recombinase Polymerase Amplification Assay for Specific, Sensitive and Rapid Detection of the US Select Agent and Toxigenic Bacterium, Rathayibacter toxicus

Simple SummaryEarly, accurate, and rapid detection of R. toxicus is extremely important to improve inspections of imported annual ryegrass hay and seed at ports of entry and enhance in-field detection. RPA is a comparatively new, easy to use, and robust technology that can be performed in the palm of the hand without losing specificity. The RPA assay was more sensitive than endpoint PCR and did not require lab equipment in the field. The developed assay has tremendous applications for in-field plant diagnostics and biosecurity surveillance.Rathayibacter toxicus is a toxigenic bacterial pathogen of several grass species and is responsible for massive livestock deaths in Australia and South Africa. Due to concern for animal health and livestock industries, it was designated a U.S. Select Agent. A rapid, accurate, and sensitive in-field detection method was designed to assist biosecurity surveillance surveys and to support export certification of annual ryegrass hay and seed. Complete genomes from all known R. toxicus populations were explored, unique diagnostic sequences identified, and target-specific primers and a probe for recombinase polymerase amplification (RPA) and endpoint PCR were designed. The RPA reaction ran at 37 °C and a lateral flow device (LFD) was used to visualize the amplified products. To enhance reliability and accuracy, primers and probes were also designed to detect portions of host ITS regions. RPA assay specificity and sensitivity were compared to endpoint PCR using appropriate inclusivity and exclusivity panels. The RPA assay sensitivity (10 fg) was 10 times more sensitive than endpoint PCR with and without a host DNA background. In comparative tests, the RPA assay was unaffected by plant-derived amplification inhibitors, unlike the LAMP and end-point PCR assays. In-field validation of the RPA assay at multiple sites in South Australia confirmed the efficiency, specificity, and applicability of the RPA assay. The RPA assay will support disease management and evidence-based in-field biosecurity decisions.

Time series forecasting of new cases and new deaths rate for COVID-19 using deep learning methods

The first known case of Coronavirus disease 2019 (COVID-19) was identified in December 2019. It has spread worldwide, leading to an ongoing pandemic, imposed restrictions and costs to many countries. Predicting the number of new cases and deaths during this period can be a useful step in predicting the costs and facilities required in the future. The purpose of this study is to predict new cases and deaths rate one, three and seven-day ahead during the next 100 days. The motivation for predicting every n days (instead of just every day) is the investigation of the possibility of computational cost reduction and still achieving reasonable performance. Such a scenario may be encountered in real-time forecasting of time series. Six different deep learning methods are examined on the data adopted from the WHO website. Three methods are LSTM, Convolutional LSTM, and GRU. The bidirectional extension is then considered for each method to forecast the rate of new cases and new deaths in Australia and Iran countries.This study is novel as it carries out a comprehensive evaluation of the aforementioned three deep learning methods and their bidirectional extensions to perform prediction on COVID-19 new cases and new death rate time series. To the best of our knowledge, this is the first time that Bi-GRU and Bi-Conv-LSTM models are used for prediction on COVID-19 new cases and new deaths time series. The evaluation of the methods is presented in the form of graphs and Friedman statistical test. The results show that the bidirectional models have lower errors than other models. A several error evaluation metrics are presented to compare all models, and finally, the superiority of bidirectional methods is determined. This research could be useful for organisations working against COVID-19 and determining their long-term plans.

Epidemiology of unintentional fatal drowning among migrants in Australia

ObjectiveThis study aimed to describe the epidemiology and risk factors contributing to drowning among migrants in Australia. MethodsA total population retrospective epidemiological study of unintentional drowning deaths in Australia between 1 July 2009 and 30 June 2019 of people born outside Australia (migrants). Cases were extracted from the National Coronial Information System. Descriptive statistics, chi‐square and relative risk were calculated. Crude drowning rates were based on country of birth and population in Australia. ResultsThere were 572 migrant deaths over the study period, 28.9% of total drowning deaths, 82.9% were male. Twenty‐one per cent were aged 25–34 years and 40.8% had lived in Australia for 20+ years. Migrants at highest risk of drowning were from: South Korea (2.63/100,000 95%CI: 0.85–8.25), Taiwan (2.29/100,000 95%CI: 0.27–13.44), and Nepal (2.15/100,000 95%CI: 0.23–11.55). Migrants were more likely to drown when around rocks (p<0.001) compared with Australian‐born people, who most frequently drowned in rivers (p<0.001). ConclusionsMigrants are not over‐represented in drowning statistics. However, unique trends were found for drowning among migrants based on country of birth and length of time in Australia. Implications for public healthHolistic drowning prevention strategies and policies are required to effectively lower drowning risk among migrant communities.

Surveillance of suicide deaths involving gases in Australia using the National Coronial Information System, 2006 to 2017

BackgroundThere have been concerns about the increased use of helium and nitrogen gas as a suicide mechanism in Australia. MethodsNational Coronial Information System data were used to investigate gas‐specific suicides in Australia over the period 2006–2017. Characteristics were compared between helium or nitrogen, carbon monoxide and seven other gases. ResultsGas inhalation accounted for 10% (3,103/31,002) of all suicide deaths in Australia between 2006 and 2017. The mean age of individuals who died by suicide was 47.6 years (SD 16.9, R 14‐97) and 83.3% were male. The number of gas suicides declined over the study period (IRR=0.96). The fall was associated with a 47% decline in carbon monoxide suicides (IRR=0.93). There was an increase in deaths due to argon (IRR=1.60) and nitrogen (IRR=1.27). Compared to individuals using other non‐carbon monoxide gases, individuals who died by suicide from helium or nitrogen were significantly more likely to be older, have a physical illness and/or disability, have contacted a euthanasia group and have accessed instructional material and purchased gas online. ConclusionsSuicides by carbon monoxide decreased between 2006 and 2017 alongside an increase in argon and nitrogen gas use – particularly among older adults. The ease of access to these gases points to new targets for means restriction. Implications for public healthIdentifying the types of gases used in suicide deaths and emerging trends may enable targeted interventions that could potentially reduce access.

Sudden cardiac death related to physical exercise and sports in the young: a nationwide cohort study of Australia

Abstract Funding Acknowledgements Type of funding sources: None. Background Sudden cardiac death (SCD) during physical exercise is uncommon but devastating. Purpose We aimed to determine risk factors, causes and circumstances of sports and exercise-related SCD in the young in Australia. Methods We retrospectively reviewed the National Coronial Information System (NCIS) registry for deaths in Australia relating to cardiovascular disease (CVD) in cases aged 10 to 35 years between 2000-2016. Included cases had been undertaking sports or physical exercise at time of event. We collected baseline demographics and circumstances of death including location, type of physical exercise, whether the event was witnessed, and engagement of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use prior to ambulance arrival. Results Over a 17-year period, 1,925 SCD cases were identified of which 110 cases (6%) related to sports/physical exercise were included in final analysis. Median age was 27 years (interquartile range [IQR] 21-32 years) with most being male (92%). Median BMI was 27 kg/m2 (IQR, 23-30) with 13 cases (12%) occurring in active athletes. Most common causes were coronary artery disease (CAD; 37%) and sudden arrhythmic death syndrome (SADS; 20%). Australian Rules Football (24%), running/jogging (14%) and soccer (14%) were the most frequently practiced at time of event. Prior symptoms were present in 39% (chest pain 37%, presyncope/syncope 26%). Most were witnessed (87%) with bystander CPR in 70%. AED use prior to ambulance arrival was 8%. Conclusions This study demonstrates the high occurrence of CAD and SADS in exercise-related SCD in the young. Although events were commonly witnessed, an AED was seldom used prior to ambulance arrival highlighting an important opportunity to improve outcomes in the post-arrest chain of survival.

Survival in borderline resectable and locally advanced pancreatic cancer is determined by the duration and response of neoadjuvant therapy

BackgroundPancreatic cancer is the 8th commonest cancer and the 5th commonest cause of cancer-related death in Australia, with a 9% average 5-year survival. This study aims to investigate the effects of neoadjuvant treatment on overall survival (OS) and recurrence-free survival (RFS) in borderline resectable (BRPC) and locally advanced (LAPC) pancreatic adenocarcinoma followed by curative resection. Materials and methodsProspectively-collected demographic, medical, surgical and pathological data of patients with BRPC and LAPC treated with both neoadjuvant therapy (NAT) and surgery at a single tertiary referral centre in Australia were reviewed and analysed. ResultsBetween 2012 and 2018, 60 patients, 34 with BRPC and 26 with LAPC, were treated with NAT followed by curative resection. The commonest neoadjuvant chemotherapy regimens were Gemcitabine + Abraxane (51.7%) and FOLFIRINOX (35.0%), with 48.3% of patients additionally receiving neoadjuvant radiotherapy. Median RFS was 30 months and median OS was 35 months. On multivariable analysis, inferior OS was predicted by enlarged loco-regional lymph nodes on initial computed tomography (p = 0.032), larger tumour size post-NAT (p = 0.006) and Common Terminology Criteria for Adverse Events post-NAT toxicity greater than grade 2 (p = 0.015). LAPC patients received more neoadjuvant chemotherapy (p = 0.008) and radiotherapy (p = 0.021) than BRPC and achieved a superior pathological response (p = 0.010). ConclusionPatients who respond to NAT likely have a favourable disease biology and will progress well following resection. It is these patients who should be selected for more aggressive upfront management, and those with resistant disease should be spared from high-risk surgery.

Exertional heat fatalities in Australian sport and recreation

ObjectivesTo describe the number and case characteristics of sport and recreation-related exertional heat deaths in Australia and summarise recommendations derived from case narratives. DesignDescriptive, population-based, retrospective cohort study. MethodsCases were identified using the National Coronial Information System (NCIS) through multiple search strategies comprising queries, keywords and cause of death codes. Cases were included where there was evidence that the deceased was actively engaged in sport or recreation and exertional heat illness was causal or contributory to the death. Data extraction were performed independently, in duplicate, to ensure accuracy. Descriptive statistics are used to report deceased's socio-demographic characteristics, incident characteristics, type of sport/recreational activity and time sequence of events. Content analysis is used to summarise recommendations. ResultsThirty-eight deaths (males n = 29, 74%; median age = 40 years, range 8–77) were identified during the study period (2001 to 2018), with 22 recommendations for five cases. Two cases occurred during organised sport and 36 during active recreation, of which 27 were in hiking. Eleven (29%) individuals were international visitors. There were 22 recommendations across 5 cases presented, with a focus on education and training. ConclusionsExertional heat deaths in outdoor recreation in Australia were far more prevalent than cases in organised sport. The largest proportion of deaths occurred in hiking with two populations featuring: males aged 15–45 years and international visitors. Considering the incident characteristics and time sequence of events, measures such as early recognition of symptoms, provision of first aid and timely access to emergency medical care are important to prevent fatalities.

Injury deaths in Australian sport and recreation: Identifying and assessing priorities for prevention.

IntroductionSport and recreation is beneficial for health and wellbeing but comes with a probability of loss, including occasional fatal injuries. Following high-profile injury deaths in Australia, concerns are raised regarding the safety of sport participation. To understand the scale and scope of injury deaths, and identify potential prevention opportunities, the aim of this investigation was to describe the number and nature of fatal injuries in Australian sport and recreation.MethodsThis is a retrospective cohort study of injury deaths reported between 1 July 2000 to 31 December 2019 using data from the National Coronial Information System, Australia. Unintentional deaths with an external cause, where the activity was recorded as sport and exercise during leisure time were included. Drowning deaths were excluded. Presented are the number and % of cases by age, sex, sport, broad cause and annual crude death rate (population).ResultsThere were 1192 deaths, averaging 63 per year. Deaths were mostly in males (84.4%), with the largest proportion in people aged 15–24 years (23.1%). Wheeled motor (26.9%) and non-motor (16.2%) sports accounted for the highest proportion of cases. The primary mechanism of death was most commonly blunt force (85.4%), followed by piercing/penetrating force (5.0%). The years 2001 and 2005 recorded the highest crude injury death rate (2001, n = 92, 0.47 per 100,000 population; 2005, n = 95, 0.47 per 100,000 population).ConclusionsOn average, there is more than one injury death per week in a sport or recreation setting in Australia. Cases occurred in many sports and recreation activities, including those generally considered to be safe (e.g. individual athletic activities, team ball sports.) Detailed investigation of the coronial recommendations that are present within each case is now needed to understand and identify potential prevention opportunities.

Trends in MDMA-related mortality across four countries.

To determine trends in 3,4 methylenedioxymethamphetamine (MDMA)-related death rates across Australia, Finland, Portugal and Turkey and to analyse the toxicology and causes of death across countries. Analysis of MDMA-related deaths extracted from a national coronial database in Australia (2001-19) and national forensic toxicology databases in Finland (2001-17), Portugal (2008-19) and Turkey (2007-17). Presentation of MDMA use and seizure data (market indicators). Australia, Finland, Portugal and Turkey. All deaths in which MDMA was considered by the forensic pathologist to be contributory to death. Information collected on cause and circumstances of death, demographics and toxicology. A total of 1400 MDMA-related deaths were identified in Turkey, 507 in Australia, 100 in Finland and 45 in Portugal. The median age ranged from 24 to 27.5years, and males represented between 81 and 94% of the deaths across countries. Standardized mortality rates significantly increased across all four countries from 2011 to 2017 during a period of increased purity and availability of MDMA. The underlying cause of death was predominantly due to drug toxicity in Australia (n=309, 61%), Finland (n=70, 70%) and Turkey (n=840, 60%) and other causes in Portugal (n=25, 56%). Minorities of all deaths across the countries were due to MDMA toxicity alone (13-25%). These deaths had a significantly higher blood MDMA concentration than multiple drug toxicity deaths in Australia, Finland and Turkey. Drugs other than MDMA commonly detected were stimulants (including cocaine, amphetamine and methamphetamine) (Australia 52% and Finland 61%) and alcohol (Australia 46% and Portugal 49%). In addition to MDMA toxicity, benzodiazepines (81%) and opioids (64%) were commonly identified in these deaths in Finland. In comparison, synthetic cannabinoids (15%) and cannabis (33%) were present in a minority of deaths in Turkey. Deaths related to 3,4 methylenedioxymethamphetamine (MDMA) increased in Australia, Finland, Portugal and Turkey between 2011 and 2017. Findings show MDMA toxicity alone can be fatal, but multiple drug toxicity remains more prevalent.

Management of patients with type 2 diabetes and cardiovascular disease in primary care.

Approximately 65% of cardiovascular disease (CVD)-related deaths in Australia occur in people with diabetes or pre-diabetes. The aim of this study was to investigate general practice management of risk factors among patients with both conditions. This was a cross-sectional study of 33,559 adult patients with both type 2 diabetes and CVD at 1 November 2018, using the general practice data program MedicineInsight. One-third of patients did not have a record in their current medications list forall three recommended medicines to reduce cardiovascular risk. Potentially suboptimal monitoring and achievement of targets for diabetes and cardiovascular risk factors was also identified. Most patients using metformin-based combination therapy were prescribed blood glucose-lowering medicines that do not have evidence of cardiovascular benefit. These data suggest opportunities to support general practices to optimise patient management. Datasets such asMedicineInsight can help practices identify patients who may benefit fromrecall.

LACK OF FUNDING AND LONG-TERM JOB SECURITY THREATENS TO HAVE PROFOUND EFFECTS ON CARDIOVASCULAR RESEARCHER RETENTION IN AUSTRALIA

Objective: Cardiovascular disease is the leading cause of death in Australia, yet funding has stagnated in recent years, resulting in economic challenges within the cardiovascular research sector. Here we investigated the challenges faced by cardiovascular researchers in Australia as an initiative of the Emerging Leaders Committee of the Australian Cardiovascular Alliance (ACvA). Design and method: We developed a questionnaire, which was distributed via email and social media to ACvA members, Australian cardiovascular societies, councils, universities and research institutes for 6 months during April-November 2019. Results: There were 548 completed responses (out of 703, 80%). The respondents primary career stage was group leader or laboratory head (40%) followed by post-doctoral (33%), most were females (53%), and 31% reported career interruptions, especially parental leave. Only 23% had permanent (ongoing) employment. Eighty one percent of full-time workers said they regularly work more than 40 hours per week, and 85% were not compensated for overtime work. Sixty eight percent said they have considered leaving the cardiovascular research sector. If their position could not be funded in the next few years, 43% would consider leaving Australia to work in cardiovascular research overseas, and only 9% said they would not leave the sector. Greater job security (76%) and government investment in cardiovascular research (71%) were highlighted as the main strategies for retaining cardiovascular researchers in the sector in Australia. Compared to male cardiovascular researchers, women were less likely to be a laboratory head, hold secure funding or have confidence in a long-term career path as cardiovascular researcher, and were more likely to consider leaving the sector (all P &lt; 0.05). Conclusions: Our survey suggests that the current lack of funding in cardiovascular research, combined with a lack of long-term job security, threatens to have profound effects on cardiovascular researcher retention in Australia, especially for women. Strategies to increase retention and address the issues highlighted by our survey are urgently needed.

Impact of COVID-19 Related Disruptions to Colorectal Cancer Screening Programs in Three Countries: A Comparative Modelling Study

Background: Colorectal cancer (CRC) screening programs worldwide have been disrupted during the COVID-19 pandemic. This study aimed to estimate the impact of hypothetical disruptions to organized CRC screening programs on short- and long-term CRC incidence and mortality in three countries using microsimulation modelling.Methods: Using CRC microsimulation models for Australia (Policy1-Bowel), Canada (OncoSim) and the Netherlands (ASCCA and MISCAN-Colon) participating in the COVID-19 and Cancer Global Modelling Consortium (CCGMC), we simulated a range of scenarios to assess the potential impact of disruptions to screening on CRC incidence and mortality. Modelled scenarios varied by disruption duration (3-, 6- and 12-months), post-disruption participation decreases, and catch-up screening strategy.Findings: Without catch-up screening, CRC deaths could increase by 0·2-0·5%, 0·4-1·0%, and 0·8-2·0% over 2020-2050 among individuals aged 50 years and older in the three modelled countries after 3-, 6-, and 12- month disruptions, respectively, compared to undisrupted screening. A 6-month disruption would result in an estimated 1,964, 1,319, and 676-856 additional CRC deaths in Australia, Canada and the Netherlands, respectively, compared to undisrupted screening. Providing catch-up screening could minimize the impact of the disruption, while a post-disruption decrease in participation could increase CRC deaths by 1·8-3·7% compared to undisrupted screening.Interpretation: Although the relative impact of the modelled CRC screening disruptions due to the COVID-19 pandemic is modest, there is a clear impact on absolute CRC deaths over the period 2020-2050. It is crucial that, if disrupted, screening programs ensure participation rates return to previously observed rates and provide catch-up screening wherever possible, as the impact of any disruption could be considerably larger otherwise.Funding Statement: The secretariat for the COVID-19 and Cancer Global Modelling Consortium (CCGMC) working group 2 is funded through Cancer Council New South Wales.Declaration of Interests: KC: Dr. Canfell reports and is co-principal investigator of an unrelated investigator-initiated trial of cervical screening in Australia (Compass; ACTRN12613001207707 and NCT02328872), which is conducted and funded by the VCS Foundation (VCS), a government-funded health promotion charity. The VCS Foundation received equipment and a funding contribution from Roche Molecular Systems USA. However, neither KC nor her institution on her behalf (Cancer Council NSW) receives direct funding from industry for this trial or any other project. All other authors declare no conflict of interest.

“Bubbling” the Fourth Age in the Time of COVID-19

“Bubbling” the Fourth Age in the Time of COVID-19

Lung cancer screening in Australia and New Zealand: the evidence and the challenge.

Lung cancer remains the commonest cause of cancer death in Australia and New Zealand. Targeted screening of individuals at highest risk of lung cancer aims to detect early stage disease, which may be amenable to potentially curative treatment. While current policy recommendations in Australia and New Zealand have acknowledged the efficacy of lung cancer screening in clinical trials, there has been no implementation of national programmes. With the recent release of findings from large international trials, the evidence and experience in lung cancer screening has broadened. This article discusses the latest evidence and implications for Australia and New Zealand.

Clinician-created Video for Patient Education on Medications Following Myocardial Infarction— The EDUCATE-MI Study Pilot Data

Coronary heart disease is the single leading cause of disease burden and death in Australia. The diagnosis of a myocardial infarction (MI) often causes patients anxiety and distress limiting their ability to retain information. Furthermore, the trend to shorter hospital stays can result in reduced opportunities for face-to-face clinician education regarding their new medications and secondary prevention.

Developing and piloting an adaptable oxycodone quality improvement strategy: steps towards opioid stewardship.

Objective In recent years, there have been considerable increases in both the utilisation and reported harms of prescription opioids in Australia. This report details the development of adaptable resources, implementation and the evaluation of pilot projects that optimise oxycodone prescribing and introduce concepts of opioid stewardship into hospital settings. Methods An adaptable suite of resources, based on principles of implementation science, was developed and used to facilitate the projects. Local prescribing practice audits of oxycodone guided the development of context-sensitive educational strategies that were piloted and evaluated in a repeat audit. The primary outcome was the proportion of oxycodone prescriptions indicating tailored prescribing practices. In emergency departments (EDs), a prescription was considered tailored if it was for ≤10 tablets. In surgery, tailored prescriptions were those given to patients who had required opioids in the 24h before discharge. Results Cumulative results of the pilot projects in three EDs demonstrated improved rates of tailored oxycodone prescribing on discharge (62% vs 90%; P<0.0001). In the surgical setting of one hospital, tailored prescribing increased significantly (from 76% to 91%; P=0.013) and was accompanied by a halving of the proportion of patients receiving oxycodone prescriptions (36% vs 18%; P<0.001). Conclusions The implementation of facilitated, adaptable, prescriber-led quality improvement projects significantly improved tailored oxycodone prescribing practices and provides a platform to advance further opioid-related practice improvement in Australia. What is known about the topic? The increasing trend in opioid prescribing, misuse, harm and death in Australia, and the potential for hospital prescribing to contribute to long-term opioid use, is well known. Recent changes to the Pharmaceutical Benefits Scheme are designed to help better identify patients who need oxycodone on discharge and the quantity to prescribe, rather than default prescribing. However, how to implement tailored prescribing has not been described in detail in the Australian literature. What does this paper add? This paper adds to the mass of literature describing the 'problem' of opioid prescribing by providing a 'solution' in the form of evidence for the implementation of a facilitated and adaptable quality improvement strategy in emergency and surgical settings. The focus is not on a reduction of opioids, but rather on providing tailored pain management and opioid prescribing. What are the implications for practitioners? This paper provides a practical, pragmatic and achievable starting point for other Australian practitioners to adapt the described processes and take the first steps towards opioid stewardship in their setting.

Can hospital doctors provide quality palliative care informed by end-of-life care legislation: An Australian perspective

Background and Aim: Approximately 50% of deaths in Australia occur in hospitals, and this number is growing. Studies consistently show that doctors have poor knowledge of end-of-life decision making; however, this has not been examined in specific groups of hospital doctors. We examined hospital doctors' knowledge of key elements of end-of-life care legislation. Materials and Methods: We conducted a prospective, observational, cross-sectional study of doctors from a large Australian public tertiary health network using six questions formulated on basic key elements of the legislation. Demographic data collected included years of work experience, clinical unit, and proportion of work hours spent with dying patients. Results: Of the 201 doctors censored, senior doctors (>10 years' experience) were the least knowledgeable group. Only approximately 20% of doctors correctly answered all questions. Thirty-two percent would potentially provide futile treatment if demanded by a competent patient. Fifty percent did not know how to locate an advance directive in the hospital record. There was confusion regarding the role of the substitute decision-maker. Conclusions: Approximately a quarter of hospital doctors practise with a poor understanding of the law over the various domains. The urgent call for education is further highlighted not only for students and junior doctors but also for senior doctors who scored poorly. Educational efforts could begin from addressing the simple key areas of legislation covered in the survey.

Developing a model of bereavement care in an adult tertiary hospital.

Objectives Hospitals are the most common place of death in Australia. Bereavement care is recognised by national standards as being central to providing high-quality care at the end of life, and has significant health implications on morbidity, mortality and health service usage. Despite this, bereavement care is not routinely or systematically provided in most Australian hospitals. This study aimed to develop a comprehensive, evidence-based model of bereavement care specific to the needs of an acute Australian adult tertiary hospital. Methods This study used a multiple-methods design, which included a scoping literature review, a survey of current institutional bereavement practices, interviews with bereaved family members and staff focus groups and the development of a model of bereavement care for the acute hospital service through advisory group and expert consensus. Results Staff and bereaved family members strongly supported a systematic approach to bereavement, perceiving the need for greater support, training, coordination and follow-up. In all, 10 core elements were developed to support a structured model of bereavement care provision and follow-up for the acute hospital organisation. Conclusions This evidence-generated model of care promotes the provision of quality and systematic bereavement care in the acute hospital setting. What is known about the topic? Acute hospitals are the most common place to die in Australia, yet there is a lack of understanding of how bereavement care is or should be provided in these environments. The bereavement period is associated with increased use of health services and worse morbidity and mortality, and thus has significant implications for public health. The provision of bereavement care in acute hospitals is often sporadic, often involving untrained staff who may not provide evidence-based care. What does this paper add? This paper describes the development of a comprehensive, evidence-based model of bereavement care specific to the needs of an Australian acute hospital. What are the implications for practitioners? Developing a consistent approach to bereavement for the acute care sector has the potential to support staff, minimise conflict at the end of life, facilitate recognition of those suffering from difficult bereavement and proactively engage services for these people. It is hoped that such a model of care can find relevance across acute hospitals in Australia, to improve the quality and consistency of bereavement care.