A brief history of ramping.

'Ramping' is a commonly used term in contemporary Australian healthcare. It is also a part of the public and political zeitgeist. However, its precise definition varies among sources. In the published literature, there are distinctions between related terms, such as 'entry overload' and 'Patient Off Stretcher Time Delay'. How ramping is defined and how it came to be defined have significance for policies and procedures relating to the described phenomenon. Through examination of the history of the term, insights are obtained into the underlying issues contributing to ramping and, accordingly, associated possible solutions.

Push or pull? Digital notification platform implementation reduces dysglycaemia.

Pushing selected information to clinicians, as opposed to the traditional method of clinicians pulling information from an electronic medical record, has the potential to improve care. A digital notification platform was designed by clinicians and implemented in a tertiary hospital to flag dysglycaemia. There were 112 patients included in the study, and the post-implementation group demonstrated lower rates of dysglycaemia (2.5% vs 1.1%, P = 0.038). These findings raise considerations for information delivery methods for multiple domains in contemporary healthcare.

The future is bright: artificial intelligence for trainee medical officers in Australia and New Zealand.

Given their frontline role in Australia and Aotearoa New Zealand (ANZ) healthcare, trainee medical officers (TMOs) will play a crucial role in the development and use of artificial intelligence (AI) for clinical care, ongoing medical education and research. As 'digital natives', particularly those with technical expertise in AI, TMOs should also be leaders in informing the safe uptake and governance of AI within ANZ healthcare as they have a practical understanding of its associated risks and benefits. However, this is only possible if a culture of broad collaboration is instilled while the use of AI in ANZ is still in its initial phase.

Antibiotic Prescribing Practices Differ between Patients with Penicillin Intolerance and Penicillin Allergy Labels.

INTRODUCTION: Penicillin allergy labels are common. However, many penicillin allergy labels have been applied incorrectly and in fact represent penicillin intolerance. Patients with penicillin intolerance can receive penicillin antibiotics. The effect of penicillin intolerance labels on prescribing practices is uncertain. METHODS: This multicenter retrospective cohort study included consecutive general medicine patients admitted to two tertiary hospitals over a 12-month period. Electronic medical records were reviewed for allergy and prescribing practices. Instances of penicillin prescription to patients with previously labeled penicillin allergies underwent case note review. RESULTS: There were 12,134 individual hospital admissions included in the study. The number of admissions with a previous penicillin allergy label was 1,312 (10.8%) and with a penicillin intolerance label was 60 (0.5%). Penicillin allergy labels were associated with increased likelihood of being prescribed vancomycin (odds ratio 1.42, 95% confidence interval 1.16-1.75, p = 0.001) and moxifloxacin (odds ratio 20.0, 95% confidence interval 13.4-29.9, p < 0.001). Penicillin intolerance was not associated with increased likelihood of receiving these antibiotics. There were 75 admissions during which an individual with a penicillin allergy label was prescribed one of the specified penicillins and only one adverse reaction in this group. These cases included eight deliberate challenges and 15 cases in which allergy history clarification was sufficient to delabel the allergy. CONCLUSIONS: This study supports that prescribing practices differ between patients with penicillin allergy labels and intolerance labels. Penicillin challenges may be undertaken safely in the inpatient setting. Further studies are required to investigate how best to interrogate penicillin allergy labels in this cohort.

Sociocultural and Demographic Factors Predict Readmissions for General Surgery Patients.

INTRODUCTION: Readmission is a poor outcome for both patients and healthcare systems. The association of certain sociocultural and demographic characteristics with likelihood of readmission is uncertain in general surgical patients. METHOD: A multi-centre retrospective cohort study of consecutive unique individuals who survived to discharge during general surgical admissions was conducted. Sociocultural and demographic variables were evaluated alongside clinical parameters (considered both as raw values and their proportion of change in the 1-2 days prior to admission) for their association with 7 and 30 days readmission using logistic regression. RESULTS: There were 12,701 individuals included, with 304 (2.4%) individuals readmitted within 7 days, and 921 (7.3%) readmitted within 30 days. When incorporating absolute values of clinical parameters in the model, age was the only variable significantly associated with 7-day readmission, and primary language and presence of religion were the only variables significantly associated with 30-day readmission. When incorporating change in clinical parameters between the 1-2 days prior to discharge, primary language and religion were predictive of 30-day readmission. When controlling for changes in clinical parameters, only higher comorbidity burden (represented by higher Charlson comorbidity index score) was associated with increased likelihood of 30-day readmission. CONCLUSIONS: Sociocultural and demographic patient factors such as primary language, presence of religion, age, and comorbidity burden predict the likelihood of 7 and 30-day hospital readmission after general surgery. These findings support early implementation a postoperative care model that integrates all biopsychosocial domains across multiple disciplines of healthcare.

Muscle Protein Synthesis after Protein Administration in Critical Illness.

Rationale: Dietary protein may attenuate the muscle atrophy experienced by patients in the ICU, yet protein handling is poorly understood. Objectives: To quantify protein digestion and amino acid absorption and fasting and postprandial myofibrillar protein synthesis during critical illness. Methods: Fifteen mechanically ventilated adults (12 male; aged 50 ± 17 yr; body mass index, 27 ± 5 kg⋅m-2) and 10 healthy control subjects (6 male; 54 ± 23 yr; body mass index, 27 ± 4 kg⋅m-2) received a primed intravenous L-[ring-2H5]-phenylalanine, L-[3,5-2H2]-tyrosine, and L-[1-13C]-leucine infusion over 9.5 hours and a duodenal bolus of intrinsically labeled (L-[1-13C]-phenylalanine and L-[1-13C]-leucine) intact milk protein (20 g protein) over 60 minutes. Arterial blood and muscle samples were taken at baseline (fasting) and for 6 hours following duodenal protein administration. Data are mean ± SD, analyzed with two-way repeated measures ANOVA and independent samples t test. Measurements and Main Results: Fasting myofibrillar protein synthesis rates did not differ between ICU patients and healthy control subjects (0.023 ± 0.013% h-1 vs. 0.034 ± 0.016% h-1; P = 0.077). After protein administration, plasma amino acid availability did not differ between groups (ICU patients, 54.2 ± 9.1%, vs. healthy control subjects, 61.8 ± 13.1%; P = 0.12), and myofibrillar protein synthesis rates increased in both groups (0.028 ± 0.010% h-1 vs. 0.043 ± 0.018% h-1; main time effect P = 0.046; P-interaction = 0.584) with lower rates in ICU patients than in healthy control subjects (main group effect P = 0.001). Incorporation of protein-derived phenylalanine into myofibrillar protein was ∼60% lower in ICU patients (0.007 ± 0.007 mol percent excess vs. 0.017 ± 0.009 mol percent excess; P = 0.007). Conclusions: The capacity for critically ill patients to use ingested protein for muscle protein synthesis is markedly blunted despite relatively normal protein digestion and amino acid absorption.

Why do we evaluate 30-day readmissions in general medicine? A historical perspective and contemporary data.

Reducing preventable readmissions is important to help manage current strains on healthcare systems. The metric of 30-day readmissions is commonly cited in discussions regarding this topic. While such thresholds have contemporary funding implications, the rationale for individual cut-off points is partially historical in nature. Through the examination of the basis for the analysis of 30-day readmissions, greater insight into the possible benefits and limitations of such a metric may be obtained.

Mixed-mode versus paper surveys for patient-reported outcomes after critical illness: A randomised controlled trial.

OBJECTIVE: The aim of the study was to determine the response rate to a mixed-mode survey using email compared with that to a paper survey in survivors of critical illness. DESIGN: This is a prospective randomised controlled trial. SETTING: The study was conducted at a single-centre quaternary intensive care unit (ICU) in Adelaide, Australia. PARTICIPANTS: Study participants were patients admitted to the ICU for ≥48 h and discharged from the hospital. INTERVENTIONS: The participants were randomised to receive a survey by paper (via mail) or via online (via email, or if a non-email user, via a letter with a website address). Patients who did not respond to the initial survey received a reminder paper survey after 14 days. The survey included quality of life (EuroQol-5D-5L), anxiety and depression (Hospital Anxiety and Depression Scale), and post-traumatic symptom (Impact of Event Scale-Revised) assessment. MAIN OUTCOME MEASURES: Survey response rate, extent of survey completion, clinical outcomes at different time points after discharge, and survey cost analysis were the main outcome measures. Outcomes were stratified based on follow-up time after ICU discharge (3, 6, and 12 months). RESULTS: A total of 239 patients were randomised. The response rate was similar between the groups (mixed-mode: 78% [92/118 patients] vs. paper: 80% [97/121 patients], p = 0.751) and did not differ between time points of follow-up. Incomplete surveys were more prevalent in the paper group (10% vs 18%). The median EuroQol-5D-5L index value was 0.83 [0.71-0.92]. Depressive symptoms were reported by 25% of patients (46/187), anxiety symptoms were reported by 27% (50/187), and probable post-traumatic stress disorder was reported by 14% (25/184). Patient outcomes did not differ between the groups or time points of follow-up. The cost per reply was AU$ 16.60 (mixed-mode) vs AU$ 19.78 (paper). CONCLUSION: The response rate of a mixed-mode survey is similar to that of a paper survey and may provide modest cost savings.

The use of smartphone-derived location data to evaluate participation following critical illness: A pilot observational cohort study.

BACKGROUND: Disability is common following critical illness, impacting the quality of life of survivors, and is difficult to measure. 'Participation' can be quantified as involvement in life outside of their home requiring movement from their home to other locations. Participation restriction is a key element of disability, and following critical illness, participation may be diminished. It may be possible to quantify this change using pre-existing smartphone data. OBJECTIVES: The feasibility of extracting location data from smartphones of survivors of intensive care unit (ICU) admission and assessing participation, using location-based outcomes, during recovery from critical illness was evaluated. METHODS: Fifty consecutively admitted, consenting adult survivors of non-elective admission to ICU of greater than 48-h duration were recruited to a prospective observational cohort study where they were followed up at 3 and 6 months following discharge. The feasibility of extracting location data from survivors' smartphones and creating location-derived outcomes assessing participation was investigated over three 28-d study periods: pre-ICU admission and at 3 and 6 months following discharge. The following were calculated: time spent at home; the number of destinations visited; linear distance travelled; and two 'activity spaces', a minimum convex polygon and standard deviation ellipse. RESULTS: Results are median [interquartile range] or n (%). The number of successful extractions was 9/50 (18%), 12/39 (31%), and 13/33 (39%); the percentage of time spent at home was 61 [56-68]%, 77 [66-87]%, and 67 [58-77]% (P = 0.16); the number of destinations visited was 34 [18-64], 38 [22-63], and 65 [46-88] (P = 0.02); linear distance travelled was 367 [56-788], 251 [114-323], and 747 [326-933] km over 28 d (P = 0.02), pre-ICU admission and at 3 and 6 months following ICU discharge, respectively. Activity spaces were successfully created. CONCLUSION: Limited smartphone ownership, missing data, and time-consuming data extraction limit current implementation of mass extraction of location data from patients' smartphones to aid prognostication or measure outcomes. The number of journeys taken and the linear distance travelled increased between 3 and 6 months, suggesting participation may improve over time.

Evaluation of coagulation status using viscoelastic testing in intensive care patients with coronavirus disease 2019 (COVID-19): An observational point prevalence cohort study.

BACKGROUND: Coronavirus Disease-19 (COVID-19) is associated with a high rate of thrombosis, the pathophysiology of which is not well defined. Viscoelastic testing may identify and characterise hypercoagulable states which are not apparent using conventional coagulation assays. OBJECTIVES: The objective of this study was to undertake viscoelastic evaluation of the coagulation state in critically ill adults with COVID-19-associated respiratory failure METHODS: This was a single-centre observational point prevalence cohort study of adults with COVID-19-associated respiratory failure requiring respiratory support in the intensive care unit. Coagulation status was evaluated using rotational thromboelastometry (ROTEM®) in conjunction with laboratory markers of coagulation. RESULTS: Six patients fulfilled inclusion criteria. Each patient had one ROTEM® performed. All patients had supranormal clot amplitude at 10 min (A10) and supranormal clot firmness (maximal clot firmness) measured in at least one ROTEM® pathway, and five were supranormal on all pathways. Minimal clot lysis was present on all analyses. Fibrinogen and D-dimer were elevated and routine markers of coagulation within normal ranges in all patients. CONCLUSION: Patients with COVID-19-associated respiratory failure admitted to the intensive care unit exhibit a hypercoagulable state which is not appreciable on conventional tests of coagulation. Supranormal clot firmness, minimal fibrinolysis, and hyperfibrinogenaemia are key findings. Further research is required into the pathophysiology of this hypercoagulable state, as well as the harms and benefits of different anticoagulation strategies.

An observational study investigating the use of patient-owned technology to quantify physical activity in survivors of critical illness.

BACKGROUND: Physical activity after intensive care unit (ICU) discharge is challenging to measure but could inform research and practice. A patient's smartphone may provide a novel method to quantify physical activity. OBJECTIVES: We aimed to evaluate the feasibility and accuracy of using smartphone step counts among survivors of critical illness. METHODS: We performed a prospective observational cohort study in 50 patients who had an ICU length of stay>48 h, owned a smartphone, were ambulatory before admission, and were likely to attend follow-up at 3 and 6 months after discharge. At follow-up, daily step counts were extracted from participants' smartphones and two FitBit pedometers, and exercise capacity (6-min walk test) and quality of life (European Quality of Life-5 Dimensions) were measured. RESULTS: Thirty-nine (78%) patients returned at 3 months and 33 (66%) at 6 months, the median [interquartile range] smartphone step counts being 3372 [1688-5899] and 2716 [1717-5994], respectively. There was a strong linear relationship, with smartphone approximating 0.71 (0.58, 0.84) of FitBit step counts, P < 0.0001, R-squared = 0.87. There were weak relationships between step counts and the 6-min walk test distance. CONCLUSION: Although smartphone ownership and data acquisition limit the viability of using extracted smartphone steps at this time, mean daily step counts recorded using a smartphone may act as a surrogate for a dedicated pedometer; however, the relationship between step counts and other measures of physical recovery remains unclear.

Wide Disagreement Between Alternative Assessments of Premorbid Physical Activity: Subjective Patient and Surrogate Reports and Objective Smartphone Data.

OBJECTIVES: Surrogate-decision maker and patient self-reported estimates of the distances walked prior to acute illness are subjective and may be imprecise. It may be possible to extract objective data from a patient's smartphone, specifically, step and global position system data, to quantify physical activity. The objectives were to 1) assess the agreement between surrogate-decision maker and patient self-reported estimates of distance and time walked prior to resting and daily step-count and 2) determine the feasibility of extracting premorbid physical activity (step and global position system) data from critically ill patients. DESIGN: Prospective cohort study. SETTING: Quaternary ICU. PATIENTS: Fifty consecutively admitted adult patients who owned a smartphone, who were ambulatory at baseline, and who remained in ICU for more than 48 hours participated. MEASURMENTS AND MAIN RESULTS: There was no agreement between patients and surrogates for all premorbid walking metrics (mean bias 108% [99% lower to 8,700% higher], 83% [97% to 2,100%], and 71% [96% to 1,080%], for distance, time, and steps, respectively). Step and/or global position system data were successfully extracted from 24 of 50 phones (48%; 95% CI, 35-62%). Surrogate-decision makers, but not patient self-reported, estimates of steps taken per day correlated with smartphone data (surrogates: n = 13, ρ = 0.56, p < 0.05; patients: n = 13, ρ = 0.30, p = 0.317). CONCLUSION: There was a lack of agreement between surrogate-decision maker and patient self-reported subjective estimates of distance walked. Obtaining premorbid physical activity data from the current-generation smartphones was feasible in approximately 50% of patients.

A Retrospective Analysis of Characteristics Favouring In-Hospital Resuscitation Plan Completion, Their Timing, and Associated Outcomes.

Background: Comprehensive resuscitation plans document treatment recommendations, such as 'Not for cardiopulmonary resuscitation'. When created early in admission as a shared decision-making process, these plans support patient autonomy and guide future treatment. The characteristics of patients who have resuscitation plans documented, their timing, and associations with clinical outcomes remain unclear. Objectives: To characterise factors associated with resuscitation plan completion, early completion, and differences in mortality rates and Intensive Care Unit (ICU) admissions based on resuscitation plan status. Methods: This retrospective study analysed non-elective admissions to an Australian tertiary centre from January to June 2021, examining plan completion timing (early < 48 h, late > 48 h) and associations with mortality and ICU admission. Results: Of 13,718 admissions, 5745 (42%) had a resuscitation plan recorded. Most plans (89%) were completed early. Furthermore, 9% of patients died during admission, and 8.2% were admitted to the ICU. For those without resuscitation plans, 0.5% died (p < 0.001), and 9.7% were admitted to the ICU (p = 0.002). Factors associated with plan completion included a medical unit, in-hours admission, older age, female gender, limited English proficiency, and non-Indigenous status. Plans completed late (>48 h) correlated with a higher mortality (14% vs. 9%; p < 0.001) and more ICU admissions (25% vs. 6%; p < 0.001). Aboriginal and/or Torres Strait Islander patients were often overlooked for resuscitation documentation before death. No resuscitation plans were documented for 62% of ICU admissions. Conclusions: Important disparities exist in resuscitation plan completion rates across highly relevant inpatient and demographic groups.

Beware of little expenses: Low-value endocrinological blood tests in geriatric medical inpatients.

OBJECTIVES: Blood tests for endocrinological derangements are frequently requested in general medical inpatients, in particular those in the older age group. Interrogation of these tests may present opportunities for healthcare savings. METHODS: This multicentre retrospective study over a 2.5-year period examined the frequency with which three common endocrinological investigations [thyroid stimulating hormone (TSH), HbA1c, 25-hydroxy Vitamin D3] were performed in this population, including the frequency of duplicate tests within a given admission, and the frequency of abnormal test results. The Medicare Benefits Schedule was used to calculate the cost associated with these tests. RESULTS: There were 28,564 individual admissions included in the study. Individuals ≥65 years old were the majority of inpatients in whom the selected tests were performed (80% of tests). TSH was performed in 6730 admissions, HbA1c was performed in 2259 admissions, and vitamin D levels were performed in 5632 admissions. There were 6114 vitamin D tests performed during the study period, of which 2911 (48%) returned outside the normal range. The cost associated with vitamin D level testing was $183,726. Over the study period, 8% of tests for TSH, HbA1c, and Vitamin D were duplicates (where a second test was performed within a single admission), which was associated with a cost of $32,134. CONCLUSIONS: Tests for common endocrinological abnormalities are associated with significant healthcare costs. Avenues by which future savings may be pursued include the investigation of strategies to reduce duplicate ordering and examining the rationale and guidelines associated with ordering tests such as vitamin D levels.

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.

Large language models can effectively extract stroke and reperfusion audit data from medical free-text discharge summaries.

INTRODUCTION: Audits are an integral part of effective modern healthcare. The collection of data for audits can be resource intensive. Large language models (LLM) may be able to assist. This pilot study aimed to assess the feasibility of using a LLM to extract stroke audit data from free-text medical documentation. METHOD: Discharge summaries from a one-month retrospective cohort of stroke admissions at a tertiary hospital were collected. A locally-deployed LLM, LLaMA3, was then used to extract a variety of routine stroke audit data from free-text discharge summaries. These data were compared to the previously collected human audit data in the statewide registry. Manual case note review was undertaken in cases of discordance. RESULTS: Overall, there was a total of 144 data points that were extracted (9 data points for each of the 16 patients). The LLM was correct in 135/144 (93.8%) of individual datapoints. This performance included binary categorical, multiple-option categorical, datetime, and free-text extraction fields. CONCLUSIONS: LLM may be able to assist with the efficient collection of stroke audit data. Such approaches may be pursued in other specialties. Future studies should seek to examine the most effective way to deploy such approaches in conjunction with human auditors and researchers.

Quantifying time from last dose: do direct oral anticoagulant assays correlate with patient's reported last dose.

INTRODUCTION: In the absence of a patient's last direct oral anticoagulant (DOAC) dose time, best practice regarding preoperative DOAC cessation remains unclear. The aim of this study was to investigate, in a real-life patient cohort, if there was an association between subjective patient recall and objective DOAC assay titre. METHODS/MATERIALS: A multicentre cohort study of consecutive surgical inpatients was conducted. DOAC assays were 'expected' if they satisfied both time and titre-based guidelines. RESULTS: Patient-recalled last dose and DOAC assay was available in 285 individuals. DOAC assay titres correlated strongly with the expected levels based on a patient's reported last dose time(rho = 0.70, P value < 0.0001). However, underweight (<50 kg; P  = 0.0339) and elderly (>80 years; P  = 0.0134) were more likely to have an unexpectedly high assay titre. CONCLUSIONS: A significant portion (∼25%) of patients had unexpected DOAC titres. DOAC levels can be clinically impactful in a significant percentage of patients, particularly in elderly and/or underweight.