State-wide Service Research Articles

A Qualitative Evaluation of Health Professionals’ Perceptions State-wide Outreach Perinatal Mental Health Service

A Qualitative Evaluation of Health Professionals’ Perceptions State-wide Outreach Perinatal Mental Health Service

How emergency departments are responding to the opioid crisis: Results from a statewide survey in Kentucky

ObjectiveThere is a rising effort for hospital emergency departments (EDs) to offer and expand substance use disorder (SUD) services. This state-wide evaluation studies SUD services offered along the continuum of implementation across Kentucky’s EDs to inform future state efforts to build ED bridge programs.MethodsWe conducted a mixed-methods study using an online survey of all Kentucky Emergency Department Directors between January and May of 2023. We created a hospital-level dataset which we used to summarize quantitative questions and thematically analyze open-ended responses.ResultsOur sample included 85 unique respondents (89% of all eligible Kentucky hospitals). Nine (11%) had active bridge programs to initiate opioid use disorder patients on buprenorphine. Respondents reported that the most challenging SUD-related services for EDs to implement were buprenorphine induction for opioid use disorder treatment (n = 36, 42%), referrals to community-based providers (n = 34, 40%), and providing social work services (n = 25, 29%). Respondents noted that the implementation and improvement of screening protocols were needed to better identify patients with SUD, expressed concerns about care continuity, and explicitly conveyed the need and desire for additional supports to provide SUD care.ConclusionsThe landscape of Kentucky’s ED SUD supports shows several hospitals that offer services along the continuum of SUD care, and highlights the importance of technical assistance and financial resources to ensure the continuum is broadly available. Kentucky’s experience speaks to broader national challenges in supporting SUD in EDs – specifically the need for financial resources, buy-in and education, and creating referral relationships to ensure care continuity.

The uptake and utility of a reflective practice group for psychiatry registrars in a state-wide forensic service.

It is essential that mental health clinicians have access to reflective processes where they may understand and make sense of emotional responses to patients, teams, and organisations. The authors share their experience of initiating and successfully running a reflective practice group, framed with Balint principles, for psychiatry registrars working in forensic settings across Victoria. We describe the process of setting up a Balint group for this professional population. Qualitative feedback was obtained from group members. The data was analysed thematically, regarding motivating factors for group attendance and feedback post pilot group. Overall, feedback on the pilot Balint group was positive, which led to the group being extended for recurring 6-month periods. We share an illustrative example of a complex case which could be formulated in a forensic psychiatry Balint group setting, alongside reflections of the facilitators of the group. Reflection is paramount for safe, effective mental health treatment, particularly in the context of forensic psychiatry. Our pilot results highlight areas where the approach of setting up a fledgling Balint group has been successful. We hope to inspire others to engage and participate in routine reflective practice.

#1377 Evaluation of state-wide health system implementation of renal supportive care shows substantial net benefits

Abstract Background and Aims In 2016, the New South Wales (NSW) Health system implemented a service to make the principles and practice of palliative medicine comprehensively available to patients receiving chronic kidney disease (CKD) care across NSW. Summative evaluation of the economic value that this multi-disciplinary State-wide RSC service provided following implementation was prospectively planned in the domains of patient experience and economic value. This abstract reports the first cost-benefit analysis of a RSC service. Method De-identified patient-level data was extracted from the NSW Renal Supportive Care Register (a linked dataset comprising admitted patient, non-admitted patient, emergency department episodes and death registrations). Data was compared between 2015/16, prior to implementation of the State-wide RSC service; and 2018/19, following settled operation of the service. A cost-benefit analysis model was constructed to estimate the economic value of the RSC service between 2015/16 and 2018/19; and the projected value to 2029/30 under different scenarios. Multivariate Cox regressions were estimated to measure survival benefits, and a polynomial regression model was employed to estimate the impact of RSC on the share of patients receiving dialysis. Results Considering the actual impact of the NSW RSC service; in 2015/16, 5% (n = 443) of all ESKD patients, (defined as receiving dialysis >3 months, non-dialysis conservative care or in receipt of a functioning transplant) received any RSC service. By 2018/19, 16% (n = 1460) of all ESKD patients had received RSC within NSW. The proportion of patients receiving RSC from a non-dialysis conservative care or dialysis context remained stable between 2015/16 and 2018/19 at 41% and 29% respectively. Patients receiving RSC were estimated to have increased survival by 3-21 weeks, depending on patient characteristics, compared to the scenario of no RSC service. Considering the projected value of ongoing RSC services; scenarios with different assumptions were modelled. Assuming that the proportion of patients receiving different ESKD modalities and the costs of care remained stable, the RSC service would deliver a net financial benefit to the commissioning health system (avoided costs of service minus RSC costs) of ${\$}$109 million Australian Dollars (AUD), with a return on investment of 212%, compared to the scenario of no RSC service. When the economic value for the whole NSW community from increased survival benefit was included, the projected value was ${\$}$275 million AUD, with return on investment of 535%. The projected economic value of RSC was modelled under scenarios of increasing access to the service by ESKD patients (Figure). Increasing RSC access from the achieved 16% to 20% of ESKD patients was projected to deliver maximal economic value, with a 3% fall in ESKD patients receiving dialysis, increasing survival benefit (${\$}$221 million AUD) and economic value ${\$}$94 million AUD. As access to RSC expands further, modelling indicates that additional dialysis substitution becomes less likely but benefits still accrue from survival up to a maximum viable rollout of 50% of the ESKD population receiving RSC, when survival benefits plateau. Conclusion Economic evaluation of this implementation of the Statewide RSC service across NSW Health shows it has been associated with both a net economic benefit and survival benefits four years after implementation. It is projected to provide an economic value of ${\$}$275 million AUD over ten years, which would increase with greater participation of ESKD patients suitable for RSC.

Timepoint for return to occupations post-burn injury using the Canadian Occupational Performance Measure (COPM).

The Canadian Occupational Performance Measure (COPM) was implemented at a state-wide burns service to ensure compliance with current best evidence as outlined by the Australian and New Zealand Burns Association 'burn trauma rehabilitation: allied health practice guidelines'- Chapter 7 Measuring Post-Burn Recovery, as a standard outcome measure for individuals with an admission time greater than 24 h. The primary aim of this study is to determine if individuals have a minimal important change in performance and satisfaction with activities that were identified as problematic on the COPM prior to their acute discharge. Previous research confirmed the feasibility of using the COPM in the acute burn ward and recommended the most appropriate timepoint for re-measurement be confirmed, which is the secondary objective of this study. The benefits of confirming this timepoint include ensuring efficient use of clinicians' time without compromising the accuracy of the assessment and ensuring effective translation of the guidelines' recommendation. A prospective longitudinal study was undertaken, where all individuals who previously completed a COPM prior to acute discharge were sought to complete a re-assessment while accessing outpatient services. Time frames for re-assessment were open. Only individuals who were actively receiving occupational therapy outpatient services were included. COPM assessments were completed in person where possible, particularly for participants who required an interpreter, with phone and video calls also used when needed. A total of 37 participants were included, with the timeframe between initial and post-COPM assessment ranging from 2 to 643 days. Outcomes plateaued at approximately 12 months (365 days) post-initial measurement (prior to discharge from acute ward). The most common occupational performance goals that participants identified were returning to work, sport, and driving. 86.5% of participants increased their satisfaction with these activities. The results of this study demonstrate improvements across the domains of performance and satisfaction occur for individuals with burns at approximately 3 months and 12 months post-injury. Based on this study, it is suggested that when using the COPM assessment in a tertiary burn setting, re-measurement be completed no earlier than 3months and later than 12 months from burn injury, or upon discharge from the service. The findings from this study will be translated into clinical practice at this facility.

To what extent are guidelines used in spasticity clinics? A qualitative study of facilitators and barriers to spasticity guideline implementation

Objective To determine the common understanding of focal muscle spasticity guidelines amongst clinicians working in spasticity clinics. To examine the facilitators and barriers to their implementation as well as their influence on clinic processes. Design A qualitative study based on a phenomenological approach. Setting Online videoconferencing platform. Participants Sixteen experienced multi-disciplinary clinicians providing specialised care across 12 spasticity clinics in Victoria, Australia. Intervention Observational. Main measures Two independent reviewers performed line by line coding of transcripts. Reflexive thematic analysis was undertaken with themes/subthemes inductively derived. Results Seven key themes emerged. First, knowledge of specific guideline recommendations was low amongst some clinicians. Second, there is a lack of health service resources to support guideline implementation. Third, a limited evidence base for guidelines affected clinicians’ willingness to implement the recommendations. Fourth, peer support was highly valued but opportunities to collaborate were limited. Fifth, a large amount of intrinsic motivation and personal time was required from clinicians to successfully implement guideline recommendations. Sixth, the standardisation of clinic processes was one way in which clinicians felt they could better align their clinical practice to guidelines. Lastly, guidelines overall had a moderate influence on spasticity clinic processes. Conclusions Knowledge of recommendations varied but, overall, guidelines had an influence on clinic processes and staff perceptions across the state-wide services. Health service resources, limited evidence for guideline recommendations and time constraints were considered barriers to spasticity guideline implementation. Multi-disciplinary expertise and teamwork, the individual's motivation to change and inter-clinic collaboration were considered to be the facilitators.

Promoting mental well-being in Western Australia: Act Belong Commit® mental health promotion campaign partners' perspectives.

The Act Belong Commit® mental health promotion campaign aims to improve population mental well-being. Based on a social-franchising model, partnerships are sought with organizations offering 'mentally healthy activities' that foster social connectedness and mental well-being. There are four categories of partner organizations sought: Site (government agencies and health services), Associate (organizations with state-wide or national services), Community (local, grass-roots community groups) and Schools. This research explored organizational perceptions of the Act Belong Commit® Partnership Program. A purposive sample of 14 organizational representatives across all four partner categories participated in semi-structured interviews online or face-to-face between July and September 2021. Reflexive thematic analysis was used to identify three main themes: (a) A passion for promoting mental health; (b) Implementation, innovation, adaption and creation (e.g. the ability to adapt, create and deliver activities aligned with the campaign message; and (c) Future sustainability (e.g. recommendations for the sustainability of the programme). The use of reflexive thematic analysis enabled deeper insights into the complexity of the partnerships. Findings describe how the Act Belong Commit® Partnership Program supports mutually desirable objectives and extends the campaign reach. Embedded in a shared belief system that incorporates a passion for good mental health, the model supports the flexibility to adapt, create and deliver fit-for-purpose activities that promote mental well-being in the places where people live, work and play.

Total versus Partial Workplace Tobacco Use Bans in Texas Behavioral Health Centers and their Associations with Employees' Report of Clear Signage, Policy Enforcement, Policy Awareness, and Their Beliefs, Training, and Practices Conducive to Addressing Clients' Tobacco Use.

Adults with behavioral health needs exhibit elevated tobacco use rates. Tobacco-free workplace policies (TFWPs) at behavioral health treatment centers can effectively curb clients' tobacco use and secondhand smoke/vape exposure. However, there is little extant observational research about how total versus partial workplace tobacco use bans are associated with employee's perceptions of signage clarity, consistency of enforcement, and stakeholders' policy awareness in behavioral health centers. Additionally, little is understood about the relations of total or partial TFWPs with other factors that may affect evidence-based client care provision including employees' beliefs and their tobacco treatment practices. This study examined these associations within Local Mental Health Authorities (LMHAs) providing behavioral healthcare throughout Texas. Employees from 30 of 39 LMHAs (covering >75% of Texas' statewide service area) responded to a 2021 survey on their TFWP characteristics, communication, awareness, enforcement, and other tobacco-related factors. Associations between the TFWP (total vs partial) and variables of interest were explored using independent proportions tests (p<0.10). Relative to their counterparts, LMHAs with total TFWPs reported clearer signage; more consistent enforcement; and greater client, contractor, and visitor awareness (ps=.013-.078). They were also more likely to offer tobacco screening training, promote the Quitline, and believe in the benefits of concurrent treatment of behavioral health needs and tobacco use (ps=.024-.079). LMHAs with partial TFWPs had weaknesses in communication, enforcement, awareness, and greater barriers to tobacco use care provision. There are opportunities for collaboration between LMHAs to share policies and care-facilitation practices to reduce the research-to-practice gap and resultant tobacco use inequities statewide.

Long term follow up and outcomes of Covid-19 vaccine associated myocarditis in Victoria, Australia: A clinical surveillance study

BackgroundMyocarditis and myopericarditis are well described adverse events of special interest (AESI) following COVID-19 vaccinations. Although reports are reassuring regarding initial clinical outcomes, information about longer term outcomes remains limited. We aimed to further this knowledge and report outcomes to 6 months post diagnosis from a single population cohort. MethodsReports of myocarditis following COVID-19 vaccination were followed up by SAEFVIC (Surveillance of Adverse Events Following Vaccination in the Community), the state-wide vaccine safety service for Victoria, Australia. Confirmed myocarditis cases (Brighton Collaboration Criteria levels 1–3) were followed up via surveys at 1, 3 and 6 months post symptom onset. Responses received between 22 February 2021 and 30 September 2022 were analysed. Results87.5 % (N = 182) of eligible participants completed at least 1 survey report. 377 reports were analysed. 76.9 % of completed reports were from male patients. The median age of patients was 21 years [IQR: 16 to 32].54.8 % (n = 74) of survey reports at 6 months, reported ongoing symptoms. At all follow-up time points, females were significantly more likely to have ongoing symptoms. At 6 months, 51.9 % of male respondents reported symptom resolution compared to 22.6 % of female patients (p = 0.002). Females were also more likely to continue medication and have ongoing exercise restrictions. However, males were significantly more likely to have higher initial peak troponin results and abnormal initial cardiac imaging investigations. ConclusionsThere appears to be a significant proportion of patients who experience ongoing symptoms to 6 months post onset amongst patients that experience these AESI. Male patients were more likely to report earlier and more complete symptom recovery, despite significantly higher average initial peak troponin. This difference in phenotypic presentation in females compared to males warrants further investigation and there is a need for longer term follow up data.

Scale-up of Direct-Acting Antiviral Treatment in Prisons Is Both Cost-effective and Key to Hepatitis C Virus Elimination.

The Surveillance and Treatment of Prisoners With Hepatitis C (SToP-C) study demonstrated that scaling up of direct-acting antiviral (DAA) treatment reduced hepatitis C virus (HCV) transmission. We evaluated the cost-effectiveness of scaling up HCV treatment in statewide prison services incorporating long-term outcomes across custodial and community settings. A dynamic model of incarceration and HCV transmission among people who inject drugs (PWID) in New South Wales, Australia, was extended to include former PWID and those with long-term HCV progression. Using Australian costing data, we estimated the cost-effectiveness of scaling up HCV treatment in prisons by 44% (as achieved by the SToP-C study) for 10 years (2021-2030) before reducing to baseline levels, compared to a status quo scenario. The mean incremental cost-effectiveness ratio (ICER) was estimated by comparing the differences in costs and quality-adjusted life-years (QALYs) between the scale-up and status quo scenarios over 40 years (2021-2060) discounted at 5% per annum. Univariate and probabilistic sensitivity analyses were performed. Scaling up HCV treatment in the statewide prison service is projected to be cost-effective with a mean ICER of A$12 968/QALY gained. The base-case scenario gains 275 QALYs over 40 years at a net incremental cost of A$3.6 million. Excluding DAA pharmaceutical costs, the mean ICER is reduced to A$6 054/QALY. At the willingness-to-pay threshold of A$50 000/QALY, 100% of simulations are cost-effective at various discount rates, time horizons, and changes of treatment levels in prison and community. Scaling up HCV testing and treatment in prisons is highly cost-effective and should be considered a priority in the national elimination strategy. NCT02064049.

Modifying the clinical reasoning cycle to enhance forensic mental health nursing utility.

Forensic mental health nursing is a specialty area of practice requiring specific knowledge and skills to work collaboratively with consumers. The Clinical Reasoning Cycle has been recognised as a potential framework to support nursing practice; however, it has been identified that adaptations are required to enhance utility in a forensic mental health services. The aim of this study was to explore and finalise a version of the cycle for forensic mental health nursing practice. Focus groups and interviews were used to explore adaptations with staff from a state-wide forensic service and forensic mental health nursing academics. Data were thematically analysed. Four main themes were interpreted: (1) allegiance to the Nursing Process, (2) moving the cycle from page to practice, (3) working as a team, or not, and (4) implementation will be a marathon and not a sprint. While nursing academics were more in favour of updating the Nursing Process to ensure contemporary practice is captured, staff from the service were supportive of the adapted cycle but emphasised the need to ensure collaboration with the consumer and their supporters. The adapted cycle was seen to articulate the contribution of forensic mental health nursing care, and support for a nursing-specific cycle was embraced by other disciplines, despite some hesitation from nurses. Prior to implementation there is a need to ensure the merits of the cycle are clearly articulated, along with a range of resources and specific contextual information to ensure the cycle can be successfully applied to enhance nursing practice and consumer care.

Visual acuity and reading print size requirements in children with vision impairment

ABSTRACT Clinical Relevance The support of students with a vision impairment throughout education could be enhanced by assessing the functional reading ability of the individual. This visual assessment could inform educators of individualised student needs and potentially improve the academic achievement for these students. Background Support for children with a vision impairment within a classroom is typically based on clinical findings of distance visual acuity and visual fields. Therefore, determining optimal print size for reading is essential to ensure best academic outcomes. Secondary aims were to investigate the possible impact of underlying pathology on reading ability. Methods Forty-seven participants were recruited from a state-wide support service for children with a vision impairment in South Australia. Three visual acuity groups were formed based on World Health Organisation definitions of mild, moderate, and severe vision impairment. Correlation between clinical measures of distance visual acuity using the Freiburg Visual Acuity Test, were compared with reading acuity and critical print size (smallest font before reading speed reduced) using Minnesota low vision reading chart (MNREAD). Results No significant correlations were found for mild (0.20–0.49 logMAR) and severe (1.00–1.52 logMAR) vision impairment groups between distance visual acuity and reading acuity read (p = .64, CI [−.585, .395]/p = .82, CI [−.48, .58]) or critical print size (p = .78, CI [−.57, .45]/p = .43, CI [−.34, .68]. A significant correlation was found for the moderate vision impairment group: 0.50–0.99 logMAR for minimum reading acuity (p < .001, CI [.44, .91]) and critical print size (p = .03, CI [.05, .80]). Conclusions Standard clinical measures of distance visual acuity are an unpredictable estimate of reading ability in children with mild and severe vision impairment. Additional measures of functional near reading ability could provide a more meaningful indicator of reading ability and help provide optimum support to students through education.

Autopsy findings and cardiac arrest rhythms in young obese patients with sudden cardiac death of uncertain etiology

Abstract Background Obesity is associated with an increased risk of sudden cardiac death (SCD) which can be particularly devastating in young adults. In a significant proportion of SCD cases in the young, a specific cause cannot be identified. Purpose The aim of this retrospective analysis was to describe the demographics, pathological changes and cardiac arrest rhythm in young obese individuals with SCD of otherwise unknown etiology. Methods Between July 2000 and December 2018, the National Coronial Information System (NCIS) identified cases of young obese (body mass index ≥ 30) individuals with SCD between 17-35 years of age (SCD-obesity). Autopsy reports of individuals with SCD where known causes had been excluded were compared to 2 matched control cohorts of death due to motor vehicle accidents (MVA) (first group matched for age, sex, height and weight (MVA-BMI-matched) and second group matched for age and sex (MVA-age-matched)). Additionally, electrocardiographic rhythms at cardiac arrest were obtained through state-wide ambulance services for SCD-obesity individuals. Results We identified 409 cases of SCD in young obese individuals, of which 94 cases met the inclusion criteria (figure 1). Mean age was 28.44±5.6 years (range 17-35). SCD-obesity individuals were commonly males (71%). SCD-obesity individuals had significantly higher cardiac masses (521g vs 417g, p&amp;lt;0.001) compared to the MVA-BMI-matched cohort. SCD-obesity individuals also had significantly increased left ventricular wall thickness (15.6mm vs 13.5mm, p&amp;lt;0.001) and increased rates of left ventricular fibrosis (73% vs 52%, p=0.045) compared to the MVA-BMI-matched cohort. ECG rhythm strips were available for 71 (72%) SCD-obesity cases, of which 16 (23%) were unwitnessed. Asystole was noted on 7 (46.67%) of witnessed cases, and 6 (40%) had a ventricular tachycardia or fibrillation (figure 2). Conclusions SCD-obesity individuals had increased cardiac organ masses, left ventricular wall thickness and cardiac fibrosis. The cardiac arrest rhythm recorded in witnessed cases were predominantly asystole and ventricular arrythmia. Future studies are needed to determine the pathological mechanisms explaining these abnormalities in young obese sufferers of SCD.Figure 1:Case identificationFigure 2:Results

Geographical challenges and inequity of healthcare access for high-risk paediatric heart disease.

Geographical context is an important consideration for health system design to promote equality in access to care for patients with childhood heart disease (CHD), particularly those living in regional, rural, and remote areas. To help inform future policy and practice recommendations, this study aimed to (i) describe the geographic distribution of high-risk CHD patients accessing an Australian state-wide specialist service and (ii) estimate travel time for accessing healthcare via general practitioners (primary), nearest paediatric centre (secondary) and specialist paediatric cardiac centre (tertiary). Participants included a cohort of children (0-18year) who accessed state-wide specialist CHD services over a 3-year period (2019-2021) in Queensland, Australia. Locations for patient residence, general practitioner, closest paediatric centre and tertiary cardiac centre were mapped using geographical information system (GIS) software (ArcGIS Online). Travel distance and times were estimated using a Google Maps Application Programming Interface (API). 1019 patients (median age 3.8 years) had cardiac intervention and were included in the sample. Of this cohort, 30.2% lived outside the heavily urbanised South East Queensland (SEQ) area where the tertiary centre is located. These patients travel substantially further and longer to access tertiary level care (but not secondary or primary level care) compared to those in SEQ. Median distance for patients residing outside SEQ to access tertiary care was 953km with a travel time of 10h 43min. This compares to 5.5km to the general practitioner and 20.6km to a paediatric service (8.9 and 54min respectively). This geographical mapping of CHD services has demonstrated a key challenge inherent in providing specialist cardiac care to children in a large state-based healthcare system. A significant proportion of high-risk patients live large distances from tertiary level care. The greater accessibility of primary care services highlights the importance of supporting primary care physicians outside metropolitan areas to acquire or build the ability and capacity to care for children with CHD. Strengthening local primary and secondary services not only has the potential to improve the outcomes of high-risk patients, but also to reduce costs and burden associated with potentially avoidable travel from regional, rural, or remote areas to access specialist CHD services.

Modified Intravenous Cannula Ventilation Tubes for Otic Barotrauma Prevention.

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

Bloodstream infections in neutropenic and non-neutropenic patients with haematological malignancies: epidemiological trends and clinical outcomes in Queensland, Australia over the last 20 years

Knowledge of the epidemiology of bloodstream infection (BSI) in haematology patients is essential to guide patient management. We investigated the epidemiology of BSI in patients with haematological malignancies in Queensland over the last 20 years (2000–2019), including all episodes diagnosed by the state-wide microbiology service. We identified 7749 BSI in 5159 patients, 58% associated with neutropenia. Gram-negatives were the main causative pathogens (58.3%), more frequent in neutropenic than non-neutropenic patients (3308/5309, 62.3% vs 1932/3678, 52.5%, p < 0.001). Amongst 8987 isolates the most common were E.coli (15.4%) and Pseudomonas spp. (14.2%). Pseudomonas spp. (16.6% vs 10.7%, p < 0.001), Klebsiella spp. (11.6% vs 6.8%, p < 0.001), viridans-group streptococci (4.4% vs 1.2%, p < 0.001) and E.faecium (2.4% vs 0.9%, p < 0.001) were more common in neutropenic than non-neutropenic patients, while S.aureus was less common (5.9% vs 15.6%, p < 0.001). Several antimicrobial resistance rates increased over time and had higher prevalence in neutropenic than non-neutropenic patients, including ciprofloxacin-resistant E.coli (94/758, 12.4% vs 42/506, 8.3%, p = 0.021), trimethoprim-sulfamethoxazole-resistant E.coli (366/764, 47.9% vs 191/517, 36.9%, p < 0.001), penicillin-resistant streptococci (51/236, 21.6% vs 28/260, 10.8%, p < 0.001) and vancomycin-resistant enterococci (46/250, 18.4% vs 9/144, 6.3%, p < 0.001). Carbapenem-resistant Pseudomonas spp. (OR 7.32, 95%CI 2.78–19.32) and fungi, including yeasts and moulds (OR 3.33, 95%CI 2.02–5.48) were associated to the highest odds of 30-day case-fatality at a multivariable logistic regression analysis. Neutropenia was associated with survival (OR 0.66, 95%CI 0.55–0.78). Differences were observed in the BSI epidemiology according to neutropenic status, with an overall increase of resistance over time associated to adverse outcome.

Motor neurone disease: A point-prevalence study of patient reported symptom prevalence, severity and palliative care needs.

Motor neurone disease is a rare but debilitating illness with incomplete evidence regarding patients' symptom burden. Palliative care and generalist clinicians are often in-experienced in caring for these patients and assessing their needs. To identify the symptom prevalence and severity experienced by patients with motor neurone disease. Secondary objectives were to examine differences in symptom burden and clusters according to phenotype, functional status, palliative care provision and those in their last months of life. A point prevalence study assessing patient-reported symptoms using a modified IPOS-Neuro assessment tool, incorporating 41 symptom items. Patients with motor neurone disease attending the State-wide Progressive Neurological Disease Service or inpatient unit at Calvary Health Care Bethlehem, Melbourne Australia, from March to December 2021. A total of 102 patients participated, the majority diagnosed with lumber-onset (30.4%), bulbar-onset (28.4%) and cervical-onset (25.5%) phenotypes. Patients experienced a median of 17 symptoms (range 2-32) with a median of 3 symptoms rated as severe/overwhelming (range 0-13). Motor and functional symptoms predominated, with differences in symptom clusters present according to phenotype. Patients had a higher number of severe/overwhelming symptoms if they were accessing palliative care services (p = 0.005), in their last 6 months of life (p = 0.003) and experiencing moderate or severe functional impairment (p < 0.001). Patients with motor neurone disease report high symptom burden. A validated motor neurone disease-specific symptom assessment tool is needed to accurately assess patients, including important variations in symptom clusters according to phenotype. Further research must focus on evidence-based treatment guidelines for symptoms experienced commonly and severely.

Access to voluntary assisted dying in Victoria: a qualitative study of family caregivers' perceptions of barriers and facilitators.

To investigate barriers to and facilitators of access to voluntary assisted dying in Victoria under the Voluntary Assisted Dying Act 2017 (Vic). Qualitative study; semi-structured interviews with people who had applied for voluntary assisted dying or their family caregivers, recruited via social media and interested advocacy groups; interviews conducted 17 August - 26 November 2021. Barriers to and facilitators of access to voluntary assisted dying. We interviewed 33 participants about 28 people who had applied for voluntary assisted dying; all but one of the interviews were with family caregivers after their relatives' deaths, and all but three were conducted via Zoom. The major barriers to access identified by participants were finding trained and willing doctors to assess eligibility for voluntary assisted dying; the time required for the application process (especially given how ill the applicants were); the prohibition of telehealth consultations; institutional objections to voluntary assisted dying; and the prohibition of health practitioners raising voluntary assisted dying with their patients. The major facilitators mentioned were care navigators (both the Statewide service and local navigators); finding a supportive coordinating practitioner; the Statewide Pharmacy Service; and system flow once the process had been initiated (although not during the early days of voluntary assisted dying in Victoria). Access was particularly difficult for people in regional areas or with neurodegenerative conditions. Access to voluntary assisted dying has improved in Victoria, and people generally felt supported while navigating the application process once they found a coordinating practitioner or a navigator. But this step, and other barriers, often still made patient access difficult. Adequate support for doctors, navigators and other facilitators of access is vital for the effective functioning of the overall process.

Exploring factors associated with paramedic work-related psychological injury through data linkage

Introduction: In comparison to the general population and other emergency services workers, paramedics experience high rates of work-related psychological injury. However, there is limited understanding of the case and practitioner-related factors that increase the risk of psychological injury among these workers. This paper aims to identify case and practitioner-related factors associated with paramedic work-related psychological injury in Victoria, Australia, through data linkage. Methods: Data linkage of 7,223 paramedic injury reports with electronic patient care records, and paramedic demographic data from the single state-wide ambulance service in Victoria, Australia – Ambulance Victoria. Injuries reported between 1 January 2015 and 30 June 2020 were included. Factors associated with paramedic psychological injury were assessed using multivariable logistic regression analysis. Results: A total of 4,641 (64%) injury reports were successfully linked, of which, 244 (5%) were psychological injuries. Shift hours between 0401 and 0800 (AOR 1.83; 95%CI: 1.12–2.97), cardiac arrest or deceased patient attendances (AOR 2.15; 95%CI: 1.06–4.34), hospital or medical center case locations (AOR 2.44; 95%CI: 1.22–4.91), and Priority 0 (AOR 2.27; 95%CI: 1.26–4.09), Priority 2 (AOR 1.56; 95%CI: 1.04–2.33), and Priority 3 (AOR 1.95; 95%CI: 1.15–3.32) dispatch codes were associated with increased odds of psychological injury. Increasing patient age (AOR 0.98; 95%CI: 0.97–0.99), and the absence of other emergency services on scene (AOR 0.50; 95%CI: 0.34–0.72) were associated with decreased odds of paramedic psychological injury. Conclusions: This is the first study to collectively examine and identify EMS case and practitioner-related characteristics associated with paramedic psychological injury through data linkage of EMS agency-level data sources. Practical application: The findings of this study highlight the dispatch case characteristics that may increase the risk of a paramedic sustaining a work-related psychological injury, and consequently facilitate the early identification, intervention, and support of the individuals most at risk.

Characteristics of paediatric pre-hospital intubation by Intensive Care Paramedics.

Emergency intubation in children is an infrequent procedure both in the pre-hospital and hospital setting. The anatomical, physiological and situational challenges together with limited clinician exposure can make this a difficult procedure with high risk of adverse events. The aim of this collaborative study between a state-wide ambulance service and a tertiary children's hospital was to describe the characteristics of pre-hospital paediatric intubations by Intensive Care Paramedics. We conducted a retrospective review of state-wide ambulance service electronic patient care records (ePCRs) in Victoria, Australia, population: 6.5 million. Children aged 0-18 years who were attended by paramedics over a 12-month period that required advanced airway management were analysed for demographics and first-pass success rate. Paramedics attended 2674 cases aged 0-18 years over the 12-month study period who received basic or advanced airway management. A total of 78 cases required advanced airway management. The median age of patients was 12 years (interquartile range 3-16) and most were male (60.2%). Sixty-eight patients (87.5%) were intubated successfully on the first attempt, first-pass success was lowest in children <1 year of age. The most common indications for pre-hospital intubation were closed head injury and cardiac arrest. It was not possible to report complication rates because of incomplete documentation. Pre-hospital intubation in children is performed infrequently in an extremely unwell patient group. Continued high-level paramedic training is required to prevent adverse events and ensure patient safety.