Presenting symptoms of COVID-19 and clinical outcomes in hospitalised older adults.

BACKGROUND: In July 2020, a COVID-19 outbreak was recognised in the geriatric wards at a subacute campus of the Royal Melbourne Hospital affecting patients and staff. Patients were also admitted to this site after diagnosis in residential care. AIMS: To describe the early symptoms and the outcomes of COVID-19 in older adults. METHODS: Patients diagnosed with COVID-19 at the facility in July or August 2020 were identified and their medical records were examined to identify symptoms present before and after their diagnosis and to determine their outcomes. RESULTS: Overall, 106 patients were identified as having COVID-19, with median age of 84.3 years (range 41-104 years); 64 were diagnosed as hospital inpatients after a median length of stay of 49 days, 31 were transferred from residential aged care facilities with a known diagnosis and 11 were diagnosed after discharge. There were 95 patients included in an analysis of symptom type and timing onset. Overall, 61 (64.2%) were asymptomatic at the time of diagnosis of COVID-19, having been diagnosed through screening initiated on site. Of these, 88.6% developed symptoms of COVID-19 within 14 days. The most common initial symptom type was respiratory, but there was wide variation in presentation, including fever, gastrointestinal and neurological symptoms, many initially not recognised as being due to COVID-19. Of 104 patients, 32 died within 30 days of diagnosis. CONCLUSIONS: COVID-19 diagnosis is challenging due to the variance in symptoms. In the context of an outbreak, asymptomatic screening can identify affected patients early in the disease course.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 2: identifying opportunities for disinvestment in a local healthcare setting.

BACKGROUND: This is the second in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. Rising healthcare costs, continuing advances in health technologies and recognition of ineffective practices and systematic waste are driving disinvestment of health technologies and clinical practices that offer little or no benefit in order to maximise outcomes from existing resources. However there is little information to guide regional health services or individual facilities in how they might approach disinvestment locally. This paper outlines the investigation of potential settings and methods for decision-making about disinvestment in the context of an Australian health service. METHODS: Methods include a literature review on the concepts and terminology relating to disinvestment, a survey of national and international researchers, and interviews and workshops with local informants. A conceptual framework was drafted and refined with stakeholder feedback. RESULTS: There is a lack of common terminology regarding definitions and concepts related to disinvestment and no guidance for an organisation-wide systematic approach to disinvestment in a local healthcare service. A summary of issues from the literature and respondents highlight the lack of theoretical knowledge and practical experience and provide a guide to the information required to develop future models or methods for disinvestment in the local context. A conceptual framework was developed. Three mechanisms that provide opportunities to introduce disinvestment decisions into health service systems and processes were identified. Presented in order of complexity, time to achieve outcomes and resources required they include 1) Explicit consideration of potential disinvestment in routine decision-making, 2) Proactive decision-making about disinvestment driven by available evidence from published research and local data, and 3) Specific exercises in priority setting and system redesign. CONCLUSION: This framework identifies potential opportunities to initiate disinvestment activities in a systematic integrated approach that can be applied across a whole organisation using transparent, evidence-based methods. Incorporating considerations for disinvestment into existing decision-making systems and processes might be achieved quickly with minimal cost; however establishment of new systems requires research into appropriate methods and provision of appropriate skills and resources to deliver them.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 5: developing a model for evidence-driven resource allocation in a local healthcare setting.

BACKGROUND: This is the fifth in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. This paper synthesises the findings from Phase One of the SHARE Program and presents a model to be implemented and evaluated in Phase Two. Monash Health, a large healthcare network in Melbourne Australia, sought to establish an organisation-wide systematic evidence-based program for disinvestment. In the absence of guidance from the literature, the Centre for Clinical Effectiveness, an in-house 'Evidence Based Practice Support Unit', was asked to explore concepts and practices related to disinvestment, consider the implications for a local health service and identify potential settings and methods for decision-making. METHODS: Mixed methods were used to capture the relevant information. These included literature reviews; online questionnaire, interviews and structured workshops with a range of stakeholders; and consultation with experts in disinvestment, health economics and health program evaluation. Using the principles of evidence-based change, the project team worked with health service staff, consumers and external experts to synthesise the findings from published literature and local research and develop proposals, frameworks and plans. RESULTS: Multiple influencing factors were extracted from these findings. The implications were both positive and negative and addressed aspects of the internal and external environments, human factors, empirical decision-making, and practical applications. These factors were considered in establishment of the new program; decisions reached through consultation with stakeholders were used to define four program components, their aims and objectives, relationships between components, principles that underpin the program, implementation and evaluation plans, and preconditions for success and sustainability. The components were Systems and processes, Disinvestment projects, Support services, and Program evaluation and research. A model for a systematic approach to evidence-based resource allocation in a local health service was developed. CONCLUSION: A robust evidence-based investigation of the research literature and local knowledge with a range of stakeholders resulted in rich information with strong consistent messages. At the completion of Phase One, synthesis of the findings enabled development of frameworks and plans and all preconditions for exploration of the four main aims in Phase Two were met.

Development, implementation and evaluation of an evidence-based program for introduction of new health technologies and clinical practices in a local healthcare setting.

BACKGROUND: This paper reports the process of establishing a transparent, accountable, evidence-based program for introduction of new technologies and clinical practices (TCPs) in a large Australian healthcare network. Many countries have robust evidence-based processes for assessment of new TCPs at national level. However many decisions are made by local health services where the resources and expertise to undertake health technology assessment (HTA) are limited and a lack of structure, process and transparency has been reported. METHODS: An evidence-based model for process change was used to establish the program. Evidence from research and local data, experience of health service staff and consumer perspectives were incorporated at each of four steps: identifying the need for change, developing a proposal, implementation and evaluation. Checklists assessing characteristics of success, factors for sustainability and barriers and enablers were applied and implementation strategies were based on these findings. Quantitative and qualitative methods were used for process and outcome evaluation. An action research approach underpinned ongoing refinement to systems, processes and resources. RESULTS: A Best Practice Guide developed from the literature and stakeholder consultation identified seven program components: Governance, Decision-Making, Application Process, Monitoring and Reporting, Resources, Administration, and Evaluation and Quality Improvement. The aims of transparency and accountability were achieved. The processes are explicit, decisions published, outcomes recorded and activities reported. The aim of ascertaining rigorous evidence-based information for decision-making was not achieved in all cases. Applicants proposing new TCPs provided the evidence from research literature and local data however the information was often incorrect or inadequate, overestimating benefits and underestimating costs. Due to these limitations the initial application process was replaced by an Expression of Interest from applicants followed by a rigorous HTA by independent in-house experts. CONCLUSION: The program is generalisable to most health care organisations. With one exception, the components would be achievable with minimal additional resources; the lack of skills and resources required for HTA will limit effective application in many settings. A toolkit containing details of the processes and sample materials is provided to facilitate replication or local adaptation by those wishing to establish a similar program.

The clinical presentation of avoidant restrictive food intake disorder in children and adolescents is largely independent of sex, autism spectrum disorder and anxiety traits.

Background: Avoidant restrictive food intake disorder (ARFID) is a new eating disorder with a heterogeneous clinical presentation. It is unclear which patient characteristics contribute to its heterogeneity. Methods: To identify these patient characteristics, we performed symptom-level correlation and driver-level regression analyses in our cross-sectional study in up to 261 ARFID patients (51% female; median age = 12.7 years) who were assessed at the Maudsley Centre for Child and Adolescent Eating Disorders, London between November 2019 and July 2022. Findings: Symptoms across the three drivers 1) avoidance based on sensory characteristics of food; 2) apparent lack of interest in eating; and 3) concern about aversive consequences positively correlated with each other. Patients' anxiety traits showed the greatest positive correlations with symptoms of concern about aversive consequences of eating. Patient sex was not significantly associated with any of the three ARFID drivers. Patients with comorbid autism spectrum disorder (ASD; 28%) showed more food-related sensory sensitivities (RR = 1.26) and greater lack of interest in eating (RR = 1.18) than those of patients without ASD (49%). Interpretation: In our clinical sample, the ARFID drivers occurred together and did not show clinically meaningful differences between the sexes. ASD may accentuate food-related sensory sensitivities and lack of interest, but may not drive a completely different symptom presentation. ARFID is multi-faceted and heterogenous, requiring a comprehensive multidisciplinary assessment to sufficiently understand the drivers of the restrictive eating behaviour. Results need replication in larger samples with more statistical power. Funding: None.

Performance of hospital-based contact tracing for COVID-19 during Australia's second wave.

BACKGROUND: Hospital-based contact tracing aims to limit spread of COVID-19 within healthcare facilities. In large outbreaks, this can stretch resources and workforce due to quarantine of uninfected staff. We analysed the performance of a manual contact tracing system for healthcare workers (HCW) at a multi-site healthcare facility in Melbourne, Australia, from June-September 2020, during an epidemic of COVID-19. METHODS: All HCW close contacts were quarantined for 14 days, and tested around day 11, if not already diagnosed with COVID-19. We examined the prevalence and timing of symptoms in cases detected during quarantine, described this group as proportions of all close contacts and of all cases, and used logistic regression to assess factors associated with infection. RESULTS: COVID-19 was diagnosed during quarantine in 52 furloughed HCWs, from 483 quarantine episodes (11%), accounting for 19% (52/270) of total HCW cases. In 361 exposures to a clear index case, odds of infection were higher after contact with an infectious patient compared to an infectious HCW (aOR: 4.69, 95% CI: 1.98-12.14). Contact with cases outside the workplace increased odds of infection compared to workplace contact only (aOR: 7.70, 95% CI: 2.63-23.05). We estimated 30%, 78% and 95% of symptomatic cases would develop symptoms by days 3, 7, and 11 of quarantine, respectively. CONCLUSION: In our setting, hospital-based contact tracing detected and contained a significant proportion of HCW cases, without excessive quarantine of uninfected staff. Effectiveness of contact tracing is determined by a range of dynamic factors, so system performance should be monitored in real-time.

Preparedness for internship: a survey of new interns in a large Victorian health service.

OBJECTIVE: To gain better understanding of the work-preparedness of new interns and identify areas where further training and education should be provided. DESIGN: Surveys of new interns assessing self-reported confidence and preparedness for tasks commonly undertaken without direct supervision. The first survey was undertaken before the cohort had started work, the second once they had completed their second intern rotation. SETTING: A large metropolitan Victorian health service. PARTICIPANTS: All interns starting in 2009 at Southern Health. Of the total 66 interns, 52 (84%) completed the first survey and 37 (56%) completed the second. MAIN OUTCOME MEASURE(S): Self-reported confidence and preparedness for common intern tasks. RESULTS: The surveys identified tasks that interns undertake frequently, their preparedness for these and their confidence in completing them. Although most felt reasonably well prepared by their university training for many tasks they commonly undertake as interns, this was not the case for all tasks. In particular, they did not feel well prepared for the following: preoperative patient review, handover, fluid and medication management, patient admissions, assessment of unstable patients, communication with patients and families, and pain management. CONCLUSIONS: There are particular domains of work-readiness for interns that could be improved. For best results, the training of interns in these common tasks should be undertaken jointly by hospitals and universities to ensure smooth transition from medical student to intern.

The Sydney Medically Supervised Injecting Centre: a controversial public health measure.

BACKGROUND: Injecting drug use remains a major public health concern, particularly because of opiate overdose and transmission of blood-borne viruses. Sydney's Medically Supervised Injecting Centre (MSIC) opened on a trial basis in May 2001 in an effort to reduce the harms of drug use. In this report, we provide a brief overview of the reported public health impact of supervising injecting facilities (SIFs) and review the history and early process evaluations of the Sydney Centre. METHODS: Medline, Internet searches and perusal of bibliographies of articles were used to identify key English language publications on SIFs. These were supplemented by interview with the Medical Director of Sydney MSIC, Dr Ingrid van Beek. DISCUSSION AND CONCLUSIONS: It is difficult to be certain of the public health impact of SIFs but evidence from overseas and Sydney's early process evaluations provide promise that they may make a positive contribution to health.