Surgery (Austin & Northern Health) - Research Publications
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ItemEpidemiology of long-stay patients in a university teaching hospital(WILEY, 2017-05)BACKGROUND: Patients admitted to acute care hospitals may have multiple comorbidities, and a small proportion may stay for a protracted period. AIMS: To assess the proportion of hospital patients who are long stay (≥14 days) and evaluate associations with baseline variables and subsequent inpatient morbidity and mortality. METHODS: This is a retrospective observational study of patients aged ≥18 years staying in hospital for at least 24 h between 1 July 2013 and 30 June 2014. RESULTS: There were 22 094 admissions in 15 623 patients. The median (interquartile range (IQR)) length of stay (LOS) was 4 (2-8) days, and 10% had a LOS >16 days. Long-stay admissions comprised 13.1% of admissions but used 49.1% of bed days. Long-stay admissions were more likely to be associated with intensive care unit admission (21.2 vs 6.0%), medical emergency team review (20.5 vs 4.3%) and a longer duration of mechanical ventilation (P < 0.0001 all comparisons). Long-stay patients were more likely to develop in-hospital complications, were more likely to die in hospital (8.2 vs 3.1%) and were less likely to be discharged home (P < 0.001 all comparisons). Multiple variable analysis revealed several associations with prolonged stay, including multiple admissions in the study period, the nature of the admitting unit, the Charlson comorbidity index at admission, admission from another hospital and any history of smoking. CONCLUSIONS: Patients staying at least 14 days comprised one seventh of hospital admissions but used half of bed days and suffered increased in-hospital morbidity and mortality. Several pre-admission associations with prolonged stay were identified.
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ItemThe epidemiology of in-hospital cardiac arrests in Australia and New Zealand(WILEY, 2016-10)BACKGROUND: The epidemiology of in-hospital cardiac arrests (IHCA) in Australia and New Zealand (ANZ) has not been systematically assessed. AIM: To conduct a systematic review of the frequency, characteristics and outcomes of adult IHCA in ANZ. METHODS: Medline search for studies published in 1964-2014 using MeSH terms 'arrest AND hospital AND Australia', 'arrest AND hospital AND New Zealand', 'inpatient AND arrest AND Australia' and 'inpatient AND arrest AND New Zealand'. RESULTS: We screened 934 studies, analysed 50 and included 30. Frequency of IHCA ranged from 1.31 to 6.11 per 1000 admissions in 4 population studies and 0.58 to 4.59 per 1000 in 16 cohort studies. The frequency was 4.11 versus 1.32 per 1000 admissions in hospitals with rapid response system (RRS) compared with those without (odds ratio: 0.32; 95% confidence interval 0.28-0.37; P < 0.001). On aggregate, the initial cardiac rhythm was ventricular tachycardia/fibrillation in 31.4% (range 19.0-48.8%) in 10 studies reporting such data. On aggregate, IHCA were witnessed in 80.2% cases (three studies) and monitored patients in 53.4% cases (four studies). Details of life support were poorly documented. On aggregate, return of spontaneous circulation occurred in 46.0% of patients. Overall, 74.6% (range 59.4-77.5%) died in-hospital but survival was higher among monitored or younger patients, in those with a shockable rhythm, or during working hours. CONCLUSION: IHCA are uncommon in ANZ and three quarters die in-hospital. However, their frequency varies markedly across institutions and may be affected by the presence of RRS. Where reported, the long-term outcomes survivors appear to have acceptable neurological outcomes.
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ItemPatient physiological status at the emergency department-ward interface and emergency calls for clinical deterioration during early hospital admission(WILEY, 2016-06)AIMS: To examine the relationship between physiological status at the emergency department-ward interface and emergency calls (medical emergency team or cardiac arrest team activation) during the first 72 hours of hospital admission. BACKGROUND: Ward adverse events are related to abnormal physiology in emergency department however the relationship between physiology at the emergency department-ward interface and ward adverse events is unknown. DESIGN: Descriptive and exploratory design. METHODS: The study involved 1980 patients at three hospitals in Melbourne Australia: i) 660 randomly selected adults admitted via the emergency department to medical or surgical wards during 2012 and who had an emergency call; and ii) 1320 adults without emergency calls matched for gender, triage category, usual residence, admitting unit and age. RESULTS/FINDINGS: The median age was 78 years and 48·8% were males. The median time to the first emergency call was 18·8 hours and ≥1 abnormal parameters were documented in 34·9% of patients during the last hour of ED care and 47·1% of patients during first hour of ward care. Emergency calls were significantly more common in patients with heart rate and conscious state abnormalities during the last hour of emergency care and abnormal oxygen saturation, heart rate or respiratory rate during the first hour of ward care. Medical emergency team afferent limb failure occurred in 55·3% patients with medical emergency team activation criteria during first hour of ward care. CONCLUSION: The use of physiological status at the emergency department-ward interface to guide care planning and reasons for and outcomes of medical emergency team afferent limb failure are important areas for future research.
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ItemDifferential clinical characteristics, management and outcome of delirium among ward compared with intensive care unit patients(WILEY, 2019-12)BACKGROUND: Delirium is common in hospitalised patients but its epidemiology remains poorly characterised. AIMS: To test the hypothesis that patient demographics, clinical phenotype, management and outcomes of patient with delirium in hospital ward patients differ from intensive care unit (ICU) patients. METHODS: Retrospective cohort of patients admitted to an Australian university-affiliated hospital between March 2013 and April 2017 and coded for delirium at discharge using the International Classification of Diseases System, 10th revision, criteria. RESULTS: Among 61 032 hospitalised patients, 2864 (4.7%) were coded for delirium. From these, we studied a random sample of 100 ward patients and 100 ICU patients. Ward patients were older (median age: 84 vs 65 years; P < 0.0001), more likely to have dementia (38% vs 2% for ICU patients; P < 0.0001) and less likely to have had surgery (24% vs 62%; P < 0.0001). Of ward patients, 74% had hypoactive delirium, while 64% of ICU patients had agitated delirium (P < 0.0001). Persistent delirium at hospital discharge was more common among ward patients (66% vs 17%, P < 0.0001). On multivariable analysis, age and dementia predicted persistent delirium, while surgery predicted recovery. CONCLUSIONS: Delirium in ward patients is profoundly different from delirium in ICU patients. It has a dominant hypoactive clinical phenotype, is preceded by dementia and is less likely to recover at hospital discharge. Therefore, delirium prevention, detection and goals of care should be adapted to the environment in which it occurs.
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ItemFrequency and outcomes of kidney donation from intensive care patients with acute renal failure requiring renal replacement therapy(WILEY, 2019-12)BACKGROUND: Kidney transplantation is the preferred treatment for end-stage renal failure. Unfortunately, donor organ shortages prevent many individuals receiving a renal transplant and there is a need to increase the pool of appropriate donors. The presence of acute kidney injury (AKI) in deceased donors has traditionally been a relative contraindication to renal transplantation, even though renal recovery may be favorable in the absence of chronic renal disease. METHODS: We undertook an 8 years retrospective observational study of potential deceased organ donors with AKI requiring renal replacement therapy (RRT). We evaluated the rate of successful transplantation as well as short term and outcomes at a median of 19.5 (13.0-52.7) months after donation. RESULTS: Amongst 1058 consented potential organ donors, 39 patients had AKI requiring RRT, of which 19 became donors (13 not medically suitable, 7 did not proceed to donation). The median (interquartile range (IQR)) donor age was 41 (34-50) years and norepinephrine, epinephrine and vasopressin were given to 18, 14 and 9 donors, respectively. From the 38 donated kidneys 34 were transplanted. The median (IQR) age of recipients was 53 (42.8-58.5) years and they were dialysis free in a median (IQR) of 5.5 (2.3-10.8) days. Only minor abnormalities were found at 3 and 6 months renal biopsies, and two patients experienced graft failure in the first 12 months. CONCLUSION: Amongst deceased donors with AKI receiving RRT and vasoactive medications outcomes of renal transplantation seems acceptable in the absence of pre-existing renal failure and other donor co-morbidity. Such patients may be an important additional source of kidney donation.
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ItemThe association of clinical frailty with outcomes of patients reviewed by rapid response teams: an international prospective observational cohort study(BMC, 2018-09-22)BACKGROUND: Frailty is a state of vulnerability to poor resolution of homeostasis after a stressor event and is strongly associated with adverse outcomes. Therefore, the assessment of frailty may be an essential part of evaluation in any healthcare encounter that might result in an escalation of care. The purpose of the study was to assess the frequency and association of frailty with clinical outcomes in patients subject to rapid response team (RRT) review. METHODS: In this multi-national prospective observational cohort study, centres with existing RRTs collected data over a 7-day period, with follow up of all patients at 24 h following their RRT call and at hospital discharge or 30 days following the event trigger (whichever came sooner). Investigators also collected data on the triggers and interventions provided and a bedside assessment on the level of patients' frailty using a clinical frailty scale. RESULTS: Amongst 1133 patients, 40% were screened as frail, which was associated with older age (p < 0.001), admission under a medical speciality (p < 0.001), increased severity of illness at the time of the RRT review (p = 0.0047), and substantially higher frequency of limitations of care (p < 0.001). Importantly, 72% of patients screened as frail were either dead or dependent on hospital care by 30 days (p < 0.001). In the multivariable analysis, the significant risk factors for the composite endpoint "poor recovery" (died or were hospital-dependent by 30 days) were age (odds ratio (OR), 1.04; 95% confidence interval (CI), 1.03-1.05; p < 0.001), frailty level (p < 0.001), existing limitation of care (OR, 2.0; 95% CI, 1.3-3.0; p < 0.001), and the quick sequential organ failure assessment (qSOFA) score (p < 0.001). CONCLUSIONS: Higher frailty scores were associated with increased mortality and dependence on health care at 30 days. Our results indicate that frailty has an influence on the clinical trajectory of deteriorating patients and that such assessment should be included in discussion of goals and expectations of care. TRIAL REGISTRATION: Netherlands Trial Registry, NTR5535 . Registered on 23 December 2015.
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ItemNo Preview AvailableClinical review: The role of the intensivist and the rapid response team in nosocomial end-of-life care(BMC, 2013)In-hospital end-of-life care outside the ICU is a new and increasing aspect of practice for intensive care physicians in countries where rapid response teams have been introduced. As more of these patients die from withdrawal or withholding of artificial life support, determining whether a patient is dying or not has become as important to intensivists as the management of organ support therapy itself. Intensivists have now moved to making such decisions in hospital wards outside the boundaries of their usual closely monitored environment. This strategic change may cause concern to some intensivists; however, as custodians of the highest technology area in the hospital, intensivists are by necessity involved in such processes. Now, more than ever before, intensive care clinicians must consider the usefulness of key concepts surrounding nosocomial death and dying and the importance and value of making a formal diagnosis of dying in the wards. In this article, we assess the conceptual background, reference points, challenges and implications of these emerging aspects of intensive care medicine.
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ItemFactors influencing the activation of the rapid response system for clinically deteriorating patients by frontline ward clinicians: a systematic review(OXFORD UNIV PRESS, 2017-12)PURPOSE: To synthesize factors influencing the activation of the rapid response system (RRS) and reasons for suboptimal RRS activation by ward nurses and junior physicians. DATA SOURCES: Nine electronic databases were searched for articles published between January 1995 and January 2016 in addition to a hand-search of reference lists and relevant journals. STUDY SELECTION: Published primary studies conducted in adult general ward settings and involved the experiences and views of ward nurses and/or junior physicians in RRS activation were included. DATA EXTRACTION: Data on design, methods and key findings were extracted and collated. RESULTS OF DATA SYNTHESIS: Thirty studies were included for the review. The process to RRS activation was influenced by the perceptions and clinical experiences of ward nurses and physicians, and facilitated by tools and technologies, including the sensitivity and specificity of the activation criteria, and monitoring technology. However, the task of enacting the RRS activations was challenged by seeking further justification, deliberating over reactions from the rapid response team and the impact of workload and staffing. Finally, adherence to the traditional model of escalation of care, support from colleagues and hospital leaders, and staff training were organizational factors that influence RRS activation. CONCLUSION: This review suggests that the factors influencing RRS activation originated from a combination of socio-cultural, organizational and technical aspects. Institutions that strive for improvements in the existing RRS or are considering to adopt the RRS should consider the complex interactions between people and the elements of technologies, tasks, environment and organization in healthcare settings.
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ItemBiliary stenting versus surgical bypass for palliation of periampullary malignancy(SPRINGER INDIA, 2013-03)BACKGROUND: Patients with periampullary cancers may not be suitable for curative resection due to locally advanced disease, metastases, or poor health. Biliary stenting and surgical bypass are utilized for symptom control, but the true benefit of one technique over the other is not clear. METHODS: A retrospective analysis of case records was undertaken of patients with periampullary (pancreatic head/uncinate process, distal bile duct, and ampulla of Vater and surrounding duodenum) malignancy treated between June 2004 and June 2010 in a tertiary center by palliative biliary stenting or palliative surgical bypass. RESULTS: Of the 69 patients included in the analysis, combined biliary and gastric bypass was performed on 28, while 41 underwent biliary stent (metallic, n = 39) insertion. Patients undergoing stenting were significantly older and less likely to be offered chemotherapy than those from the surgical bypass group. Overall, there were significantly more complications in the stent insertion group (85 %) than the surgical bypass group (36 %) (p = 0.003). The stent group required significantly more subsequent procedures than the surgical bypass group. Metal stent obstruction occurred in 16 of 39 (41 %) patients, with a median stent patency of 224 days. The overall median survival of patients in this study was 7 months with no significant difference between the groups (p = 0.992). The presence of metastases at presentation was the only independent factor associated with decreased survival. CONCLUSION: There was no survival difference between stenting vs. surgical bypass for palliation of periampullary cancer. There was, however, a high rate of stent occlusion and need for repeat procedures in patients treated by metal stenting, suggesting that stenting may be best suited to patients predicted as having the shortest survival.