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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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ItemNo Preview AvailableOutcomes for emergency department patients with suspected and confirmed COVID-19: An analysis of the Australian experience in 2020 (COVED-5)(WILEY, 2021-10)OBJECTIVE: The aim of the present study was to describe the characteristics and outcomes of patients presenting to Australian EDs with suspected and confirmed COVID-19 during 2020, and to determine the predictors of in-hospital death for SARS-CoV-2 positive patients. METHODS: This analysis from the COVED Project presents data from 12 sites across four Australian states for the period from 1 April to 30 November 2020. All adult patients who met local criteria for suspected COVID-19 and underwent testing for SARS-CoV-2 in the ED were eligible for inclusion. Study outcomes were mechanical ventilation and in-hospital mortality. RESULTS: Among 24 405 eligible ED presentations over the whole study period, 423 tested positive for SARS-CoV-2. During the 'second wave' from 1 July to 30 September 2020, 26 (6%) of 406 SARS-CoV-2 patients received invasive mechanical ventilation, compared to 175 (2%) of the 9024 SARS-CoV-2 negative patients (odds ratio [OR] 3.5; 95% confidence interval [CI] 2.3-5.2, P < 0.001), and 41 (10%) SARS-CoV-2 positive patients died in hospital compared to 312 (3%) SARS-CoV-2 negative patients (OR 3.2; 95% CI 2.2-4.4, P = 0.001). For SARS-CoV-2 positive patients, the strongest independent predictors of hospital death were age (OR 1.1; 95% CI 1.1-1.1, P < 0.001), higher triage category (OR 3.5; 95% CI 1.3-9.4, P = 0.012), obesity (OR 4.2; 95% CI 1.2-14.3, P = 0.024) and receiving immunosuppressive treatment (OR 8.2; 95% CI 1.8-36.7, P = 0.006). CONCLUSIONS: ED patients who tested positive for SARS-CoV-2 had higher odds of mechanical ventilation and death in hospital. The strongest predictors of death were age, a higher triage category, obesity and receiving immunosuppressive treatment.
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ItemRestrictive interventions in Victorian emergency departments: A study of current clinical practice(WILEY, 2020-06)OBJECTIVE: To determine current clinical practices for managing behavioural emergencies within Victorian public hospital EDs. METHODS: A multi-centre retrospective study involving all patients who attended ED in 2016 at the Alfred, Ballarat, Dandenong, Geelong and Royal Melbourne Hospitals. The primary outcome was the rate of patient presentations with at least one restrictive intervention. Secondary outcomes included the rate of security calls for unarmed threats (Code Grey), legal status under the Mental Health Act at both the time of ED arrival and the restrictive intervention, and intervention details. For each site, data on 100 patients who had a restrictive intervention were randomly extracted for indication and methods of restraint. RESULTS: In 2016, 327 454 patients presented to the five EDs; the Code Grey rate was 1.49% (95% CI 1.45-1.54). Within the Code Grey population, 942 had at least one restrictive intervention (24.3%, 95% CI 23.0-25.7). Details were extracted on 494 patients. The majority (62.8%, 95% CI 58.4-67.1) were restrained under a Duty of Care. Physical restraint was used for 165 (33.4%, 95% CI 29.3-37.8) patients, 296 were mechanically restrained (59.9%, 95% CI 55.4-64.3), median mechanical restraint time 180 min (IQR 75-360), and 388 chemically restrained (78.5%, 95% CI 74.6-82.0). CONCLUSIONS: Restrictive interventions in the ED largely occurred under a Duty of Care. Care of patients managed under legislation that covers assessment and treatment of mental illness has a strong clinical governance framework and focus on minimising restrictive interventions. However, this is not applied to the majority of patients who experience restraint in Victorian EDs.
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ItemThe Snake Study: Survey of National Attitudes and Knowledge in Envenomation(MDPI, 2021-07)Despite recent reviews of best practice for the treatment of Australian venomous bites and stings, there is controversy about some aspects of care, particularly the use of antivenom. Our aim was to understand current attitudes and practice in the management of suspected snake envenoming. A single-stage, cross-sectional survey of Australian emergency care physicians who had treated snake envenomation in the previous 36 months was conducted. Hospital pharmacists were also invited to complete a survey about antivenom availability, usage, and wastage in Australian hospitals. The survey was available between 5 March and 16 June 2019. A total of 121 snake envenoming cases were reported, and more than a third (44.6%) of patients were not treated with antivenom. For those treated with antivenom (n = 67), 29 patients (43%) received more than one ampoule. Nearly a quarter of respondents (21%) identified that antivenom availability was, or could be, a barrier to manage snake envenoming, while cost was identified as the least important factor. Adverse reactions following antivenom use were described in 11.9% of cases (n = 8). The majority of patients with suspected envenoming did not receive antivenom. We noted variation in dosage, sources of information, beliefs, and approaches to the care of the envenomed patient.
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ItemIntramuscular midazolam, olanzapine, or haloperidol for the management of acute agitation: A multi-centre, double-blind, randomised clinical trial(ELSEVIER, 2021-02)BACKGROUND: The safety and effectiveness of intramuscular olanzapine or haloperidol compared to midazolam as the initial pharmacological treatment for acute agitation in emergency departments (EDs) has not been evaluated. METHODS: A pragmatic, randomised, double-blind, active-controlled trial was conducted from December 2014 to September 2019, in six Hong Kong EDs. Patients (aged 18-75 years) with undifferentiated acute agitation requiring parenteral sedation were randomised to 5 mg intramuscular midazolam (n = 56), olanzapine (n = 54), or haloperidol (n = 57). Primary outcomes were time to adequate sedation and proportion of patients who achieved adequate sedation at each follow-up interval. Sedation levels were measured on a 6-level validated scale (ClinicalTrials.gov Identifier: NCT02380118). FINDINGS: Of 206 patients randomised, 167 (mean age, 42 years; 98 [58·7%] male) were analysed. Median time to sedation for IM midazolam, olanzapine, and haloperidol was 8·5 (IQR 8·0), 11·5 (IQR 30·0), and 23·0 (IQR 21·0) min, respectively. At 60 min, similar proportions of patients were adequately sedated (98%, 87%, and 97%). There were statistically significant differences for time to sedation with midazolam compared to olanzapine (p = 0·03) and haloperidol (p = 0·002). Adverse event rates were similar across the three arms. Dystonia (n = 1) and cardiac arrest (n = 1) were reported in the haloperidol group. INTERPRETATION: Midazolam resulted in faster sedation in patients with undifferentiated agitation in the emergency setting compared to olanzapine and haloperidol. Midazolam and olanzapine are preferred over haloperidol's slower time to sedation and potential for cardiovascular and extrapyramidal side effects. FUNDING: Research Grants Council, Hong Kong.
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ItemCharacteristics and clinical outcomes for mental health patients admitted to a behavioural assessment unit: Implications for model of care and practice(WILEY, 2021-02)Behavioural assessment units (BAU) have been established in emergency departments (EDs) to provide short‐term observation, treatment, and care to people experiencing acute behavioural disturbance. A prospective observational study was conducted in a cohort of adult patients admitted to one BAU located within an ED (July–December 2017) to compare clinical characteristics, treatment outcomes, and use of restrictive interventions for those who received a specialist mental health (MH) assessment with those who did not. Of the 457 patients, 61.5% received a specialist MH assessment. This group had a lower acuity (Australasian Triage Score 10.4%; CI 0.2–2.0% vs 13.6%; CI 9.3–19.5%); more arrived with police (28.8%; CI 23.8–34.3 vs 5.1%; CI 2.7–9.4%); and were subjected to restrictive interventions while in the BAU. Security responses for unarmed threat (code grey) were higher (10.9%; CI 7.8–15.0% vs 4.4%; CI 2.3–8.5%), as was the use of chemical restraint (4.2%; CI 2.4–7.2 vs 0.0% CI 0.0 – 2.1%). Those requiring specialist MH assessment had a longer length of stay (12.7 vs 5.2 hours). Further development of the BAU model of care must include targeted, evidence‐based strategies to minimize the use of restrictive interventions and ensure timely access to acute mental health services.