Teaching Hospital In Sydney Research Articles

The influence of postoperative morbidity on long-term quality of life outcomes following pelvic exenteration

IntroductionPelvic exenteration provides significant survival benefits for selected patients diagnosed with locally advanced rectal cancer. However, in-hospital postoperative morbidity such as abdominal abscess, sepsis, and anastomotic leak remain highly prevalent, which can have short/long-term impacts on patient quality of life (QoL). The aim of this study was to determine the influence of postoperative morbidity on QoL outcomes in patients following pelvic exenteration. MethodsThis prospective cohort study included patients who underwent pelvic exenteration at a tertiary teaching hospital in Sydney, between 2008 and 2023. QoL measures were collected at baseline, 6, 12, 18, 24, 36, 48, and 60 months using the short-form 36 (SF-36v2) survey. The predictors included variables relating to postoperative morbidity, including hospital and ICU length of stay (LOS), post-discharge mortality and the number of postoperative complications. Mixed-effects analyses were used to determine the influence of these postoperative outcomes on physical and mental QoL trajectories. ResultsThis study included 674 patients, with a median age of 61 years. Shorter hospital and ICU LOS, and fewer or no postoperative complications were associated with higher physical QoL scores across all time points. Conversely, postoperative morbidity did not exhibit a significant impact on mental QoL scores. Furthermore, there was a longitudinal improvement in mental QoL outcomes compared to baseline, independent of postoperative morbidity. ConclusionPostoperative morbidity significantly impacted physical QoL outcomes after pelvic exenteration, whereas mental QoL outcomes were not influenced. Interventions aimed at mitigating postoperative morbidity may hold the potential to enhance long-term QoL outcomes following pelvic exenteration.

Effects of the nursing practice environment, nurse staffing, patient surveillance and escalation of care on patient mortality: A multi-source quantitative study

BackgroundA favourable nursing practice environment and adequate nurse staffing have been linked to reduced patient mortality. However, the contribution of nursing care processes such as patient surveillance and escalation of care, on patient mortality is not well understood. ObjectiveThe aim of this study was to investigate the effect of the nursing practice environment, nurse staffing, missed care related to patient surveillance and escalation of care on 30-day inpatient mortality. DesignA multi-source quantitative study including a cross-sectional survey of nurses, and retrospective data extracted from an audit of medical and admission records. Setting(s)A large tertiary teaching hospital (600 beds) in metropolitan Sydney, Australia. MethodsData on the nursing practice environment, nurse staffing and missed care were obtained from the nursing survey. Patient deterioration data and patient outcome data were collected from the medical and admission records respectively. Logistic regression models were used to examine the association between the nursing practice environment, patient deterioration and 30-day inpatient mortality accounting for clustering of episodes within patients using generalised estimating equations. ResultsSurveys were completed by 304 nurses (84.5 % female, mean age 34.4 years, 93.4 % Registered Nurses) from 16 wards. Patient deterioration data was collected for 30,011 patient deterioration events and 63,847 admitted patient episodes of care. Each additional patient per nurse (OR = 1.22, 95 % CI = 1.04–1.43) and the presence of increased missed care for patient surveillance (OR = 1.13, 95 % CI = 1.03–1.23) were associated with higher risk of 30-day inpatient mortality. The use of a clinical emergency response system reduced the risk of mortality (OR = 0.82, 95 % CI = 0.76–0.89). A sub-group analysis excluding aged care units identified a 38 % increase in 30-day inpatient mortality for each additional patient per nurse (OR = 1.38, 95 % CI = 1.15–1.65). The nursing practice environment was also significantly associated with mortality (OR = 0.79, 95 % CI: 0.72–0.88) when aged care wards were excluded. ConclusionsPatient mortality can be reduced by increasing nurse staffing levels and improving the nursing practice environment. Nurses play a pivotal role in patient safety and improving nursing care processes to minimise missed care related to patient surveillance and ensuring timely clinical review for deteriorating patients reduces inpatient mortality. Tweetable abstractPatient mortality can be reduced by improving the nursing practice environment & increasing the number of nurses so that nurses have more time to monitor patients. Investing in nurses results in lower mortality and better outcomes. #PatientSafety #NurseStaffing #WorkEnvironment #Mortality.

Substance use during hospitalisation requiring an urgent clinical response: an opportunity for intervention.

There are few reports on drug use in patients while hospitalised and none regarding management or clinical outcomes. To describe cases of drug use by inpatients requiring an urgent clinical response. We retrospectively reviewed cases at a teaching hospital in Sydney, Australia, from February 2019 to March 2021. Thirty cases were identified, with no deaths. Two patient groups were identified: (i) substance use disorders, using illicit drugs and (ii) self-harm history, using prescribed or over-the-counter drugs. Management involved cardiac monitoring (40%), intensive care (30%), charcoal (20%), antidotes (20%) and intubation (13%). Discharge was planned in 22 of 30 patients, against medical advice in four and directed by medical staff in four. Inpatient drug use requiring an urgent clinical response was infrequently recognised but presents a risk of harm to patients and staff and increases service utilisation and costs. Both harm reduction and systematic approaches guided by institutional policy are recommended. Using these events as reachable moments to address driving factors may modify patients' risk from future events.

Skills for the aspiring surgeon in Australia: A needs assessment

Introduction: The increasing duration of time before the commencement of formal surgical education training (SET) in Australia has emphasised the need for pre-SET “aspiring” surgical trainees to develop greater competency in both generic and specialty-specific skills to fulfil these public hospital positions, however there is no formalised curriculum or guide. This paper investigates current inconsistencies in the training of Australian pre-SET aspiring surgical trainees and attempts to define which skills are required. Methods: We conducted semi-structured interviews with pre-SET supervisors in general and specialty surgery fields at a large tertiary teaching hospital in Sydney, Australia, to assess expectations and competencies of pre-SET surgical trainees. A mixed-method analysis was used with inductive content analysis used for the rich interview data and quantitative analysis of 5-point Likert scale scores for the essential skills syllabus and eligibility requirements. Results: Eighteen interviews were conducted. Three major themes arose from inductive content analysis: participants perceived that pre-SET trainees met basic expectations, significant variability in skill level exists between trainees, and simulation was suggested as a potential solution to address gaps in training. Quantitative analysis of Likert scores suggests that trainee competency was inadequate (or not required) for several skills. For general surgery, trainee competency was deemed inadequate for proctoscopy, rigid sigmoidoscopy and appendicectomy. Conclusions: There is a critical need to clearly define the skills expected of pre-SET trainees and their role within the healthcare system. This study provides insights into the content of that skillset, which could be used to design relevant and useful training programs for pre-SET trainees. The value of simulation training was universally noted by participants. They believed that this could improve competency for pre-SET trainees in technical and non-technical skills.

Characteristics and outcomes of hospital-acquired and community-acquired peritonitis in patients on peritoneal dialysis: a retrospective cohort study.

Peritonitis remains a significant complication of peritoneal dialysis. However, there is limited information on the clinical characteristics and outcomes of hospital-acquired peritonitis compared to community-acquired peritonitis in patients undergoing peritoneal dialysis. Furthermore, the microbiology and outcomes of community-acquired peritonitis may vary from hospital-acquired peritonitis. Therefore, the aim was to gather and analyse data to address this gap. Retrospective review of the medical records of all adult patients on peritoneal dialysis within the peritoneal dialysis units in four university teaching hospitals in Sydney, Australia, who developed peritonitis between January 2010 and November 2020. We compared the clinical characteristics, microbiology and outcomes of community-acquired peritonitis and hospital-acquired peritonitis. Community acquired peritonitis was defined as the development of peritonitis in the outpatient setting. Hospital-acquired peritonitis was defined as: (1) developed peritonitis anytime during hospitalisation for any medical condition other than peritonitis, (2) diagnosed with peritonitis within 7days of hospital discharge and developed symptoms of peritonitis within 3days of the hospital discharge. Overall, 904 episodes of peritoneal dialysis-associated peritonitis were identified in 472 patients, of which 84 (9.3%) episodes were hospital-acquired. Patients with hospital-acquired peritonitis had lower mean serum albumin levels compared to those with community-acquired peritonitis(22.95g/L vs. 25.76g/L, p = 0.002). At the time of diagnosis, lower median peritoneal effluent leucocyte and polymorph counts were observed with hospital-acquired peritonitis compared to community-acquired peritonitis (1236.00/mm3 vs. 3183.50/mm3, p < 0.01 and 1037.00/mm3 vs. 2800.00/mm3, p < 0.01, respectively). Higher proportions of peritonitis due to Pseudomonas spp. (9.5% vs. 3.7%, p = 0.020) and vancomycin-resistant Enterococcus (2.4% vs. 0.0%, p = 0.009), lower rates of complete cure (39.3% vs. 61.7%, p < 0.001), higher rates of refractory peritonitis (39.3% vs. 16.4%, p < 0.001) and higher all-cause mortality within 30days of peritonitis diagnosis (28.6% vs. 3.3%, p < 0.001) were observed in the hospital-acquired peritonitis group compared to the community-acquired peritonitis group, respectively. Despite having lower peritoneal dialysis effluent leucocyte counts at the time of diagnosis, patients with hospital-acquired peritonitis had poorer outcomes, including lower rates of complete cure, higher rates of refractory peritonitis and higher rates of all-cause mortality within 30days of diagnosis, compared to those with community-acquired peritonitis.

Implementation of an in-reach rehabilitation program can increase the rate of discharge home from acute hospital care.

Objective This study describes how a model of early rehabilitation ('in-reach rehabilitation') can be integrated into acute care provision for hospitalised patients with high rehabilitation needs. This pragmatic evaluation aimed to assess service impact on home discharge rates from acute care. Methods An integrated early rehabilitation service was implemented at a tertiary teaching hospital in Sydney, Australia. Eligible patients were screened, placed on a waitlist, and treated in order of debility (six to eight patients concurrently). Routine data were collected and compared between those who received an in-reach rehabilitation program, and controls who remained on waitlist. Results From December 2021 to September 2022, 229 patients were identified as suitable for in-reach rehabilitation; of whom 100 received an in-reach program and the remaining 129 were waitlist controls. Patients who received in-reach rehabilitation achieved a significantly higher rate of discharge home from acute care compared to waitlist controls (46.0% vs 24.0%, P = 0.002) and lower rates of transfer to subacute inpatient rehabilitation (43.0% vs 62.0%). This was despite in-reach patients having high functional care needs (60% needed assistance from ≥two people to mobilise) and complex medical needs (median hospital length of stay 44.5 days, IQR 27.8-66.0). Conclusions It is feasible to deliver in-reach rehabilitation to hospitalised patients with heterogeneous diagnoses who have high rehabilitation needs. The rate of discharge home directly from acute wards is higher among those patients who received early in-reach rehabilitation compared to those on a waitlist.

Susceptibility pattern of bacterial isolates in equine ulcerative keratitis: Implications for empirical treatment at a university teaching hospital in Sydney.

Corneal ulceration is a common ophthalmic condition in horses. It is frequently caused by trauma to the corneal surface, followed by secondary infection by commensal or pathogenic organisms including Streptococcus equi subspecies zooepidemicus, Pseudomonas aeruginosa and Staphylococcus spp. Emerging antimicrobial resistance amongst these organisms has raised the need for appropriate antimicrobial therapy selection, to optimise treatment efficacy while minimising further antimicrobial resistance. Medical records of 38 horses presented at the University Veterinary Teaching Hospital Camden for ulcerative keratitis between 2010 and 2020 were reviewed to identify those with positive bacterial cultures and antimicrobial susceptibility profiles (13/38). Common susceptibility patterns were identified and used to guide the empirical treatment of equine bacterial corneal ulcers. Pseudomonas spp. (64.3%), Streptococcus equi subspecies zooepidemicus (14.3%) and Actinobacillus spp. (14.3%) were most commonly identified. Susceptibility to amikacin, gentamicin and ciprofloxacin was observed in 100%, 66.7% and 85.7% Pseudomonas spp. isolates respectively. Resistance to polymyxin B and neomycin occurred in 85.7% and 71.4% of Pseudomonas spp., respectively. All Streptococcus equi subspecies zooepidemicus organisms in this study were susceptible to ceftiofur, cephalexin, penicillin and ampicillin, while they were all resistant to gentamicin, neomycin, enrofloxacin and marbofloxacin. Predominating in this study, Pseudomonas spp. maintained overall aminoglycoside susceptibility despite some emerging resistance, and good fluoroquinolone susceptibility. High resistance to Polymyxin B could have arisen from its common use as first-line therapy for bacterial corneal ulcers. Although further research is required, these new findings about predominant bacteria in equine corneal ulceration in the Camden region and their antimicrobial susceptibility patterns can be used to guide the empirical treatment of bacterial corneal ulcers in horses.

Pandemic Loneliness in Healthcare Workers. Does It Predict Later Psychological Distress?

Increased loneliness associated with the COVID-19 pandemic has been widely reported, with healthcare workers at increased risk compared to the general population. Pre-pandemic research indicates that loneliness has long-term detrimental effects on mental well-being, but the effect of loneliness in the context of COVID-19 is not clear. We conducted an online survey of healthcare workers (HCWs) at a large teaching hospital in Sydney, Australia after the peak of the first wave of the pandemic in 2020. Over one-third experienced loneliness at the peak of the first wave. An observed association with high psychological distress in subsequent months was attenuated after adjusting for status of mental well-being during the peak and before the pandemic. Mental well-being during the peak of the pandemic and, to a lesser extent, mental well-being before the pandemic were the strongest predictors of later distress. Increased conflict at home was also predictive of later distress. The mental health of HCWs is an important consideration at any time and is especially so in the face of crises such as the current global pandemic. Strategies to enhance baseline mental well-being and bolster well-being during crisis situations should assist HCWs cope with unexpected stressors and reduce the associated detrimental psychological consequences.

Quantification of changes in lung aeration associated with physiotherapy using lung ultrasound in mechanically ventilated patients: a prospective cohort study

BackgroundLung ultrasound (LUS) is a novel and emerging tool for physiotherapists in ICU and may provide a way of monitoring lung aeration change in response to respiratory physiotherapy treatment during a patient’s ICU stay. ObjectiveTo measure change in the LUS score associated with a respiratory physiotherapy treatment; to determine whether change in LUS score correlates with other physiological measures. Design and settingA single-centre prospective cohort study was undertaken in a tertiary teaching hospital in Sydney, Australia. PatientsAdult mechanically ventilated patients in ICU with suspicion of atelectasis. MeasurementsPrimary outcome: pre-post difference in LUS score. Secondary outcomes: PaO2/FiO2 (PF) ratio, tidal volume (VT), lung auscultation score, driving pressure (DP) and the modified radiological atelectasis score (mRAS) on CXR. Results43 patients were included. There was a mean improvement in total LUS score after physiotherapy treatment of − 2.9 (95%CI −4.4, −1.4), and a mean improvement in LUS of the right and left lungs of − 1.6 (−2.5, −0.7) and − 1.3 (−2.5, −0.1) respectively. There was a mean improvement in PF ratio, VT and auscultation score of 10.4 (−11.89, 32.7), 19 (−7.4, 44.5) and − 1.8 (−2.6, −1.0) respectively. There was no improvement in mRAS or DP. There was a weak correlation between change in LUS score compared with change in mRAS score. LimitationsLimitations included the prospective cohort single site design and the small sample size. ConclusionsThe LUS score can be used to detect changes in lung aeration associated with respiratory physiotherapy treatment for acute lobar atelectasis in mechanically ventilated patients.Australian and New Zealand Clinical Trials Registry Number: ACTRN12619000783123. Contribution of the Paper•Assessment and measurement tools currently used by physiotherapists lack diagnostic accuracy. Lung ultrasound has high diagnostic accuracy in detecting pathologies pertinent to physiotherapists and may be helpful in monitoring treatment response.•The lung ultrasound score detects changes in lung aeration associated with respiratory physiotherapy treatment.•This study highlights lung ultrasound as a potential new tool for lung monitoring for physiotherapists in ICU.

Preventable presentations of older adults to emergency departments: General practitioners' perspectives.

To describe general practitioners' (GP) perspectives of older patients presenting to the ED, reasons they would refer to the ED and how they utilise community services to help manage older adults. A descriptive study conducted in the Sutherland Shire, Sydney. Case files were compiled using electronic medical records for 50 patients over 70 years old who presented to the ED of The Sutherland Hospital, a teaching hospital in Sydney. Surveys were provided to 10 GPs who each analysed five patients' presentations. Primary outcome was whether the GP would refer the patient to the ED. Secondary outcomes included reasons GPs referred to the ED, and their referral patterns of local community services. Of the 50 patients who presented to the ED, GPs would have referred 21 (42%) to the ED and managed 29 (58%) in the community. The most common reasons GPs would have referred to the ED was that they were 'too unwell', or needed 'urgent imaging or blood tests'. In 26 (52%) of the patients, GPs were aware of a local service that could help manage the patient and would have made that referral in 21 (42%) patients. Rapid Access Diagnosis and Intervention Unit and Geriatric Flying Squad are two of the local aged care services GPs would have referred to most commonly. GPs reported they would have been able to manage a significant proportion of older adults who presented to the ED in the community without referring to the ED. Severe and acute illness requiring urgent evaluation and intervention was the main reason GPs would refer to the ED.

The impact of nursing staff education on diabetes inpatient glucose management: a pilot cluster randomised controlled trial

BackgroundAn increasing number of patients in hospital have diabetes, with most of them cared for by non-specialist staff. The effect of diabetes education for staff on patient outcomes, as well as the most effective method of staff education is unclear. Therefore, the aim of this study was to compare diabetes outcomes in medical wards where nursing staff were offered one face-to-face (F2F) session followed by access to online education (online), F2F education only, or standard care (control).MethodsWe conducted a pilot cluster randomised controlled trial involving 16-weeks baseline/rollout followed by a 28-week post-intervention period across three medical wards (clusters) in a Sydney Teaching Hospital. The online ward provided an online competency-based diabetes education program and 1-h F2F teaching from a diabetes nurse educator (DNE), the F2F ward provided four separate 1-h teaching sessions by a DNE, with no additional sessions in the control ward. The primary outcome was length of stay (LOS); secondary outcomes included good diabetes days (GDD), hypoglycaemia and medication errors. Poisson and binary logistic regression were used to compare clusters.ResultsStaff attendance/completion of ≥ 2 topics was greater with online than F2F education [39/48 (81%) vs 10/33 (30%); p < 0.001]. Among the 827/881 patients, there was no difference in LOS change between online [Median(IQR) 5(2–8) to 4(2–7) days], F2F [7(4–14) to 5(3–13) days] or control wards [5(3–9) to 5(3–7) days]. GDD improved only in the online ward 4.7(2.7–7.0) to 6.0(2.3–7.0) days; p = 0.038. Total patients with hypoglycaemia and appropriately treated hypoglycaemia increased in the online ward.ConclusionsThe inclusion of online education increased diabetes training uptake among nursing staff. GDD and appropriate hypoglycaemia management increased in the online education wards.Trial registrationProspectively registered on the Australia New Zealand Clinical Trials Registry (ANZCTR) on 24/05/2017: ACTRN12617000762358.

Low exposure of urban dogs in metropolitan Sydney, Australia to Toxocara canis demonstrated by ELISA using T. canis excretory-secretory (E/S) larval antigens

Canine roundworm, Toxocara canis, is considered ubiquitous but patent infections are rare in adult owned urban dogs. Hepato-pulmonary migration of T. canis is common in young dogs, but in adult dogs, the migration of T. canis is arrested in tissues and larvae are inhibited. During this somatic migration, T. canis release excretory-secretory (E/S) larval antigens against which the host mounts an immune response. Detection of anti-T. canis E/S immunoglobulins is considered a proxy for the presence of arrested somatic T. canis larvae. By screening several cohorts of dogs in New South Wales (NSW), Australia, we determined the seroprevalence of anti-T. canis E/S in urban owned dogs visiting a veterinary teaching hospital in Sydney to be 3.8 % (n = 53), which was significantly lower (two-proportion z-test, P < 0.05) than the seroprevalence in pet dogs in regional western NSW (22.2 %, n = 63), and rehomed greyhounds (53.6 %, n = 28). Using a logistic regression model, the risk of testing positive in regional pet dogs (odds ratio [OR] = 37.0) and rehomed greyhounds (OR = 81.0) was significantly higher than in urban dogs (P < 0.05). Although routine deworming of dogs eliminates patent infection, our data show a low number of urban dogs with anti-T. canis E/S antibodies, which implies that the majority of these dogs were not exposed to T. canis previously, do not possess inhibited T. canis larvae, and in the case of intact females, will not transmit it to their puppies.

Ramadan and gestational diabetes: maternal and neonatal outcomes

AimsThe impact of Ramadan exposure to Gestational Diabetes Mellitus (GDM) pregnancies is not known. We therefore aimed to assess the association of Ramadan with maternal and neonatal outcomes among pregnant women with GDM.MethodsRetrospective cohort study of 345 Muslim women with singleton pregnancies who attended a major Sydney teaching hospital during the period 1989–2010, was undertaken. Exposure to Ramadan was stratified by the: (1) total pregnancy days exposed to Ramadan, (2) duration (hours) of daily fasting and (3) trimester of exposure. Maternal and neonatal outcomes were examined by exposure status, and never exposed pregnancies were comparator in all three analyses. Fasting status was not recorded.ResultsWe found no significant effect of Ramadan exposure on mean birthweight, macrosomia and maternal outcomes. However, we found a significant trend for increased neonatal hyperbilirubinemia with increasing Ramadan days exposure and later trimester exposure (ptrend ≤ 0.02 for both), with adjusted OR 3.9 (p=0.03) for those with ≥ 21 days exposure to Ramadan and adjusted OR 4.3 (p=0.04) for third trimester exposure. Conversely longer Ramadan exposure and late trimester exposure were independently associated with a lower prevalence of neonatal hypoglycaemia (adjusted OR 0.4 and 0.3 for ≥ 21 days and third trimester exposure, respectively). Furthermore, neonatal hypoglycaemia decreased for the fasting period of > 15 h group (adjusted OR 0.2, p = 0.01).ConclusionsRamadan exposure is associated with reduced neonatal hypoglycaemia, with no effect on birthweight, implying more favourable glycaemic control. However, the fourfold excess of neonatal hyperbilirubinemia indicates a need for further study of Ramadan and GDM.

The Role of Lifestyle and Cardiovascular Risk Factors in Dropout From an Australian Cardiac Rehabilitation Program. A Longitudinal Cohort Study

Cardiac rehabilitation (CR) programs reduce the risk of further cardiac events and improve the ability of people living with cardiovascular disease to manage their symptoms. However, many people who experience a cardiac event do not attend or fail to complete their CR program. Little is known about the characteristics of people who drop out compared to those who complete CR. To identify subgroups of patients attending a cardiac rehabilitation program who are more likely to dropout prior to final assessment by (1) calculating the dropout rate from the program, (2) quantifying the association between dropout and socio-demographic, lifestyle, and cardiovascular risk factors, and (3) identifying independent predictors of dropout. The study population is from a large metropolitan teaching hospital in Sydney, Australia, and consists of all participants consecutively enrolled in an outpatient CR program between 2006 and 2017. Items assessed included diagnoses and co-morbidities, quality of life (SF-36), psychological health (DASS-21), lifestyle factors and physical assessment. Dropout was defined as failure to complete the outpatient CR program and post CR assessment. Of the 3,350 patients enrolled in the CR program, 784 (23.4%; 95%CI: 22.0-24.9%) dropped out prior to completion. The independent predictors of dropout were smoking (OR 2.4; 95%CI: 1.9-3.0), being separated or divorced (OR 2.0; 95%CI: 1.5-2.6), younger age (<55 years) (OR 1.9; 95%CI: 1.6-2.4), obesity (OR 1.6; 95%CI: 1.3-2.0), diabetes (OR 1.6; 95%CI: 1.3-2.0), sedentary lifestyle (OR 1.3; 95%CI: 1.1-1.6) and depressive symptoms (OR 1.3; 95%CI: 1.1-1.6). To improve the CR program completion rate, clinicians need to consider the impact of socio-demographic, lifestyle, and cardiovascular risk factors on their patients' ability to complete CR. Tailored strategies which target the independent predictors of dropout are required to promote adherence to CR programs and thereby potentially reduce long-term cardiovascular risk.

Impact of an Australian/New Zealand organisational position statement on extended-release opioid prescribing among surgical inpatients: a dual centre before-and-after study.

Extended-release opioids are often prescribed to manage postoperative pain despite being difficult to titrate to analgesic requirements and their association with long-term opioid use. An Australian/New Zealand organisational position statement released in March 2018 recommended avoiding extended-release opioid prescribing for acute pain. This study aimed to evaluate the impact of this organisational position statement on extended-release opioid prescribing among surgical inpatients. Secondary objectives included predictors and clinical outcomes of prescribing extended-release opioids among surgical inpatients. We conducted a retrospective, dual centre, 11-month before-and-after study and time-series analysis by utilising electronic medical records from two teaching hospitals in Sydney, Australia. The primary outcome was the proportion of patients prescribed an extended-release opioid. For surgical patients prescribed any opioid (n = 16,284), extended-release opioid prescribing decreased after the release of the position statement (38.4% before vs. 26.6% after, p < 0.001), primarily driven by a reduction in extended-release oxycodone (31.1% before vs. 14.1% after, p < 0.001). There was a 23% immediate decline in extended-release opioid prescribing after the position statement release (p < 0.001), followed by an additional 0.2% decline per month in the following months. Multivariable regression showed that the release of the position statement was associated with a decrease in extended-release opioid prescribing (OR 0.54, 95%CI 0.50-0.58). Extended-release opioid prescribing was also associated with increased incidence of opioid-related adverse events (OR 1.52, 95%CI 1.35-1.71); length of stay (RR 1.44, 95%CI 1.39-1.51); and 28-day re-admission (OR 1.26, 95%CI 1.12-1.41). Overall, a reduction in extended-release opioid prescribing was observed in surgical inpatients following position statement release.

Single-step direct drug provocation testing is safe for delabelling selected non–low-risk penicillin allergy labels

BackgroundPenicillin allergy labels are prevalent, and removal of incorrect labels improves patient outcomes and health economics. Labels may be classified as “low-risk” or “non–low-risk,” of which the symptoms of the latter chiefly suggest immunoglobulin E–mediated etiology. Traditionally, “non–low-risk” allergy labels are evaluated by penicillin skin testing followed by graded multistep penicillin drug provocation testing (DPT). ObjectiveTo evaluate the safety of assessing “non–low-risk” labels with single-step direct DPT. MethodsWe consecutively enrolled inpatients and outpatients of a teaching hospital in Sydney, Australia, with penicillin allergy labels requiring penicillin for first-line treatment. Patients were classified as “low-risk” or “non–low-risk” based on the allergy labels. All patients proceeded directly to amoxicillin DPT, unless there was a history of anaphylaxis within 10 years of assessment to a beta-lactam (except for cefazolin) or Gell and Coombs type 2, type 3, or severe type 4 reaction. This was followed by a course of amoxicillin. ResultsA total of 149 patients (41 inpatients, 108 outpatients) were enrolled. No patient was excluded from the study. No patient experienced life-threatening reactions to the protocol. There were 85 patients who reported “non–low-risk” allergy labels. One patient developed generalized pruritus and rash that resolved with standard-dose antihistamines, 2 developed delayed benign maculopapular exanthem, and 3 experienced diarrhea during the course of amoxicillin. ConclusionIn our cohort, direct single-step DPT was safe, with only 6 patients with “non–low-risk” allergy experiencing benign reactions. We hope that further studies can be performed into single-step direct DPT to evaluate “non–low-risk” penicillin allergy labels. Trial RegistrationClinicalTrials.gov Identifier: LNR/16/HAWKE/452.

Comparison of the quick Sepsis‐related Organ Failure Assessment and adult sepsis pathway in predicting adverse outcomes among adult patients in general wards: a retrospective observational cohort study

BackgroundQuick Sepsis‐related Organ Failure Assessment (qSOFA) is recommended for use by the most recent international sepsis definition taskforce to identify suspected sepsis in patients outside the intensive care unit (ICU) at risk of adverse outcomes. Evidence of its comparative effectiveness with existing sepsis recognition tools is important to guide decisions about its widespread implementation.AimTo compare the performance of qSOFA with the adult sepsis pathway (ASP), a current sepsis recognition tool widely used in NSW hospitals and systemic inflammatory response syndrome criteria in predicting adverse outcomes in adult patients on general wards.MethodsA retrospective observational cohort study was conducted which included all adults with suspected infections admitted to a Sydney teaching hospital between December 2014 and June 2016. The primary outcome was in‐hospital mortality with two secondary composite outcomes.ResultsAmong 2940 patients with suspected infection, 217 (7.38%) died in‐hospital and 702 (23.88%) were subsequently admitted to ICU. The ASP showed the greatest ability to correctly discriminate in‐hospital mortality and secondary outcomes. The area under the receiver‐operating characteristic curve for mortality was 0.76 (95% confidence interval (CI): 0.74–0.78), compared to 0.64 for the qSOFA tool (95% CI: 0.61–0.67, P < 0.0001). Median time from the first ASP sepsis warning to death was 8.21 days (interquartile range (IQR): 2.29–16.75) while it was 0 days for qSOFA (IQR: 0–2.58).ConclusionsThe ASP demonstrated both greater prognostic accuracy and earlier warning for in‐hospital mortality for adults on hospital wards compared to qSOFA. Hospitals already using ASP may not benefit from switching to the qSOFA tool.

Comparison of compliance and outcomes in adolescents with type 1 diabetes mellitus attending a co-located pediatric and transition diabetes service

Abstract Objectives Adolescence is a challenging period for diabetes management, particularly when transitioning to adult care. There are reports highlighting concerns that transition to adult care may lead to poor glycemic control and clinic engagement. Our aim was to determine if a co-located pediatric and transition diabetes service would lead to better transition outcomes. Methods A retrospective medical records review was conducted on patients with type 1 diabetes attending a transition clinic in a metropolitan teaching hospital in Sydney, Australia. Patients referred from the hospital’s co-located pediatric diabetes clinic to the transition clinic were compared to those referred from external sources regarding important clinical outcomes such as glycosylated haemoglobin (HbA1c), clinic attendances, and complication rates between referral sources. Confounders such as age, gender, duration of diabetes and socioeconomic status were considered. Results Data was collected from 356 patients of which 121 patients were referred from the co-located pediatric diabetes clinic (IRG) and 235 patients from external sources (ERG). Improvements in HbA1c were only seen in the ERG at 6 and 12 months (p&lt;0.001). Altogether 93% attended one or more medical appointments in the IRG compared to 83% in the ERG (p=0.03). There were more admissions for acute diabetes complications (17 vs. 8%, p=0.01) and more microvascular complications (20 vs. 9%, p&lt;0.01) in the IRG vs. ERG group. Conclusions Although co-location of a pediatric and transition clinic improved medical engagement, this did not equate to better glycemic control or complication rates. Further research is warranted to determine what other strategies are required to optimise the transition process in diabetes care.

Prevalence of antibiotic allergy labels and their consequences in people presenting to a teaching hospital Emergency Department; a retrospective chart review.

Antibiotic allergy labels have a direct impact on individual patient care and on the consumption of broad-spectrum antibiotics. Our aim was to establish the prevalence of antibiotic allergies and to determine whether patients with documented antibiotic allergy labels received guideline concordant antimicrobial therapy. Additionally we wanted to evaluate the quality of allergy documentation in the medical record. Prospective audit of all patients presenting to the Emergency Department of an adult teaching hospital in Sydney over a 4 month period. Documented allergy labels, diagnoses, antibiotic administration and outcomes were recorded. Appropriateness of antibiotic choice was based on the Australian National Antimicrobial Prescribing Survey. 9.9% of presentations had at least one antibiotic allergy recorded. Significantly more women than men had antibiotic allergies documented. One third of patients with documented antibiotic allergies were prescibed inappropriate antibiotic therapy and some had significant adverse events. The documentation of antibiotic allergy labels and choice of antibiotic treatment can be significantly improved. Strategies to safely de-label people with documented allergies who are not truly allergic need to be implemented.

Mortality is not increased with Diabetes in hospitalised very old adults: a multi-site review

BackgroundFew data exist regarding hospital outcomes in people with diabetes aged beyond 75 years. This study aimed to explore the association of diabetes with hospital outcome in the very old patient.MethodsA retrospective review was conducted of all presentations of patients aged 65 years or more admitted to three Sydney teaching hospitals over 6 years (2012–2018), exploring primarily the outcomes of in-hospital mortality, and secondarily the outcomes of length of stay, the development of hospital-acquired adverse events and unplanned re-admission to hospital within 28 days of discharge. Demographic and outcome data, the presence of diabetes and comorbidities were determined from ICD10 coding within the hospital’s electronic medical record. Logistic and negative binomial regression models were used to assess the association of diabetes with outcome.ResultsA total of 139,130 separations (mean age 80 years, range 65 to 107 years; 51% female) were included, with 49% having documented comorbidities and 26.1% a diagnosis of diabetes.When compared to people without diabetes, diabetes was not associated with increased odds of mortality (OR: 0.89 SE (0.02), p < 0.001). Further, because of a significant interaction with age, diabetes was associated with decreased odds of mortality beyond 80 years of age. While people with diabetes overall had longer lengths of stay (10.2 days SD (13.4) v 9.4 days SD (12.3), p < 0.001), increasing age was associated with shorter lengths of stay in people aged more than 90 years. Diabetes was associated with increased odds of hospital-acquired adverse events (OR: 1.09 SE (0.02), p < 0.001) and but not 28-day re-admission (OR: 0.88 SE (0.18), p = 0.523).ConclusionDiabetes has not been shown to have a negative impact on mortality or length of stay in hospitalised very old adults from data derived from hospital administrative records. This may allow a more measured application of diabetic guidelines in the very old hospitalised patient.