Air Medical Retrieval of Central Australian Women in Labor: A Retrospective Observational Study.

OBJECTIVE: The aim of this study was to describe the characteristics and outcomes of remote-dwelling pregnant women with threatened labor referred for air medical retrieval to a regional birthing center as well as factors associated with birth within 48 hours. METHODS: This was a retrospective observational study of all pregnant women in the remote Central Australian region referred to the Medical Retrieval Consultation and Coordination Centre for labor > 23 weeks' gestation between February 12, 2018, and February 12, 2020. Univariate and multivariate statistical analyses were performed. RESULTS: There were 116 women referred for retrieval for labor. There were no births during transport, and less than half of the cases resulted in birth within 48 hours of retrieval. Tocolysis was frequently used. Predictors of birth within 48 hours were cervical dilatation ≥ 5 cm, preterm gestational age, and ruptured membranes in the univariate analysis. Nearly one third of this cohort required intervention or had complications during birth. CONCLUSION: Birth during transport for threatened labor did not occur in this cohort, and more than half of the retrievals did not result in birth within 48 hours; however, the high risk of birth complications may offset any benefit of avoiding air medical transport from remote regions. Retrieval clinicians should consider urgent transfer in cases of ruptured membranes, cervical dilatation of 5 cm or more, or gestational age less than 37 weeks.

Aeromedical Retrieval for Stroke in Australia.

INTRODUCTION: Rural, remote, and Indigenous stroke patients have worse stroke outcomes than urban Australians. This may be due to lack of timely access to expert facilities. OBJECTIVES: We aimed to describe the characteristics of patients who underwent aeromedical retrieval for stroke, estimate transfer times, and investigate if flight paths corresponded with the locations of stroke units (SUs) throughout Australia. METHODS: Prospective review of routinely collected Royal Flying Doctor Service (RFDS) data. Patients who underwent an RFDS aeromedical retrieval for stroke, July 2014-June 2018 (ICD-10 codes: I60-I69), were included. To define the locations of SUs throughout Australia, we accessed data from the 2017 National Stroke Audit. The main outcome measures included determining the characteristics of patients with an in-flight diagnosis of stroke, their subsequent pickup and transfer locations, and corresponding SU and imaging capacity. RESULTS: The RFDS conducted 1,773 stroke aeromedical retrievals, consisting of 1,028 (58%) male and 1,481 (83.5%) non-Indigenous and 292 (16.5%) Indigenous patients. Indigenous patients were a decade younger, 56.0 (interquartile range [IQR] 45.0-64.0), than non-Indigenous patients, 66.0 (IQR 54.0-76.0). The most common diagnosis was "stroke not specified," reflecting retrieval locations without imaging capability. The estimated median time for aeromedical retrieval was 238 min (95% confidence interval: 231-244). Patients were more likely to be transferred to an area with SU and imaging capability (both p < 0.0001). CONCLUSION: Stroke patients living in rural areas were younger than those living in major cities (75 years, Stroke Audit Data), with aeromedically retrieved Indigenous patients being a decade younger than non-Indigenous patients. The current transfer times are largely outside the time windows for reperfusion methods. Future research should aim to facilitate more timely diagnosis and treatment of stroke.

Adherence to blood pressure and glucose recommendations in chronic kidney disease hospital inpatients: Clinical inertia and patient adherence.

AIMS: To determine the extent to which targets for blood pressure (BP) (<140.90 mmHg) and random blood glucose level (BGL) (<7.7 mmol/L) control in patients with chronic kidney disease (CKD) are achieved; and the extent clinical inertia affects BP and glucose control in CKD and diabetes mellitus (DM). METHODS: Data was collected from the 1st January 2015 until 31st December 2015 on key patient pathology, admission reason, final discharge diagnosis, and information concerning clinical guideline adherence. RESULTS: Eighty-seven (n = 87) CKD patients were included. The average hospital BP for all CKD patients was 134.3/73.4 mmHg, adhering to recommendations of <140/90 mmHg. The average CKD patient pre-admission BP was 134.8/72.2 mmHg compared to the discharge BP of 129.8/72.2 mmHg. At admission, 63.3% and 93.1% of patients adhered to systolic and diastolic BP recommendations, which significantly (p = < .05) increased at discharge to a systolic and diastolic BP adherence of 83.9% and 98.8%, respectively. The average random hospital BGL was 7.7 mmol/L, indicating good control, whereas the pre-hospital HbA1c average was 7.58%, indicating poor control (>7.0% >53 mmol/mol). There were 21 cases of clinical inertia, affecting 18 out of 87 patients (20.7%), with significant adverse hospital discharge differences (p = <.05) between clinical inertia and non- clinical inertia patient systolic BP (144.2 vs. 132.8 mmHg), deranged BGL (66.7% vs. 35.3%), and reduction in kidney function (83.3% vs. 30.9%). CONCLUSION: Adherence appears to be related to inpatient clinical inertia and outpatient patient health literacy and empowerment.

Blood glucose and pressure controls in diabetic kidney disease: Narrative review of adherence, barriers and evidence of achievement.

AIMS: To review the epidemiology and the clinical evidence regarding achieving blood pressure (BP) and blood glucose control in patients with chronic kidney disease (CKD) and diabetes mellitus (DM), with emphasis on adherence and barriers within the context of Australian clinical guidelines. This article then considers Australian services aimed at BP, DM, and CKD, guideline adherence and control. METHODS: Evidence from PubMed-listed articles published between 1994 and 2016 is considered, including original research, focusing on randomised controlled trials and prospective studies, review articles, meta- analyses, expert and professional bodies' guidelines as well as our experience. RESULTS: There have been no Australian studies that consider adherence to BP control in DM and CKD patients. This is a major limitation in preventing DM and renal disease progression. It is possible that Australian clinicians are not adhering to DM, hypertension (HT), and glucose recommendations, thus resulting in reduced patient outcomes. CONCLUSIONS: It is hoped that future studies ascertain the extent to which the required BP and glucose control in patients is achieved, and the potential barriers to adherence. The significance of this is immense since the impact of failure to control blood glucose levels and BP leads to renal damage.

Does a hospital diabetes inpatient service reduce blood glucose and HbA1c levels? A prospective cohort study.

BACKGROUND: Diabetes education is believed to bring about sustained benefits in diabetes mellitus (DM) patient outcomes. These benefits have not been widely studied in an inpatient hospital setting, and as such the aim was to determine whether a hospital diabetes in-service, and specifically diabetes education, results in reduced blood glucose and HbA1c levels after hospital discharge. METHODS AND MATERIALS: A cohort review was performed at a large teaching hospital, in Canberra, Australia. Sixty seven patients comprising 35 males and 32 females who were referred upon discharge to the Diabetes Services as having a history of uncontrolled DM from February 1st, 2015 until January 31st, 2016 were evaluated. The retrospective discharge blood glucose level (BGL) was compared to prospective BGL 3 months after hospital discharge. HbA1c was prospectively taken before and 3 months after Diabetes Service education. A between subjects t-Test was used to compare patients' glucose and HbA1c averages. RESULTS: The average discharge BGL result was 13.3 mmol/L, compared to the post-discharge result of 11.2 mmol/L, indicating a significant decrease (p = < 0.01). The average pre-HbA1c result was 10.45%, and decreased to the post-HbA1c result of 8.96%, which was significant (p = <0.05). CONCLUSION: This study is the first to measure the direct glucose adherence benefits associated DM education within Australia and provides evidence on the effectiveness of a Diabetes Service in reducing patient BGLs. Utilisation of Diabetes Services to control glycaemia encourages ongoing efforts and translates to reduced micro and macro cardiovascular risk factors associated with DM.

Services aimed at achieving desirable clinical outcomes in patients with chronic kidney disease and diabetes mellitus: A narrative review.

There is a large number of patients with chronic kidney disease (CKD), diabetes mellitus (DM), and hypertension (HT) but whether the targets on blood pressure (BP) control in patients with DM and/or CKD are met is not clear. This narrative review therefore investigated evidence on services aimed at achieving desirable clinical results in patients with CKD and DM, and HT in Australia. Literature pertaining to pathology diagnosis and management of these patients as well as the complexities in management were considered. This involved evidence from PubMed-listed articles published between 1993 and 2016 including original research studies, focusing on randomised controlled trials and prospective studies where possible, systematic and other review articles, meta- analyses, expert consensus documents and specialist society guidelines, such as those from the National Heart Foundation of Australia, American Diabetes Association, the Department of Health, The Royal College of Pathologists of Australasia, and The Australasian College of Emergency Medicine. Based on the literature reviewed, it is yet unknown as to how effective programs, such as diabetes inpatient services, endocrine out-patient services, and cardiac rehabilitation services, are at achieving guideline recommendations. It is also not clear how or whether clinicians are encumbered by complexities in their efforts of adhering to DM, HT, and glucose control recommendations, and the potential reasons for clinical inertia. Future studies are needed to ascertain the extent to which required BP and glucose control in patients is achieved, and whether clinical inertia is a barrier.

The art of self-knowledge and deduction in clinical practice.

Clinical reasoning involves interviewing the patient, taking a history, and carefully scrutinising objects in the environment, via a physical examination, and the interpretation of medical results. Developments in medicine are trending towards the routine use of sophisticated diagnostic tools. While important, these trends may be leading clinicians to rely on expensive tests, while not using or improving the art of clinical deduction. The ideal clinician knows themselves and their environment, truly observes, imagines the possibilities, deduces from what they observe, and continually learns. This allows the clinician to use all of their senses, while not primarily relying on a diagnostic test.

Are all after-hours diagnostic imaging appropriate? An Australian Emergency Department pilot study.

BACKGROUND: This study was aimed at determining the extent to which after-hours diagnostic imaging is appropriate within the case hospital's Emergency Department. This was amid growing concerns of the inappropriateness of some medical investigations within the Australian health-care system. METHODS: After-hours referral data and patient notes were used in reviewing the clinical case. Diagnostic imaging was deemed appropriate if reflective of clinical guidelines, and if not reflective, whether the investigation changed the patient's ongoing management. RESULTS: Results indicated that 96.37% of after-hours diagnostic imaging adhered to clinical guidelines and was appropriately requested, with 95.85% changing the ongoing management of the patient. The most sought after diagnostic imaging procedures were Chest X-Ray (30.83%), and CT Brain (16.58%), with 99.16% and 98.44 appropriateness respectively. Chest pain (14.49%) and motor vehicle accidents (8.12%) were the leading reason for ordering after-hours imaging. CONCLUSION: This study provided an Emergency Department example as it relates to after-hours diagnostic imaging appropriateness. This study found that most after-hours referrals were appropriate.