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ItemThe Emerging Drugs Network of Australia - Victoria Clinical Registry: A state-wide illicit substance surveillance and alert network(WILEY, 2023-02)OBJECTIVES: With an increasingly dynamic global illicit drug market, including the emergence of novel psychoactive substances, many jurisdictions have moved to establish toxicosurveillance systems to enable timely detection of harmful substances in the community. This paper describes the methodology for the Emerging Drugs Network of Australia - Victoria (EDNAV) project, a clinical registry focused on the collection of high-quality clinical and analytical data from ED presentations involving illicit drug intoxications. Drug intelligence collected from the project is utilised by local health authorities with the aim to identify patterns of drug use and emerging drugs of concern. METHODS: The project involves 10 public hospital EDs in Victoria, Australia. Patients 16 years and over, presenting to a network ED with a suspected illicit drug-related toxicity and a requirement for venepuncture are eligible for inclusion in the study under a waiver of consent. Clinical and demographic parameters are documented by site-based clinicians and comprehensive toxicological analysis is conducted on patient blood samples via specialised forensic services. All data are then deidentified and compiled in a project specific database. RESULTS: Cases are discussed in weekly multidisciplinary team meetings, with a view to identify potentially harmful substances circulating in the community. High-risk signals are escalated to key stakeholders to produce timely and proportionate public health alerts with a focus on harm minimisation. CONCLUSIONS: The EDNAV project represents the first centralised system providing near real-time monitoring of community drug use in Victoria and is fundamental in facilitating evidence-based public health intervention.
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ItemNo Preview AvailableStaff perceptions of barriers to self-harm care in the emergency department: A cross-sectional survey study.(Elsevier BV, 2024-03)BACKGROUND: Emergency departments (EDs) are often the first point of contact for people with self-harm; however, they do not always receive optimal care. The study objective was to examine the perspectives of ED staff who respond to self-harm presentations, perceived barriers to providing optimal, guideline-concordant care, and staff's familiarity with existing guidelines. METHODS: An online cross-sectional survey comprising purpose-designed questions concerning self-harm in the ED was completed by 131 staff (83.2% nurses) from two hospitals in Victoria, Australia. Survey results were analysed using Stata version 16 and frequencies and percentages were calculated. RESULTS: Respondents reported knowledge of how to appropriately manage a person presenting with self-harm. However, lack of space (62.3%) and time (78.7%) to conduct the appropriate assessments, lack of self-harm training (71.8%), and limited awareness of or access to guidelines and recommendations for self-harm management within the ED (63.6%), were identified as primary barriers to their ability to appropriately manage these presenters. CONCLUSIONS: Improvements to the ED environment and processes, as well as the provision of regular self-harm specific education and training for all ED staff are needed. Implementation of best-practice standards should prioritise guideline-concordant care, with a particular focus on the education needs of nursing staff.
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ItemCharacteristics of self-harm presentations to the emergency department of the Royal Melbourne Hospital, 2012-2019: Data from the Self-Harm Monitoring System for Victoria(ELSEVIER SCI LTD, 2023-09)BACKGROUND: Rates of self-harm and suicide are increasing world-wide, particularly in young females. Emergency departments (EDs) are a common first point-of-contact for young people who self-harm. We examined age- and sex-related differences in: (1) rates of self-harm over an eight-year period; (2) changes in demographic, presentation, and treatment characteristics over this period, and; (3) rates of, and time to, self-harm re-presentation. METHODS: This was a retrospective observational study of all self-harm presentations in persons aged nine years and older to the Royal Melbourne Hospital ED over an eight-year period, 1 January 2012-31 December 2019. The Royal Melbourne Hospital is one of the largest and busiest public EDs in Melbourne, Australia and serves a primary catchment area of approximately 1.5 million people. RESULTS: There were 551,692 presentations to the Royal Melbourne Hospital ED over this period (57.6 % by females). Of these, 7736 (1.4 %) were self-harm related. These self-harm presentations involved 5428 individuals (54.8 % female), giving an overall repetition event-rate of 11.2 %. Self-harm related presentations increased by 5 % per year (Incidence Rate Ratio [IRR 1.05, 95 % CI 1.02-1.08); a 44 % increase over the eight-year period (IRR 1.44, 95 % CI 1.15-1.80). This increase was more pronounced for young people aged< 25 years. The most common method was self-poisoning, primarily by anxiolytics or analgesics. The proportion of presentations involving self-poisoning alone declined modestly over time, whilst the proportion involving self-injury alone increased. For just over half of all presentations the person was seen by ED mental health staff. The median time to first re-presentation was 4.5 months (Inter-Quartile Range [IQR] 0.7-13.2 months). CONCLUSIONS: Rates of hospital presenting self-harm may be increasing, particularly amongst young people, whilst most self-harm presentations occurred outside office hours; so appropriate ED staffing, training and clinical care models are needed. Around half of those with a repeat episode of self-harm repeated within three months of their index (i.e., first recorded) presentation. Efforts to establish appropriate aftercare services, including alternatives to ED services with service availability 24 h a day 7 days a week, aimed at reducing repetition rates, should be prioritised.
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ItemRecently Acquired Blood-borne Virus Infections in Australian Deceased Organ Donors: Estimation of the Residual Risk of Unexpected Transmission.(Ovid Technologies (Wolters Kluwer Health), 2023-03)UNLABELLED: Unexpected donor-derived infections of hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV are rare but important potential complications of deceased organ transplantation. The prevalence of recently acquired (yield) infections has not been previously described in a national cohort of Australian deceased organ donors. Donor yield infections are of particularly significance, as they can be used to gain insights in the incidence of disease in the donor pool and in turn, estimate the risk of unexpected disease transmission to recipients. METHODS: We conducted a retrospective review of all patients who commenced workup for donation in Australia between 2014 and 2020. Yield cases were defined by having both unreactive serological screening for current or previous infection and reactive nucleic acid testing screening on initial and repeat testing. Incidence was calculated using a yield window estimate and residual risk using the incidence/window period model. RESULTS: The review identified only a single yield infection of HBV in 3724 persons who commenced donation workup. There were no yield cases of HIV or HCV. There were no yield infections in donors with increased viral risk behaviors. The prevalence of HBV, HCV, and HIV was 0.06% (0.01-0.22), 0.00% (0-0.11), and 0.00% (0-0.11), respectively. The residual risk of HBV was estimated to be 0.021% (0.001-0.119). CONCLUSIONS: The prevalence of recently acquired HBV, HCV, and HIV in Australians who commence workup for deceased donation is low. This novel application of yield-case-methodology has produced estimates of unexpected disease transmission which are modest, particularly when contrasted with local average waitlist mortality. Supplemental Visual Abstract; http://links.lww.com/TXD/A503.
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ItemClinical decision support for increased-risk organ transplants: Participatory Design(Association for Computer Machinery: Digital Library, 2021)Currently there are over 1,600 Australians awaiting a life-saving organ transplant. Approximately 20% of potential donors have a history of behaviors before their death that increased their risk of acquiring and transmitting HIV, Hepatitis B or Hepatitis C to potential recipients. Donation and transplant professionals need to weigh the risks of disease transmission against the benefits of timely transplantation. Using participatory design methodology, we explored the design needs for a mobile and web-based disease transmission risk calculator to support transplant decisions. We held five design activities involving different occupation groups. Participants included donation and transplantation clinicians, coordinators, administrators, and specialist consultants. Methods included surveys, workshops, interviews, and usability studies. This paper describes our design process, presents the findings, and describes our design decisions and the resulting app. The application will soon be trialed within multiple hospitals in Australia.
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ItemNo Preview AvailableRelation of substance use disorders to mortality, accident and emergency department attendances, and hospital admissions: A 13-year population-based cohort study in Hong Kong(ELSEVIER IRELAND LTD, 2021-12-01)BACKGROUND: The impact of substance use disorders (SUD) in an Asian population has not been fully explored. We aimed to assess the risk of mortality, accident and emergency (A&E) department attendances, and hospital admissions associated with SUD in a population-based cohort study. METHOD: Patients diagnosed with SUD in public A&E departments from 2004 to 2016 (N = 8,423) were identified in the Clinical Database Analysis and Reporting System of the Hong Kong Hospital Authority and 1:1 matched to patients without SUD by propensity score (N = 6,074 in each group). Relative risks of mortality, A&E attendances and hospital admissions were assessed using Cox regression and Hurdle negative binomial regression. RESULTS: Patients with SUD had higher mortality (hazard ratio=1.43; 95% confidence interval [CI]=1.26-1.62) and more often died from poisoning or toxicity and injuries. The odds ratio (OR) for A&E attendances and all-cause hospital admissions associated with SUD were 2.80 (95% CI=2.58-3.04) and 3.54 (95% CI=3.26-3.83), respectively. The impact of SUD on the above outcomes was greatest among school-aged individuals (≤ 21 years) and decreased with age. The relative risk of mental disorder-related hospital admissions was much higher than that for infections, respiratory diseases, and cardiovascular diseases. In patients with SUD, ketamine and amphetamine use were associated with increased A&E attendances than opioid use. CONCLUSIONS: SUD was associated with increased mortality, A&E attendances and hospital admissions, especially in school-aged individuals. Our findings suggest prioritising early treatment and preventive interventions for school-aged individuals and focusing on the management of comorbid mental disorders and the use of ketamine and amphetamine.
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ItemPrevalence of Blood-Borne Viruses and Predictors of Risk in Potential Organ Donors in Australia.(Frontiers Media SA, 2022)Internationally, the designation of a patient as an increased viral risk organ donor has been associated with lower utilisation rates. The actual prevalence of blood borne viruses in Australian potential organ donors, and the predictive performance of questionnaires administered to stratify this risk, remains unknown. We conducted a retrospective review of all patients who commenced workup for donation on the national database between 2014-2020. The prevalence of HIV, Active HBV and Active HCV in 3650 potential organ donors was 0.16%, 0.9%, and 2.2%, respectively. The behavioural risk profile was assessed in a subset of 3633 patients. Next-of-kin reported increased risk behaviours were associated with an increased prevalence of HCV but not of HIV or HBV (OR 13.8, p < 0.01, OR 0.3. p = 0.42, OR 1.5, p = 0.14). Furthermore, the majority of HIV and HBV infections occurred in potential donors without a disclosed history of increased risk behaviours. In this series, donors had a higher prevalence of HCV, and similar rates of HBV and HIV to the broader community. Behavioural transmission risks were poorly predictive of HIV and HBV. Rather than pre-transplantation behavioural risk screening, routine post-transplant recipient screening may provide a more powerful tool in mitigating the consequences of unexpected viral transmission.
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ItemRemote COVID-19 patient monitoring system: a qualitative evaluation(BMJ PUBLISHING GROUP, 2022-05)BACKGROUND: Many COVID-19 patients are discharged home from hospital with instructions to self-isolate. This reduces the burden on potentially overwhelmed hospitals. The Royal Melbourne Hospital (RMH) Home Monitoring Programme (HMP) is a model of care for COVID-19 patients which chiefly tracks pulse oximetry and body temperature readings. OBJECTIVE: To evaluate the feasibility and acceptability of the HMP from a patient perspective. DESIGN, SETTINGS AND PARTICIPANTS: Of 46 COVID-19 patients who used the HMP through RMH during April to August 2020, 16 were invited to participate in this qualitative evaluation study; all accepted, including 6 healthcare workers. Attempts were made to recruit a gender-balanced sample across a range of COVID-19 severities and comorbidities. Participants completed a brief semistructured phone interview discussing their experience of using the HMP. OUTCOME MEASURES AND ANALYSIS: A thematic analysis of interview data was conducted. Feasibility was defined as the HMP's reported ease of use. Acceptability was considered holistically by reviewing themes in the interview data. RESULTS: The HMP allowed clinical deterioration to be recognised as it occurred enabling prompt intervention. All participants reported a positive opinion of the HMP, stating it was highly acceptable and easy to use. Almost all participants said they found using it reassuring. Patients frequently mentioned the importance of the monitoring clinicians as an information conduit. The most suggested improvement was to monitor a broader set of symptoms. CONCLUSIONS: The HMP is highly feasible and acceptable to patients. This model of care could potentially be implemented on a mass-scale to reduce the burden of COVID-19 on hospitals. A key benefit of the HMP is the ability to reassure patients they will receive suitable intervention should they deteriorate while isolating outside of hospital settings.
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ItemEpidemiology and clinical features of emergency department patients with suspected COVID-19: Insights from Australia's 'second wave' (COVED-4)(WILEY, 2021-04)OBJECTIVE: The aim of the present study was to describe the epidemiology and clinical features of patients presenting to the ED with suspected and confirmed COVID-19 during Australia's 'second wave'. METHODS: The COVID-19 ED (COVED) Project is an ongoing prospective cohort study in Australian EDs. This analysis presents data from 12 sites across four Australian states for the period from 1 July to 31 August 2020. All adult patients who met the criteria for 'suspected COVID-19' and underwent testing for SARS-CoV-2 in the ED were eligible for inclusion. Study outcomes included a positive SARS-CoV-2 test result, mechanical ventilation and in-hospital mortality. RESULTS: There were 106 136 presentations to the participating EDs and 12 055 (11.4%; 95% confidence interval [CI] 11.2-11.6) underwent testing for SARS-CoV-2. Of these, 255 (2%) patients returned a positive result. Among positive cases, 13 (5%) received mechanical ventilation during their hospital admission compared to 122 (2%) of the SARS-CoV-2 negative patients (odds ratio 2.7; 95% CI 1.5-4.9, P = 0.001). Nineteen (7%) SARS-CoV-2 positive patients died in hospital compared to 212 (3%) of the SARS-CoV-2 negative patients (odds ratio 2.3; 95% CI 1.4-3.7, P = 0.001). Strong clinical predictors of the SARS-CoV-2 test result included self-reported fever, sore throat, bilateral infiltrates on chest X-ray, and absence of a leucocytosis on first ED blood tests (P < 0.05). CONCLUSIONS: In this prospective multi-site study during Australia's 'second wave', a substantial proportion of ED presentations required SARS-CoV-2 testing and isolation. Presence of SARS-CoV-2 on nasopharyngeal swab was associated with an increase in the odds of death and mechanical ventilation in hospital.
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ItemBehavioural assessment unit improves outcomes for patients with complex psychosocial needs(WILEY, 2018-06)OBJECTIVE: We aimed to assess the impact of a new model of care for patients presenting to the ED with acute behavioural disturbance. METHODS: This pre-/post-intervention study involved creating a dedicated, highly resourced six bed unit, the behavioural assessment unit (BAU). Co-located with the ED at the Royal Melbourne Hospital, the unit was designed to fast-track the admission of patients affected by intoxication, mental illness or psychosocial crisis and provide front-loaded interventions. RESULTS: In 12 months from 1 April 2016, 2379 patients were admitted to the BAU. They were compared with a similar cohort of 3047 patients from the entire 2015 ED population. The BAU resulted in a decreased wait to be seen (40 min [interquartile range (IQR): 17-86] vs 68 min [IQR: 24-130], P < 0.001), a decreased wait for a mental health review (117 min [IQR: 49-224] vs 139 min [IQR: 57-262], P = 0.001) and a decreased ED length of stay (180 min [IQR: 101-237] vs 328 min [IQR: 227-534], P < 0.001). Patients admitted to the BAU were less likely to have a security code (349 (14.7%) vs 538 (17.7%), P = 0.003) and less likely to have mechanical restraint (156 episodes (6.6%) vs 275 (9.0%), P < 0.001) or therapeutic sedation (156 episodes (6.6%) vs 250 (8.2%), P < 0.001). CONCLUSION: A unit specifically designed to improve the care of patients requiring prolonged ED care due to mental illness and/or intoxication reduces the time spent in the ED and the use of some restrictive interventions. We recommend this model of care to EDs that care for this complex and challenging group of patients.
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