Queensland Public Hospitals Research Articles

Impact of COVID-19 state-wide lockdown on older adult presentations to Queensland emergency departments.

To determine the impact of the COVID-19 state-wide lockdown on ED presentations for older adults in Queensland, Australia. A retrospective cohort study pertaining to adults aged 70+ years who presented to Queensland public hospital EDs across three separate time periods; 11 March to 30 June 2018 and 2019 (pre-pandemic average), 2020 (COVID-19 state-wide lockdown) and 2021 (post-state-wide lockdown). The primary outcome was change in presentation rates to ED. Secondary outcomes included change in triage category rates, length of stay (LOS), diagnosis and disposition. There was 380 854 older adult presentations. During the COVID-19 state-wide lockdown, ED presentation rates decreased by 12.5% (incidence rate ratio 0.875 [95% confidence interval 0.867-0.883]). All triage category presentation rates decreased, as did ED LOS and reasons for presentation, except sepsis and disorders of the nervous system. In the post-state-wide lockdown period a 22% (incidence rate ratio 1.22 [95% confidence interval 1.21-1.23]) increase in the presentation rate was observed and presentations in all triage categories increased. ED LOS increased to longer than pre-pandemic (P < 0.001). Respiratory presentations increased by 346%. Patients who 'did not wait' increased by 212% and ED mortality rose by 42% compared to during the lockdown. There was a significant decrease in presentation rates to EDs during the COVID-19 state-wide lockdown for the older population, followed by an increase in presentation rates, longer ED LOS, and an increased ED mortality rate, in the post-state-wide lockdown period. It is important to ensure older adults continue to seek appropriate, timely medical care, during a pandemic.

Out-of-pocket fees for health care in Australia: implications for equity.

Out-of-pocket fees for health care in Australia: implications for equity.

Recognition and Management of Hospital-Acquired Sepsis Among Older General Medical Inpatients: A Multi-Site Retrospective Study.

To assess accuracy of early diagnosis, appropriateness and timeliness of response, and clinical outcomes of older general medical inpatients with hospital-acquired sepsis. Hospital abstracts of inpatient encounters from seven digital Queensland public hospitals between July 2018 and September 2020 were screened retrospectively for diagnoses of hospital-acquired sepsis. Electronic medical records were retrieved and cases meeting selection criteria and classified as confirmed or probable sepsis using pre-specified criteria were included. Investigations and treatments following the first digitally generated alert of clinical deterioration were compared with a best practice sepsis care bundle. Outcome measures comprised 30-day all-cause mortality after deterioration, and unplanned readmissions at 14 days after discharge. Of the 169 screened care episodes, 59 comprised probable or confirmed cases of sepsis treated by general medicine teams at the time of initial deterioration. Of these, 43 (72.9%) had no mention of sepsis in the differential diagnosis on first medical review, and only 38 (64%) were managed as having sepsis. Each care bundle component of blood cultures, serum lactate, and intravenous fluid resuscitation and antibiotics was only delivered in approximately 30% of cases, and antibiotic administration was delayed more than an hour in 28 of 38 (73.7%) cases. Early recognition of sepsis and timely implementation of care bundles are challenging in older general medical patients. Education programs in sepsis care standards targeting nurses and junior medical staff, closer patient monitoring, and post-discharge follow-up may improve patient outcomes.

Outpatient Letters in Real Time for Better Patient Outcomes

The Sunshine Coast Hospital and Health Service commenced a six-month proof-of-concept to trial speech recognition and self-type software in 2020. This action was taken in response to an ageing medical transcription workforce; an increase in outpatient letters due to population growth and the novel coronavirus pandemic; and more timely transfer of care communication to GPs. The proof-of-concept presented the health service with a unique opportunity as no other public hospital in Queensland had leveraged speech recognition or self-type software for the production and distribution of outpatient letters. The proof-of-concept trial provided 18 clinicians with the choice to type or dictate outpatient letters, electronically sign, and distribute to referring general practitioners (GPs) in one transaction. The results of the proof-of-concept demonstrated a 39% uptake of speech recognition and self-type software, demonstrating an opportunity to supplement the medical transcription workforce to address the rising outpatient activity. The proof-of-concept also demonstrated an average reduction in transaction time of 25% from the baseline measure over the six-month trial period. This finding supports the timely transfer of communication to GPs. However, it will need to be carefully analysed against the participant frustrations of voice to text accuracy to minimise the risk of poor adoption.

Emergency department presentations during the COVID-19 pandemic in Queensland (to June 2021): interrupted time series analysis.

To assess emergency department (ED) presentation numbers in Queensland during the coronavirus disease 2019 (COVID-19) pandemic to mid-2021, a period of relatively low COVID-19 case numbers. Interrupted time series analysis. All 105 Queensland public hospital EDs. Numbers of ED presentations during the COVID-19 lockdown period (11 March 2020 - 30 June 2020) and the period of easing restrictions (1 July 2020 - 30 June 2021), compared with pre-pandemic period (1 January 2018 - 10 March 2020), overall (daily numbers) and by Australasian Triage Scale (ATS; daily numbers) and selected diagnostic categories (cardiac, respiratory, mental health, injury-related conditions) and conditions (stroke, sepsis) (weekly numbers). During the lockdown period, the mean number of ED presentations was 19.4% lower (95% confidence interval, -20.9% to -17.9%) than during the pre-pandemic period (predicted mean number: 5935; actual number: 4786 presentations). The magnitudes of the decline and the time to return to predicted levels varied by ATS category and diagnostic group; changes in presentation numbers were least marked for ATS 1 and 2 (most urgent) presentations, and for presentations with cardiac conditions or stroke. Numbers remained below predicted levels during the 12-month post-lockdown period for ATS 5 (least urgent) presentations and presentations with mental health problems, respiratory conditions, or sepsis. The COVID-19 pandemic and related public restrictions were associated with profound changes in health care use. Pandemic plans should include advice about continuing to seek care for serious health conditions and health emergencies, and support alternative sources of care for less urgent health care needs.

Evaluation of a closed loop-blood sampling system in intensive care: A pilot randomised controlled trial. The ENCLOSE trial

To test the feasibility of conducting a randomised controlled trial to evaluate the impact of a closed-loop blood sampling system and blood conservation bundle. Single site, parallel group, pilot randomised control trial comparing open system sampling to closed system sampling and conservation bundle aligned with national guidelines. Randomisation sequence was generated by an independent statistician and allocation concealment maintained via sealed opaque envelopes. The study setting was the general intensive care unit of a major metropolitan public hospital in Queensland, Australia. Participants were≥18years who had an arterial catheter inserted in intensive care. Main outcome measures included trial feasibility, blood sample loss, haematocrit (HCT) change, and packed red blood cell transfusion use. Eighty patients were randomised (n=39 open group, n=41 closed group). Characteristics in each group were equal at baseline with overall median age 60years (IQR 48.6-70.4), 58% male, and median APACHE II score 16 (IQR 11-22). The proportion of patients eligible was 29% and missed eligible was 65%. Otherwise, feasibility criteria were met with proportion of eligible patients agreeing to enrolment 99%, 100% of patients receiving allocated treatment; only 1% of data missing. Analysis demonstrated a significant reduction in mean daily blood sample losses (open 32.7 (SD 1.58) mL vs closed 15.5 (SD 5.79) mL, t =-8.454, df=78, p<0.001). A large, multi-site trial is feasible with enhanced eligibility criteria, increased recruitment support. The intervention reduced daily blood sample volumes and transfusion use. Further trials are required to provide both effectiveness and implementation outcomes.

Efficient algorithms for real-time syndromic surveillance

ObjectiveOutbreaks of influenza-like diseases often cause spikes in the demand for hospital beds. Early detection of these outbreaks can enable improved management of hospital resources. The objective of this study was to test whether surveillance algorithms designed to be responsive to a wide range of anomalous decreases in the time between emergency department (ED) presentations with influenza-like illnesses provide efficient early detection of these outbreaks. MethodsOur study used data on ED presentations to major public hospitals in Queensland, Australia across 2017–2020. We developed surveillance algorithms for each hospital that flag potential outbreaks when the average time between successive ED presentations with influenza-like illnesses becomes anomalously small. We designed one set of algorithms to be responsive to a wide range of anomalous decreases in the time between presentations. These algorithms concurrently monitor three exponentially weighted moving averages (EWMAs) of the time between presentations and flag an outbreak when at least one EWMA falls below its control limit. We designed another set of algorithms to be highly responsive to narrower ranges of anomalous decreases in the time between presentations. These algorithms monitor one EWMA of the time between presentations and flag an outbreak when the EWMA falls below its control limit. Our algorithms use dynamic control limits to reflect that the average time between presentations depends on the time of year, time of day, and day of the week. ResultsWe compared the performance of the algorithms in detecting the start of two epidemic events at the hospital-level: the 2019 seasonal influenza outbreak and the early-2020 COVID-19 outbreak. The algorithm that concurrently monitors three EWMAs provided significantly earlier detection of these outbreaks than the algorithms that monitor one EWMA. ConclusionSurveillance algorithms designed to be responsive to a wide range of anomalous decreases in the time between ED presentations are highly efficient at detecting outbreaks of influenza-like diseases at the hospital level.

Understanding the Digital Disruption of Health Care: An Ethnographic Study of Real-Time Multidisciplinary Clinical Behavior in a New Digital Hospital.

Understanding electronic medical record (EMR) implementation in digital hospitals has focused on retrospective "work as imagined" experiences of multidisciplinary clinicians, rather than "work as done" behaviors. Our research question was "what is the behavior of multidisciplinary clinicians during the transition to a new digital hospital?" The aim of the study is to: (1) Observe clinical behavior of multidisciplinary clinicians in a new digital hospital using ethnography. (2) Develop a thematic framework of clinical behavior in a new digital hospital. The setting was the go-live of a greenfield 182-bed digital specialist public hospital in Queensland, Australia. Participants were multidisciplinary clinicians (allied health, nursing, medical, and pharmacy). Clinical ethnographic observations were conducted between March and April 2021 (approximately 1 month post-EMR implementation). Observers shadowed clinicians in real-time performing a diverse range of routine clinical activities and recorded any clinical behavior related to interaction with the digital hospital. Data were analyzed in two phases: (1) content analysis using machine learning (Leximancer v4.5); (2) researcher-led interpretation of the text analytics to generate contextual meaning and finalize themes. A total of 55 multidisciplinary clinicians (41.8% allied health, 23.6% nursing, 20% medical, 14.6% pharmacy) were observed across 58 hours and 99 individual patient encounters. Five themes were derived: (1) Workflows for clinical documentation; (2) Navigating a digital hospital; (3) Digital efficiencies; (4) Digital challenges; (5) Patient experience. There was no observed harm attributable to the digital transition. Clinicians primarily used blended digital and paper workflows to achieve clinical goals. The EMR was generally used seamlessly. New digital workflows affected clinical productivity and caused frustration. Digitization enabled multitasking, clinical opportunism, and benefits to patient safety; however, clinicians were hesitant to trust digital information. This study improves our real-time understanding of the digital disruption of health care and can guide clinicians, managers, and health services toward digital transformation strategies based upon "work as done."

Hospital nurses' management of agitation in older cognitively impaired patients: do they recognise pain-related agitation?

cognitively impaired hospital patients often experience agitation and aggression due to pain. Agitation complicates care, increasing the risk of adverse outcomes and patient-to-nurse violence. Managing agitation is challenging for nurses. Literature suggests they may rely on antipsychotics while missing other more appropriately targeted treatments. However, nurses' management of agitation remains unclear and under-researched. the aim of this study was to investigate hospital nurses' management of agitation in older cognitively impaired patients with pain. this was a descriptive correlational study using virtual simulation. a total of 274 registered medical and surgical nurses from 10 public hospitals in Queensland, Australia participated in the study. nurses undertook a virtual simulation requiring them to manage agitation in a patient with dementia and an injury. Nurses also completed a post-simulation questionnaire. Their simulation performances were correlated with demographics such as seniority, workplace, training, experience and gerontology-specific knowledge. Constructed from an original, validated vignette, the simulation included branching pathways, video scenarios and an avatar that could converse with participants. thirteen nurses (4.7%) recognised and treated the virtual patient's agitation as pain-related. Most nurses (89%) gave antipsychotics of which 207 (78%) gave these first-line and 102 (38%) used them twice. Independent of other variables, nurses most likely to diagnose pain were dementia-unit nurses (OR = 8.7), surgical-unit nurses (OR = 7.3) and senior nurses (OR = 5). hospital nurses predominately managed agitation with antipsychotics, a decision that most made after undertaking inadequate patient assessments. This confirmed a common gap in practice that may lead to the missing of pain in the clinical care of agitated patients with dementia and/or delirium.

Patient and Staff Perceptions on Using Bioelectrical Impedance Analysis in an Outpatient Haemodialysis Setting: A Qualitative Descriptive Study.

Bioelectrical impedance analysis (BIA) is an objective hydration and body composition assessment method recommended for use in haemodialysis patients. Limited research exists on the acceptability and utility of BIA in clinical practice. This qualitative study explored patient and staff acceptability and perceived value of BIA in an outpatient haemodialysis setting at a tertiary public hospital in Queensland, Australia. Participants included five patients receiving outpatient haemodialysis and 12 multidisciplinary clinical staff providing care to these patients. Semi-structured interviews were employed and data were analysed thematically. Patients were satisfied with the BIA measurement process and most thought the BIA data would be useful for monitoring changes in their nutrition status. Clinical staff valued BIA data for improving fluid management, assessing nutrition status and supporting patient care. Staff recommended targeting BIA use to patient groups who would benefit the most to improve its uptake in the haemodialysis setting. Conclusions: BIA use in the outpatient haemodialysis setting is acceptable and provides valuable objective data to support health-related behaviour changes in patients and enhance clinical practice. Implementation of BIA should be tailored to the local context and staff should be supported in its use.

Analysing triggers for anti-NMDA-receptor encephalitis including herpes simplex virus encephalitis and ovarian teratoma: results from the Queensland Autoimmune Encephalitis cohort.

Anti-N-methyl-D-aspartate-receptor (anti-NMDA-R) encephalitis is a complex autoimmune neuropsychiatric syndrome. Although initially associated with ovarian teratoma, subsequent studies have demonstrated that anti-NMDA-R encephalitis may occur without an identifiable cause or be triggered by viral infection of the central nervous system such as herpes simplex virus encephalitis (HSVE). To present details from a Queensland cohort analysing triggering events in patients with anti-NMDA-R encephalitis in an Australian context. The authors identified patients with anti-NMDA-R encephalitis diagnosed and managed through public hospitals in Queensland, Australia, between 2010 and the end of 2019. Data collected included demographics, clinical presentation, investigation results, management and outcome measurements. Thirty-one cases of anti-NMDA-R encephalitis were included in the study. Three cases of anti-NMDA-R encephalitis were triggered by prior HSVE, five cases were associated with ovarian teratoma and 23 cases had no identifiable trigger. There were an additional three cases in which anti-NMDA receptor antibodies were present in the context of other disease states but where the patient did not develop anti-NMDA-R encephalitis. Cases triggered by HSVE or associated with ovarian teratoma experienced a more severe disease course compared to cases with no identifiable trigger. All groups responded to immunosuppressive or immunomodulatory therapy. Analysis of clinical characteristics revealed a complex heterogeneous syndrome with some variability between groups. In this cohort, the number of cases of anti-NMDA-R encephalitis triggered by HSVE is comparable to those triggered by ovarian teratoma. However, the majority of cases of anti-NMDA-R encephalitis had no identifiable trigger or associated disease process.

Epidemiology of ascites fluid infections in patients with cirrhosis in Queensland, Australia from 2008 to 2017: A population-based study.

Spontaneous bacterial peritonitis (SBP), a common infection in patients with cirrhosis and ascites, is associated with high morbidity and mortality. The aim of this study was to investigate changes in the epidemiology of ascites fluid infections over time in an Australian population, including patient demographics, trends in mortality, length of hospital stay and the nature and antibiotic resistance profile of causative organisms.An observational descriptive population-based epidemiological study of patients with cirrhosis admitted to public hospitals in Queensland during 2008–2017 was performed, linking demographic/clinical and microbiology data.Among 103,165 hospital admissions of patients with cirrhosis, ascites was present in 16,550 and in 60% (9977) a sample of ascitic fluid was tested. SBP was diagnosed in 770 admissions (neutrophil count >250/ml) and bacterascites in 552 (neutrophil count <250/ml with positive culture). The number of admissions with an ascites fluid infection increased by 76% from 2008 to 2017, paralleling an 84% increase in cirrhosis admissions over the same timeframe. Patients with SBP had a longer hospital stay (median 15.7 vs 8.3 days for patients without SBP, P < .001) and higher in-hospital mortality, although this decreased from 39.5% in 2008 to 2010 to 24.8% in 2015 to 2017 (P < .001). Common Gram-positive isolates included coagulase negative staphylococci (37.9%), viridans group streptococci (12.1%), and Staphylococcus aureus (7.2%). Common Gram-negative isolates included Escherichia coli (13.0%), Klebsiella pneumoniae (3.1%) and Enterobacter cloacae (2.6%). The prevalence of resistance to any tested antibiotic was <10%.SBP remains associated with high in-hospital mortality and long hospital stay. Typical skin and bowel pathogens were common, therefore, empirical antibiotic therapy should target these pathogens. This study provides valuable evidence informing infection management strategies in this vulnerable patient population.

Nurses’ and patients’ perceptions on interruptions on admission processes at an acute public hospital using cross-sectional survey

ProblemAdmissions are a critical component of patient care. However, nurses get interrupted during care provision. There is limited understanding of the dynamics regarding interruptions during admission and their effect. AimTo ascertain how often and why interruptions occurred; and whether these impacted patients. MethodsThe cross-sectional survey study took place in the hospital of a 327-bed regional acute public hospital in Queensland, Australia, during July 2020. Nurses completed a survey asking about the admissions and interruptions they had encountered. Patients completed a survey asking about their perceptions of admissions and interruptions during the admission process. FindingsNurses across five units completed 171 surveys, and patients completed 55 surveys. There was no statistical difference in interruptions per hour between admissions of 15-44 min, 45 min to 1 h 15 min, and over 1 h 15 min. When the admissions with and without interruptions were compared, the ‘interrupted’ group had a median admission time of 50 min (interquartile range 35−75), and the ‘non-interrupted' group was 30 min (20-39) (p < 0.01). Nurses identified three themes of what could be improved to streamline admission processes: Simpler admission paperwork, admission timing and process, and emergency department input on admission documentation. Overall, patients were satisfied with the admission process. Patients' satisfaction was not impacted by the interruptions. ConclusionWhile nurses reported that admission processes were repetitive and could be simplified, patients were not concerned with the interruptions during admission in our study. However, future research with robust measures is required.

The financial burden of complications of overseas breast implants at the Royal Brisbane and Women's Hospital

Introduction: An increasing number of Australians are travelling overseas for aesthetic surgery. This study aims to establish the financial costs of complications arising from overseas inserted breast implants. Method: Data from the Australian Breast Device Registry (ABDR) on patients who have undergone removal of overseas inserted implants at the Royal Brisbane and Women’s Hospital from October 2014 to October 2019 was analysed. Financial costs were calculated using electronic medical records and discharge codes. Results: Of the 331 cases of implant removals recorded, only eight (2.4%) were from overseas inserted devices. Seven of these were performed as emergency procedures. Two patients required more than one operation. Length of stay (LOS) ranged from two to 28 days with a median LOS of 8.6 days. Most patients had multi-disciplinary team involvement with infectious diseases being the most consulted specialty. All patients required in-hospital IV antibiotic therapy and dressing changes. All were offered more than one out patient follow-up appointment. The total cost to our department surpassed AU$110,000 which represents four per cent of the total hospital spending on breast device explantations. Conclusion: Surgical complications from overseas implant procedures cost a small percentage of the hospital budget for breast procedures. However, with the increasing popularity of cosmetic tourism, this figure could increase in the following years. We can use this information to educate individuals on making better choices while potentially reducing the financial burden to public hospitals in Queensland.

Syndromic surveillance to detect disease outbreaks using time between emergency department presentations.

Early warning of disease outbreaks is paramount for health jurisdictions. The objective of the present study was to develop syndromic surveillance monitoring plans from routinely collected ED data with application to detecting disease outbreaks. The study involved secondary data analysis of ED presentations to major public hospitals in Queensland and South Australia spanning 2017-2020. Monitoring plans were developed for all major Queensland and South Australian public hospitals using an adaptation of Exponentially Weighted Moving Averages - a process control method used in detecting anomalies in industrial production processes. The methods rely on setting a threshold (control limit) relating to the time between an event of interest (e.g. flu outbreak) using ED presentations as a signal to monitor. An outbreak is flagged as this time gets significantly smaller, and each event offers a decision point on whether an outbreak has occurred. The models incorporate differing levels of temporal memory to cover outbreaks of different sizes. The novel approach to real-time outbreak detection indicates outbreaks for individual hospitals coinciding with the first wave of the COVID-19 outbreak in Queensland and South Australia as well as the large 2017 and 2019 influenza seasons. Outbreak detection models demonstrate the ability to quickly flag an outbreak based on clinician-assigned ED diagnoses. An implemented syndromic surveillance approach can pick up geographic outbreaks quickly so they can be contained. Such capability can help with surveillance related to the current COVID-19 pandemic and potential future pandemics.

Australian nurses' perceptions about workplace violence management, strategies and support services.

This study ascertained nurses' perceptions about workplace violence management, strategies and support services. Nurses regularly encounter verbal and physical violence in their workplace. Workplace violence has long-term consequences on nurses' personal lives and professional work ability. However, more needs to be known about nurses' perceptions of violence management and interventions used. Ninety-eight nurses from a regional public hospital in Queensland, Australia, completed a survey about workplace violence. Nurses worked in the Emergency Department, Intensive Care Unit or Mental Health Department. Ninety-five per cent of nurses stated that all violence should be reported, but 18% would take no action, and 22% would not complete an incident from. Perceptions and preferred responses differed for verbal and physical violence. Low-level interventions and aggression management training were preferred by nurses. Nearly all nurses felt that they should be involved in the development of workplace violence policies. Nurses rate aggression management training highly, and they desire more input into violence policies. The under-reporting of violent incidents remains an issue for future management. Understanding nurses' perceptions of workplace violence management enables the identification of gaps when applying policy and adopting practical approaches to reduce the incidence and severity of workplace violence.

Impact of 1-hour and 3-hour sepsis time bundles on patient outcomes and antimicrobial use: A before and after cohort study

SummaryBackgroundSepsis bundles, promulgated by Surviving Sepsis Campaign have not been widely adopted because of variability in sepsis identification strategies, implementation challenges, concerns about excess antimicrobial use, and limited evidence of benefit.MethodsA 1-hour septic shock and a 3-hour sepsis bundle were implemented using a Breakthrough Series Collaborative in 14 public hospitals in Queensland, Australia. A before (baseline) and after (post-intervention) study evaluated its impact on outcomes and antimicrobial prescription in patients with confirmed bacteremia and sepsis.FindingsBetween 01 July 2017 to 31 March 2020, of 6976 adults presenting to the Emergency Departments and had a blood culture taken, 1802 patients (732 baseline, 1070 post-intervention) met inclusion criteria. Time to antibiotics in 1-hour 73.7% vs 85.1% (OR 1.9 [95%CI 1.1-3.6]) and the 3-hour bundle compliance (48.2% to 63.3%, OR 1.7, [95%CI 1.4 to 2.1]) improved post-intervention, accompanied by a significant reduction in Intensive Care Unit (ICU) admission rates (26.5% vs 17.5% (OR 0.5, [95%CI 0.4 to 0.7]). There were no significant differences in-hospital and 30-day post discharge mortality between the two phases. In a post-hoc analysis of the post-intervention phase, sepsis pathway compliance was associated with lower in-hospital mortality (9.7% vs 14.9%, OR 0.6, 95%CI 0.4 to 0.8). The proportions of appropriate antimicrobial prescription at baseline and post-intervention respectively were 55.4% vs 64.1%, (OR 1.4 [95%CI 0.9 to 2.1]).InterpretationImplementing 1-hour and 3-hour sepsis bundles for patients presenting with bacteremia resulted in improved bundle compliance and a reduced need for ICU admission without adversely influencing antimicrobial prescription.

Disparities in Unmet Needs in Indigenous and Non-Indigenous Australians with Cirrhosis: An Exploratory Study.

PurposeUnderstanding and responding to the supportive care needs of people with cirrhosis is essential to quality care. Indigenous Australians, Aboriginal and Torres Strait Islander people, are overrepresented amongst patients with cirrhosis. This study documented the nature and extent of supportive care needs of Indigenous Australians with cirrhosis, in comparison with non-Indigenous Australians.Patients and MethodsThe supportive care needs of adult patients diagnosed with cirrhosis attending public hospitals in Queensland were assessed through the Supportive Needs Assessment tool for Cirrhosis (SNAC). Patients indicated how much additional help they needed on four subscales: 1. psychosocial issues; 2. practical and physical needs; 3. information needs; and 4. lifestyle changes. We examined the rate of moderate-to-high unmet needs based on Indigenous status (Poisson regression; incidence rate ratio (IRR)).ResultsIndigenous (n=20) and non-Indigenous (n=438) patients included in the study had similar sociodemographic and clinical characteristics except for a lower educational level among Indigenous patients (p<0.01). Most Indigenous patients (85.0%) reported having moderate-to-high unmet needs with at least one item in the SNAC tool. Following adjustment for key sociodemographic and clinical factors, Indigenous patients had a greater rate of moderate-to-high unmet needs overall (IRR=1.5, 95% CI 1.31–1.72; p<0.001), and specifically for psychosocial issues (IRR=1.7, 95% CI 1.39–2.15; p<0.001), and practical and physical needs subscales (IRR=1.5, 95% CI 1.22–1.83; p<0.001), compared to non-Indigenous patients.ConclusionIndigenous Australians with cirrhosis more frequently had moderate-to-high unmet supportive care needs than non-Indigenous patients. Specific targeting of culturally appropriate supportive care for psychosocial, practical and physical needs may optimize cirrhosis care and improve the quality of life for Indigenous Australians with cirrhosis.

Unnecessary removal of vascular access devices due to suspected infection in Australian intensive care units

BackgroundVascular access devices suspected of infection are often removed unnecessarily and frequently require replacement. The aim of this study was to identify the prevalence and economic impact of premature, unnecessary device removal due to suspected infection in adult patients admitted to the intensive care unit. MethodsSecondary data analysis of a prospectively collected data set detailing central venous catheters and peripheral arterial catheters in 1458 adult patients was conducted in nine Australian intensive care units. Data extracted from the parent database included patient demographics, device, and infection-specific data including the reason for device removal. Cost estimates were based on a recently published review of device utilisation and associated costs in Queensland public hospitals. ResultsA total of 6144 central venous catheter days and 4696 arterial catheter days were studied. Median device dwell time was 7.2 (interquartile range: 5.6–9.0) days for central venous catheters and 6.5 (interquartile range: 4.8–8.5) days for arterial catheters. Device removal due to suspected infection occurred at a rate of 25.7 and 15.3 episodes/1000 catheter days in central venous and arterial catheters, respectively. Central venous and arterial catheter–related bloodstream infections occurred at a rate of 1.8 and 0.2 episodes/1000 catheter days, respectively. Central line–associated bloodstream infection occurred at a rate of 3.3 episodes/1000 catheter days. Local central venous and arterial catheter infection occurred at 0.16 and 0.02 episodes/1000 catheter days, respectively. The difference in incidence between devices suspected of infection and those responsible for infection resulted in AUD$67,087 unnecessarily spent on device replacement. ConclusionsUnnecessary device removal due to suspected infection presents a substantial clinical problem which is costly for the healthcare organisation and time-consuming for clinicians and places the patient at an increased risk of iatrogenic complications. There is a need for robust evidence and clinical practice guidelines to inform clinical decision-making to reduce unnecessary device removal.

Multi-incident analysis of reviews of serious adverse clinical events in children with serious bacterial infection and/or sepsis in Queensland, Australia between 2012 and 2017.

To report on findings from a multi-incident analysis of reviews of serious paediatric adverse clinical events related to serious bacterial infection and/or sepsis (hereafter referred to as sepsis for brevity) in Queensland, Australia, between 2012 and 2017. The Queensland Paediatric Quality Council reviewed documentation from reviews of serious adverse events occurring in children (<18 years) with a diagnosis of sepsis at Queensland public hospitals between 2012 and 2017, including clinical details, coronial reports, autopsy reports and root cause analysis documents. A multi-incident tool was designed and used by an expert panel to identify patient and facility demographics, contributing factors, and human and system factors associated with paediatric serious adverse events. There were 28 serious adverse clinical events reported related to paediatric sepsis, characterised by a high proportion of deaths (23) and a predominance of children aged under 4 years. Approximately half of all facilities were classified as rural and remote health services. Contributing factors included difficulty in recognising and responding to the deteriorating patient, inadequate management/treatment, diagnostic error (mainly diagnostic delay) and escalation delay/failure. Major system factors included communication issues, incorrect use of the early warning tool, inadequate coordination of care planning, policy/protocol/guideline failures and workforce problems. Multi-incident analysis is a useful tool for identifying themes that recur in similar events and presents opportunities for system-wide improvement. Common themes and contributing factors were identified which may provide possibilities for earlier identification and intervention in childhood serious bacterial infection and/or sepsis.