This study aims to identify the common pathways of appendicectomy, the most common emergency surgery in Australia’s public hospitals and any variations within a regional public health district in New ...South Wales, Australia.
We analyzed the electronic medical records of 3,943 patients who underwent appendicectomy between January 2014 and July 2020 at 2 hospitals in the Illawarra Shoalhaven Local Health District, New South Wales, Australia, using the PM2 approach for surgical pathway identification and subsequent statistical analyses.
Among 3,943 patients, 3,606 (91.5%) followed an 11-step main pathway: (1) emergency department admission, (2) surgery booking, (3) anesthesia start, (4) operating room entry, (5) surgery start, (6) surgery end, (7) anesthesia end, (8) operating room discharge, (9) postanesthesia care unit admission, (10) postanesthesia care unit discharge, and (11) hospital discharge. The median length of stay was 48.13 hours (interquartile range 32.74). The main pathway differed from either variation 1 (n = 246, 6.2%) or variation 2 (n = 30, 0.8%) only in the timing and location of anesthesia administration or conclusion. Variation 3 (n = 26, 0.7%) included patients who underwent appendicectomy twice, whereas variation 4 (n = 25, 0.6%) included patients booked for surgery before emergency department admission through community doctor referrals. Thirteen exceptional cases experienced combinations of the aforementioned pathways. The length of stay and phase durations varied between the main pathway and these variations.
The appendicectomy pathway was largely standardized across the studied hospitals, with the location of anesthesia administration or conclusion affecting specific stages but not the overall length of stay. Only a complex 2-surgery pathway increased length of stay.
Objective
Shoalhaven District Memorial Hospital is a rural (MM3) secondary hospital which is over an hour travel time from the nearest tertiary centre. The objective of the present study was to pilot ...the implementation of the BEFAST (Balance, Eyes, Face, Arms, Speech and Time) stroke screening tool at the ED, and determine whether its usage improved timely stroke detection.
Methods
During initial implementation and training (October–December 2019), triage nurses consulted with senior medical officers before activating stroke calls. Data were collected for the subsequent 24 months (January 2020–2022), and retrospective records for confirmed strokes during a 24‐month period prior to BEFAST implementation (October 2017–2019) were also collected. The main outcome measures were triage category, CT scan result time, discharge destination, length of stay (LOS) and Modified Rankin Score (MRS).
Results
After BEFAST implementation, patients (n = 268) were three times more likely to be triaged at category 1 or 2, and door‐to‐CT scan time was reduced by 20.7 min on average. More patients were discharged to their usual residence and more quickly (LOS 7.9 vs 11.1 days). MRS 90 days after stroke was less, and patients were nearly twice as likely to experience an improvement in neurological symptoms.
Conclusions
Patient outcomes were improved after implementation of the BEFAST stroke triage tool. More stroke patients were identified upon presentation to the ED, and in a timely fashion. For those with a stroke diagnosis, time‐critical interventions can take place earlier, allowing patients to return home sooner, and with less disability.
The BEFAST stroke screening tool uses Balance, Eyes, Face, Arms, Speech and Time to assess potential stroke. This study evaluated outcomes after implementation of this tool at a Rural ED. More stroke patients were identified and in a timely fashion, allowing patients to return home sooner and with less disability.
Researchers have reported limitations with research governance processes across Australia. This study aimed to streamline research governance processes across a local health district. Four basic ...principles were applied to remove non‐value‐adding and non‐risk‐mitigating processes. Average processing times were reduced from 29 to 5 days and end‐user satisfaction was improved, all within the same staffing levels.
Shoalhaven District Memorial Hospital is a rural (MM3) 150-bed hospital in Nowra, New South Wales, whose ED has evolved to a FACEM-led model of care (MOC). It has never had an emergency short stay ...area (ESSA). The objective of the present study was to pilot an ESSA and determine whether this MOC would increase the operational performance of the ED.
An ESSA was designed and delivered by emergency medicine medical, nursing and allied health practitioners. The study period was July-December 2021, with a seasonally matched retrospective cohort of records extracted for comparison (July-December 2020). Both took place within the context of the ongoing COVID-19 pandemic. The primary outcome measured was percentage of admitted patients meeting Emergency Treatment Performance (ETP). Secondary outcomes included discharge ETP, overall ED and inpatient length of stay (LOS), mortality and representation rates.
The admission ETP for patients after the implementation of the ESSA significantly increased, from 13.9% to 31.6% (χ
= 288, P < 0.001). Discharge ETP significantly declined. There was no effect improvement on overall ETP. There was no change to mortality or representation rates. Average admission LOS decreased.
The introduction of the ESSA significantly improved the ETP of admitted patients. Ongoing refinement of the ESSA admission processes, as well as the lifting of certain COVID-19 restrictions, could show even greater improvements in this and other areas. Ongoing research in this field is necessary, as well as a more detailed cost-benefit analysis.
The outcomes of survivors of critical illness due to coronavirus disease (COVID-19) compared with non-COVID-19 are yet to be established.
We aimed to investigate new disability at 6 months in ...mechanically ventilated patients admitted to Australian ICUs with COVID-19 compared with non-COVID-19.
We included critically ill patients with COVID-19 and non-COVID-19 from two prospective observational studies. Patients were eligible if they were adult (age ⩾ 8 yr) and received ⩾24 hours of mechanical ventilation. In addition, patients with COVID-19 were eligible with a positive laboratory PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Demographic, intervention, and hospital outcome data were obtained from electronic medical records. Survivors were contacted by telephone for functional outcomes with trained outcome assessors using the World Health Organization Disability Assessment Schedule 2.0. Between March 6, 2020, and April 21, 2021, 120 critically ill patients with COVID-19, and between August 2017 and January 2019, 199 critically ill patients without COVID-19, fulfilled the inclusion criteria. Patients with COVID-19 were older (median interquartile range, 62 55-71 vs. 58 44-69 yr;
= 0.019) with a lower Acute Physiology and Chronic Health Evaluation II score (17 13-20 vs. 19 15-23;
= 0.011). Although duration of ventilation was longer in patients with COVID-19 than in those without COVID-19 (12 5-19 vs. 4.8 2.3-8.8 d;
< 0.001), 180-day mortality was similar between the groups (39/120 32.5% vs. 70/199 35.2%;
= 0.715). The incidence of death or new disability at 180 days was similar (58/93 62.4% vs. 99/150 66/0%;
= 0.583).
At 6 months, there was no difference in new disability for patients requiring mechanical ventilation for acute respiratory failure due to COVID-19 compared with non-COVID-19. Clinical trial registered with www.clinicaltrials.gov (NCT04401254).
Abstract Objective Cervical spinal immobilisation procedures often include rigid cervical collars which, despite associated complications, may provide less immobilisation than previously thought. The ...present study reports the incidence of worsening neurological outcomes following soft collar application, and additionally reports patient comfort, compliance with spinal immobilisation, and paramedic perspectives on usage. Methods This was an observational cohort study conducted in selected metropolitan and regional areas of NSW Ambulance between 1 May 2022 and 31 March 2023. Soft collars were used exclusively in place of rigid collars. The SPEED (SPinal Emergency Evaluation of Deficits) tool was used to evaluate new or worsening neurological deficits following pre‐hospital soft collar application. Secondary outcomes included patient‐reported comfort of the device, and paramedic assessment of efficacy. Results Overall, 2098 soft collars were applied, of which 74 patients (3.5%) were subsequently found to have a cervical spine injury. Eight patients had a spinal cord injury, of which two experienced a worsening neurological deficit after soft collar application. In both instances, comprehensive case reviews determined that this was unlikely to have been attributable to the soft collar. The majority of patients found the soft collar comfortable, and they were well‐tolerated by patients who generally complied with immobility directions. Paramedics found the collar easy to apply, and felt it assisted in minimising patient movement. Conclusions Pre‐hospital use of soft collars does not appear to increase the risk of significant injury. Patients found these devices relatively comfortable, and clinicians reported overall ease of use with good patient compliance with immobility directives.
Background
The role of routine intraoperative cholangiograms (IOCs) for prevention of bile duct injury (BDI) is contentious. There are recent reports of limited utility of IOC in preventing BDI. In ...Australia, IOCs are used more frequently than internationally. This study aimed to evaluate the rate of IOC use in Australia and explore potential changes in practice in light of evolving evidence for the utility of IOC.
Methods
Data were collated using service item numbers in Medicare Benefits Scheme records on the Australian Government Medicare website, for services claimed between 1 January 2001 and 31 December 2019. These data were used to analyse trends in rates of IOC, cholecystectomy and BDI repair. Data were age‐standardized to account for changes in the population over time.
Results
The number of IOCs claimed increased by 31.8% and cholecystectomies by 7.0% over the study period. Age‐standardized service rates per 100 000 persons increased by 5.5 and 32.6, respectively. Rates of IOC per 100 000 cholecystectomies steadily increased across the study period, while BDI repair rates remained low and erratic.
Conclusion
Increasing use of IOC over the last 20 years reflects a trend towards routine rather than selective IOC; however, there is little discernible change in the number of BDIs requiring repair procedures. This suggests that routine IOC use to prevent or minimize BDI is unwarranted. Further investigation is required into the selective IOC use in high‐risk patients rather than mandatory use in all patients.
Increasing the use of IOC over the last 20 years reflects a trend towards routine rather than selective IOC. Despite this, there is little discernible change in the number of BDIs requiring repair procedures. This suggests that recommending routine IOC use to prevent or minimize BDI is unwarranted.
Objectives
To evaluate an integrated care program expanding the physician in the practice model into geriatrics, focussing on dementia assessment and management.
Design
Observational descriptive ...study.
Setting
The rural section of a local health district in New South Wales, Australia.
Participants
Patients attending eight general practices, in addition to practice nurses and general practitioners.
Interventions
Self‐report questionnaires completed by patients, specialist general practitioners and practice nurses. Responses to open‐ended questions were analysed using content analysis. Routinely collected health data of patients who took part in the program were compared with data of patients from the same institution who did not take part in the program.
Main outcome measures
A number of planned reviews, actual reviews and emergency department presentations for participating patients, self‐efficacy amongst general practitioners and practice nurses, and patient satisfaction and comfort levels.
Results
The GIP program was well received by most patients, GPs and practice nurses. Almost 90% of patients found it easier to see the specialist at their general practice. They were less likely to have planned reviews, actual reviews and emergency department presentations than patients who did not take part in the program. GPs and practice nurses expressed increased confidence in and knowledge of dementia assessment and management.
Conclusions
Dementia assessment and management programs based on the physician in the practice model may be well received in similar rural settings. Larger prospective studies are needed to further examine the relationship between programs and patients’ health outcomes.
Background and Aim
According to the European Society of Gastrointestinal Endoscopy (ESGE), gastroscopy should be conducted within 6 h for complete obstruction and 24 h for incomplete obstruction due ...to food bolus impaction. This study explores whether adults with acute esophageal food bolus (FB) impaction experience adverse outcomes when their time to esophagogastroduodenoscopy (EGD) deviates from the recommended guidelines.
Methods
A retrospective review was performed on the records of 248 patients who presented at the study site between 2015 and 2022 with symptoms of FB impaction.
Results
Two hundred and forty‐eight patients underwent EGD for FB impaction. Grade 1 (erosion, ulceration), Grade 2 (tear), and Grade 3 (perforation) complications were present in 31.6%, 6.9%, and 0.8% of cases, respectively. Of the 134 (54.0%) patients with complete obstruction, 51 (38.1%) received EGD within the recommended 6 h. Of the 114 (46%) patients with incomplete obstructions, 93 (81.6%) received EGD within the recommended 24 h. There was no statistically significant correlation between length of stay (LOS) post‐EGD and any of ingestion to presentation time, presentation to EGD time, or ingestion to EGD time. Age and complication level were greater predictors of longer LOS than presentation to EGD time. Patients who presented in hours were significantly more likely to receive EGD within the 6‐ and 24‐h guidelines than those who presented out of hours (50.7% vs 22.0%).
Conclusion
Neither time to EGD from ingestion of food bolus nor time to EGD from hospital presentation correlated with complication rate, complication severity, or length of stay post‐EGD.
The study examined 248 patients with acute esophageal food bolus impaction to see if timing of esophagogastroduodenoscopy (EGD) affects outcomes. Results showed no significant correlation between the timing of EGD and complication rates, severity, or length of hospital stay. Patients who presented during regular hours were more likely to receive timely EGD. Age and complication severity were stronger predictors of longer hospital stays than EGD timing. Compliance with EGD timing guidelines did not significantly impact adverse outcomes.
Introduction . Breast cancer management is complex, requiring personalised care from multidisciplinary teams. Research shows that there is unwarranted clinical variation in mastectomy rates between ...rural and metropolitan patients; that is, variation in treatment which cannot be explained by disease progression or medical necessity. This study aims to determine the clinical and nonclinical factors contributing to any unwarranted variation in breast cancer management in rural patients and to evaluate how these factors and variations relate to patient outcomes. Methods . Comprehensive data from patients who had primary breast cancer surgery from 2010 to 2014 in either a rural or metropolitan location in a single local health district was analysed ( n = 686). Records were subset into two rurality groupings based on the postcode in which the patient resided, and the Modified Monash Model (MMM), an Australian system for classifying rurality. Statistical analysis was used to compare rural and metropolitan cohorts on treatments, patient characteristics, timeliness, and outcomes (recurrence and survival). Results . Rural patients had higher mastectomy rates than metropolitan patients (57% vs. 34%, p < 0.001), despite a lack of difference in clinical or demographic factors accounting for such variation. The length of time between treatment pathway stages was consistently longer amongst rural patients ( p < 0.01). Rural women also had worse survival outcomes, especially amongst HER2‐positive patients who had significantly lower survival (5‐year 74% vs 82%; 10‐year 49% vs 71%, p < 0.05) than metropolitan HER2‐positive patients. Conclusion . This study reveals clinical disparities among rural breast cancer patients, that cannot be explained by demographic and clinical factors alone. Rural patients face lower rates of breast‐conserving surgery and treatment delays, attributable to systemic barriers such as limited access to specialist care, high travel costs, and suboptimal care coordination. These findings have important implications for improving equity and collaboration in delivering person‐centred breast cancer care.
PDF
