Translational artificial intelligence-led optimization and realization of estimated discharge with a supportive weekend interprofessional flow team (TAILORED-SWIFT).

Weekend discharges occur less frequently than discharges on weekdays, contributing to hospital congestion. Artificial intelligence algorithms have previously been derived to predict which patients are nearing discharge based upon ward round notes. In this implementation study, such an artificial intelligence algorithm was coupled with a multidisciplinary discharge facilitation team on weekend shifts. This approach was implemented in a tertiary hospital, and then compared to a historical cohort from the same time the previous year. There were 3990 patients included in the study. There was a significant increase in the proportion of inpatients who received weekend discharges in the intervention group compared to the control group (median 18%, IQR 18-20%, vs median 14%, IQR 12% to 17%, P = 0.031). There was a corresponding higher absolute number of weekend discharges during the intervention period compared to the control period (P = 0.025). The studied intervention was associated with an increase in weekend discharges and economic analyses support this approach as being cost-effective. Further studies are required to examine the generalizability of this approach to other centers.

A community of practice to address system-based issues and promote clinical leadership among trainee medical officers in a large public health service: an evaluation of a trainee-led forum.

Clinical leadership is necessary to improve the performance of large public hospitals. Trainee medical officers (TMOs) are important stakeholders in organisation-wide initiatives that affect the medical workforce and support clinician engagement. This case study describes the development of a representative body known as the 'TMO Forum' within the Central Adelaide Local Health Network as a mechanism to promote engagement between medical trainees and the hospital executive to facilitate escalation and discussion of system-based issues. Over the past 8 years, this group has evolved into a community of practice with steady and sustained growth since inception. Trainees have fostered relationships with the executive, and have engaged in leadership and quality improvement initiatives. Here we explore the evolution, value and barriers to success of the TMO Forum. Our discussion is supplemented with findings from anonymous online evaluation surveys of both the TMO and executive stakeholder groups. We propose that initiatives such as the described may offer reciprocal benefits to both constituent groups regarding communication, and that the development of a dedicated community of practice will enhance engagement of TMOs in health service improvement initiatives and advocacy. However, there are obstacles to overcome in order to attract a greater number of trainees and maximise the benefits from this initiative.

Impact of perioperative direct oral anticoagulant assays: a multicenter cohort study.

BACKGROUND: There is little evidence to guide the perioperative management of patients on a direct oral anticoagulant (DOAC) in the absence of a last known dose. Quantitative serum titers may be ordered, but there is little evidence supporting this. AIMS: This multi-center retrospective cohort study of consecutive surgical in-patients with a DOAC assay, performed over a five-year period, aimed to characterize preoperative DOAC assay orders and their impact on perioperative outcomes. MATERIALS AND METHODS: Patients prescribed regular DOAC (both prophylactic and therapeutic dosing) with a preoperative DOAC assay were included. The DOAC assay titer was evaluated against endpoints. Further, patients with an assay were compared against anticoagulated patients who did not receive a preoperative DOAC assay. The primary endpoint was major bleeding. Secondary endpoints included perioperative hemoglobin change, blood transfusions, idarucizumab or prothrombin complex concentrate administration, postoperative thrombosis, in-hospital mortality and reoperation. Adjusted and unadjusted linear regression models were used for continuous data. Binary logistic models were performed for dichotomous outcomes. RESULTS: 1065 patients were included, 232 had preoperative assays. Assays were ordered most commonly by Spinal (11.9%), Orthopedics (15.4%), and Neurosurgery (19.4%). For every 10 ng/ml increase in titer, the hemoglobin decreases by 0.5066 g/L and the odds of a preoperative reversal increases by 13%. Compared to those without an assay, patients with preoperative DOAC assays had odds 1.44× higher for major bleeding, 2.98× higher for in-hospital mortality and 16.3× higher for receiving anticoagulant reversal. CONCLUSION: A preoperative DOAC assay order was associated with worse outcomes despite increased reversal administration. However, the DOAC assay titer can reflect the patient's likelihood of bleeding.

Perioperative micronutrients, macroscopic benefits?

'Micronutrients' are vitamins and minerals vital for healthy metabolic function, wound healing and disease and infection prevention. Micronutrients may play a role in significantly improving postoperative recovery and indices of patient comfort; however, minimal research exists for surgical patients. Furthermore, current guidelines on perioperative nutrition have a macronutrient focus which may fail to guide detection and treatment of the subclinical micronutrient deficiency in a patient who is not obviously malnourished. Limited research into supplementation of some micronutrient deficiencies shows favourable results; however, given the financial implications of wound care, the prevalence of micronutrient deficiency and possible benefits from attention to micronutrition for postoperative recovery, further research into this area is urgently warranted. Interventions to guide optimal future clinical practice are suggested.

Treatment of immune thrombocytopenia in Australian adults: A multicenter retrospective observational study.

Background: In Australia, prescribing restrictions limit access to internationally recommended second-line therapies such as rituximab and thrombopoietin agonists (TPO-A) (eltrombopag and romiplostim). Subsequent lines of therapy include an array of immunosuppressive and immune-modulating agents directed by drug availability and physician and patient preference. Objectives: The objective of the study was to describe the use of first and subsequent lines of treatment for adult immune thrombocytopenia (ITP) in Australia and to assess their effectiveness and tolerability. Patients/Methods: A retrospective review of medical records was conducted of 322 patients treated for ITP at eight participating centers in Australia between 2013 and 2020. Data were analyzed by descriptive statistics and frequency distribution using pivot tables, and comparisons between centers were assessed using paired t tests. Results: Mean age at diagnosis of ITP was 48.8 years (standard deviation [SD], 22.6) and 58.3% were women. Primary ITP was observed in 72% and secondary ITP in 28% of the patients; 95% of patients received first-line treatment with prednisolone (76%), dexamethasone (15%), or intravenous immunoglobulin (48%) alone or in combination. Individuals with secondary ITP were less steroid dependent (72% vs. 76%) and required less treatment with a second-line agent (47% vs. 58%) in the study sample. Over half (56%) of the cohort received treatment with one or more second-line agents. The mean number of second-line agents used for each patient was 1.9 (SD, 1.2). The most used second-line therapy was rituximab, followed by etrombopag and splenectomy. These also generated the highest rates of complete response (60.3%, 72.1%, and 71.8% respectively). The most unfavorable side effect profiles were seen in long-term corticosteroids and splenectomy. Conclusion: A wide range of "second-line" agents were used across centers with variable response rates and side effect profiles. Findings suggest greater effectiveness of rituximab and TPO-A, supporting their use earlier in the treatment course of patients with ITP across Australia.

COVID-19 prompts rapid and safe transition of chemotherapy into homes.

With the identification of the COVID-19 pandemic in early 2020, cancer-based clinical services in South Australia moved quickly to protect patients on active anti-cancer treatment who are particularly vulnerable to infective complications. This took the form of shifting 600 chemotherapy visits into the patients' homes via expansion of an existing arrangement between a public hospital network and an established private home chemotherapy service. Despite calls for caution from some oncology organisations and a relative paucity in specific clinical data supporting this approach, it proved to be a safe and efficient transition with additional unexpected benefits.

Evaluation of the introduction of the OSCE to the fifth-year Geriatric Medicine Teaching Programme.

AIM: An Observed Structured Clinical Examination (OSCE) was integrated into the assessment for senior medical students undertaking a 4.5-week geriatric medicine teaching block at one campus. The feasibility and acceptability of an OSCE were examined. METHODS: Students completed eight questions regarding the OSCE using a 6-point Likert scale and two additional questions, using free text, highlighting the strengths and potential areas for improvement. Changes were made every 6 months over a two-year period in response to student evaluation. RESULTS: Improvements included adjusting the format to conform with end-of-year examinations and introducing simulated patients. Following these improvements, students perceived improved structure and sequence to the assessments, improved opportunity for demonstration of skills and knowledge and that the assessment was fair. CONCLUSION: This preliminary research provides evidence that it is feasible to introduce OSCE as a form of assessment into a geriatric medicine teaching programme and student evaluation can be used to inform improvements.