Medical Education - Research Publications
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ItemNo Preview AvailableFactors associated with readmission after chronic obstructive pulmonary disease related hospitalisation(WILEY, 2018-03)Introduction/Aim: Acute exacerbations of Chronic Obstructive Pulmonary Disease (COPD) are associated with increased morbidity and mortality. Readmission within 30 or 60 days of discharge remains common. The purpose of this study was to identify factors in COPD admissions that are associated with readmission at two Melbourne teaching hospitals. Methods: Admissions where COPD was the principal diagnosis between August 1st and December 31st 2016 were retrospectively reviewed through the electronic database of Western Health. Information pertaining to the patient, COPD severity and treatment, as well as to the admission itself was recorded. Admissions were not recorded if they were incomplete, if follow-up was not possible, or if the admission concluded with death. Data was analysed through STATA (v14.2). Results: 211 admissions were included. The outcome 30-day readmission occurred 39 times (19.0%) and the outcome 60-day readmission occurred 60 times (28.4%). Patients who were readmitted were generally older and male. Univariate analysis demonstrated that the risk of 30-day readmissions was higher in patients with more previous COPD or total admissions, lower FEV1, higher bicarbonate levels, abnormal chest x-rays, admissions to Footscray Hospital, higher number of regular medications, and a recent history of pulmonary rehabilitation or Hospital Admission Risk Program participation. Multivariate analysis showed that a higher number of regular medications, a recent COPD admission, a higher white blood cell count, and higher bicarbonate levels on admission were associated with 30-day readmissions (corrected for age, sex, and hospital site). Similar associations were observed for 60-day readmission. Conclusion: Readmission within 30 and 60 days of discharge after admission for AECOPD are common in the Western Health population. Several factors were significantly associated with readmission, in particular those related to COPD severity.
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ItemNo Preview AvailableQuality of communication regarding patient care in the Intermediate Respiratory Care Unit (ircu)(WILEY-BLACKWELL, 2016-04)Introduction/Aim: Intermediate Respiratory Care Units (IRCU) are commonly used to facilitate management of patients in respiratory failure requiring a period of non-invasive ventilation (NIV) who can be managed in the ward (non-intensive care) setting. At Western Health, these patients are admitted under the Respiratory unit or an alternative unit (for example General Medicine). Patients requiring NIV are managed collaboratively by their admitting unit and the Respiratory unit with support from allied health and nursing staff. Clear delineation of responsibility and good communication is essential between those managing IRCU patients to ensure timely decision making and optimal patient care. There is anecdotal evidence that the communication between specialties managing these patients is often suboptimal. An objective assessment of the limitations in understanding and communication will allow delivery of appropriate and meaningful education to those involved in IRCU patient care. Methods: Staff involved in the management of patients admitted to the IRCU at Footscray Hospital were surveyed to assess their understanding of the role of the Unit and their responsibilities with regard to shared management of patients in the unit. Additionally, the inpatient records of all patients admitted to the unit over three non-consecutive months in 2014 were reviewed to assess the quality of written communication between the Respiratory unit, home unit (where applicable), nursing staff and allied health using a standard assessment form. Results: Preliminary review of survey responses reflects a reported good understanding of the role of IRCU and the indications/contraindications for management of patients in IRCU. There was a less satisfactory understanding of appropriate lines of communication and division of responsibility between specialties. We expect in-depth review of the survey responses to elicit clear areas that need further education. Analysis of the inpatient records will provide objective evidence of quality of written communication regarding patient care and decision making. Conclusion: Ongoing analysis of inpatient notes and survey responses will provide a clear picture of areas requiring further education and improvement. This will enable the improvement of current guidelines for the management of patients in IRCU and an education package to improve understanding of staff managing these patients. This will ultimately result in improvement in quality of patient care in the Unit.
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ItemNo Preview AvailablePrevalence of illegal inhalant use among patients undergoing respiratory function tests at Western Health(WILEY, 2017-03)Introduction/Aim: In 2014, 75% of Victorian Illicit Drug Reporting System participants reported recently using methamphetamine (75%), significantly higher than in 2013 (55%, p < 0.001). Cannabis lifetime use was 97%, with 75% recent users and 47% daily users. Lifetime use of E-cigarettes was 27% and recent use was 23%, with a median frequency of use of two days. (IDRS 2014)1 Little is known about the prevalence of illicit inhalant use in Melbourne's Western suburbs. Footscray and Sunshine Hospitals serve the most disadvantaged areas of Melbourne with the highest rates of unemployment. It has been found that the unemployed population is 1.6 times more likely to use cannabis and 2.4 times more likely to use methamphetamines. (AIHW 2014)2 The purpose of this study is to identify the prevalence of illegal inhalant use among patients undergoing respiratory function tests at Western Health. Methods: This study is a prospective audit and involves the completion of an anonymous questionnaire by patients performing respiratory function tests over three months. The questionnaire explores recent and current usage of inhaled methamphetamine, marijuana and tobacco via E-cigarettes and standard cigarettes. The questionnaire is available in multiple languages. The anticipated dataset is 300–500 patients. Voluntary completion of the survey is requested from all adult patients (>18 years) with implied consent. Results: Data collection has commenced across two laboratories. We anticipate the data will corroborate anecdotal reports of high drug use amongst the Western Health patient population. Conclusion: Counselling regarding the use of illicit inhalants represents an important and under-emphasised aim for patients at Western Health. Through demonstrating the prevalence of illicit inhalant use within our population, we hope to increase awareness of this issue amongst our doctors. Concurrent education on topics such as street names and modes of delivery will enable doctors to elicit a more thorough illicit drug history.
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ItemNo Preview Available165-OR: Early Electronic Consultation Reduces Glucose and Health Care–Associated Infection in Hospital—The STOIC-D Surgery Randomised Controlled Trial(American Diabetes Association, 2023)Aims: To assess the effect of early intervention with electronic-based proactive specialist diabetes care in surgical inpatients on glycaemia and clinical outcomes. Methods: The Specialist Treatment of Inpatients: Caring for Diabetes (STOIC-D) Surgery randomised controlled trial (RCT) recruited consecutive adults admitted to surgical units of the Royal Melbourne Hospital (Australia) in 2021 with diabetes or blood glucose ≥200 mg/dL and length of stay (LOS) ≥24 hours. Intervention arm patients received remote proactive consultation by the inpatient diabetes service (IDS) in the electronic medical record (Epic®) within 24 hours of admission and, if escalation criteria were met, received a bedside consultation. Patients receiving standard care were reviewed by the IDS at the bedside only following referral. Insulin and non-insulin agents were used to target glucose 90-180 mg/dL. Outcomes included glucometrics, healthcare-associated infection (HAI), and mortality. Registration: ACTRN12620001303932. Results: 1,383 admissions met inclusion criteria; 689 received the intervention. The primary outcome of mean patient-day mean glucose was lower in the active (158.4 mg/dL, standard deviation [SD] 48.6) vs. control arm (162.0 mg/dL, SD 46.8, p<0.001). HAI (most commonly pneumonia) was lower in the active vs. control arm (11% vs. 16%, p=0.02). Mortality (2.4% vs. 4.2%, p=0.08) and LOS (10.7 vs. 10.0 days, p=0.26) were no different. The number needed to treat for HAI prevention was 22. Hypoglycaemia <72 mg/dL was not increased (1.0% active vs. 0.9% control, p=0.23). The IDS performed a bedside consultation in 333 (49%) of the active vs. 93 (14%) of the control arm. Conclusion: The STOIC-D Surgery trial is the largest RCT of a diabetes model-of-care intervention in non-critical care. Early, electronic-based specialist diabetes intervention significantly reduced patient-day mean glucose and HAIs in a surgical population.
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ItemNo Preview AvailableUse of collaborative request model was highly correlated with organ donation consent.(LIPPINCOTT WILLIAMS & WILKINS, 2019-11)Background: There continues to be a disconnect between Australian’s self-reported support for organ donation and formal end-of-life family consent rates. In 2015, a multi-site Australian study by Lewis et al. demonstrated that consent rates were optimised by involving a clinician who had specific training in donation conversations, and in addition, was independent of the treating team. This approach is known as “Collaborative requesting” in Australia. The aim of the study was to report our single institution’s experience in introducing and augmenting the collaborative request model. Methods: The Royal Melbourne Hospital (RMH), is one of two adult tertiary trauma centres for the city of Melbourne, Australia. Additionally, the hospital has specialist neurosurgical and stroke services. Australia permits organ donation via both brain death and controlled circulatory death pathways. The hospital co-employs 4 embedded Donation Specialist Nursing Coordinators, and 3 fractionally appointed Medical Donation Specialists. Both craft groups have specialist communication training, and in addition, nursing coordinators have detailed end-to-end case donation management experience. Over a three-year period, the RMH progressively implemented the request model. Rather than using “any” independent clinician with donation communication training (the Lewis Model), the unit promoted the use of embedded Donation Specialist Nursing Coordinators as the collaborative requestors (the augmented collaborative model). Results: From January 2016 to June 2018 there were 135 donation requests raised by staff. Donation conversations raised by the family were excluded from analysis, as they have a consent rate at our hospital of over 90%. During the study period collaborative requesting increased from 50% (Jan 2016) to 96% (Jun 2018). Over the 3 study years (2016, 2017 and first half of 2018), the consent rate was highly positively correlated with the increased use of a collaborative model (r2=0.984). Conclusions: Since the introduction of embedded donation specialist nursing coordinators in RMH ICU, the hospital has seen both a clinically and statistically significant improvement in organ donation consent rates.
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ItemModifiable Lifestyle Factors Associated With Response to Treatment in Early Rheumatoid Arthritis(WILEY, 2020-06)OBJECTIVE: We aimed to evaluate the associations between response to algorithm-directed treat-to-target conventional synthetic disease-modifying antirheumatic drug therapy and potentially modifiable lifestyle factors, including dietary fish oil supplementation, body mass index (BMI), and smoking history in a rheumatoid arthritis (RA) inception cohort. METHODS: Patients with RA with a duration of less than 12 months were reviewed every 3 to 6 weeks to adjust therapy according to disease response. All patients received advice to take fish oil supplements, and omega-3 status was measured as plasma levels of eicosapentaenoic acid (EPA). Lifestyle factors and other variables potentially prognostic for 28-joint Disease Activity Score (DAS28) remission and DAS28 low disease activity (LDA) at the 12-month visit were included in multivariable logistic regression models. RESULTS: Of 300 participants, 57.7% reached DAS28 LDA, and 43.7% were in DAS28 remission at 1 year. Increase in plasma EPA was associated with an increase in the odds of being in LDA (adjusted odds ratio [OR] = 1.27; P < 0.0001) and remission (adjusted OR = 1.21; P < 0.001). There was some evidence that the effect of BMI on LDA might be modified by smoking history. An increase in BMI was associated with a decrease in the odds of being in LDA in current and former smokers but had no impact on LDA in patients who had never smoked. There were no meaningful associations between BMI or smoking history and remission. CONCLUSION: Omega-3 status, BMI, and smoking history are potential predictors of outcome in early RA. The possibility of an effect modification by smoking on the predictive value of BMI merits further investigation.
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ItemNo Preview AvailableEndoscopic features of buried Barrett's mucosa: visible to the trained eye?(Wiley, 2019-12-01)
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ItemNo Preview AvailableFemale genital cosmetic surgery toolkit for general practitioners and other health professionals(BMJ PUBLISHING GROUP, 2015)