Cost-analysis of opportunistic influenza vaccination in general medical inpatients.

Influenza vaccination is an important preventative health measure in the elderly and those with medical comorbidities. It has been shown to reduce hospitalisations, cardiovascular and respiratory complications. A significant proportion of patients admitted to general medicine are eligible for opportunistic inpatient influenza vaccination. This study explores the cost-effectiveness of such a strategy in reducing subsequent healthcare utilisation costs.

'Cold and lonely': emergency presentations of patients with hypothermia to a large Australian health network.

BACKGROUND: Extreme heat is a public health priority in Australia with the health effects of cold poorly studied. A record-breaking cold winter prompted an institutional investigation into the epidemiology and outcomes of hypothermic presentations. AIMS: To describe the clinical and epidemiological characteristics of hypothermic emergency presentations including patient outcomes as well as gaps in practice. METHODS: This was a retrospective cohort observational study of hypothermic emergency presentations between 7 July 2009 and 1 September 2016 with a temperature of ≤35°C. Independent predictors for inpatient mortality and characteristics of exposure versus non-exposure presentations were evaluated. RESULTS: There were 217 patients with 226 presentations comprising male gender in 54%, median age 76.5 years (interquartile range (IQR) 53-88) and median initial temperature 33.3°C (IQR 31.2-34.3°C). Non-exposure presentations being found indoors, accounted for 78% overall, with elderly persons ≥65 years (P = 0.002) and multimorbidity (Charlson comorbidity index ≥4, P = 0.013) overrepresented in this subgroup. Among the non-exposure cohort, 55% were pensioners and 42% lived alone. Inpatient mortality was 11% overall and significantly higher in non-exposure versus exposure cohorts (16 vs 2%, P = 0.01). Independent predictors of inpatient mortality included heart failure (P = 0.04), metastatic malignancy (P < 0.01), chronic kidney disease (P < 0.05) and sepsis (P < 0.01). In contrast, exposure-related presentations were characterised by younger patients with intoxication due to alcohol and/or illicit drugs and psychiatric comorbidity. CONCLUSIONS: Hypothermia is a marker of clinical and socioeconomic vulnerability. The dominant presentation of the elderly patient with multimorbidity, and few social supports being found indoors, raises broader questions around the social determinants of health.

Prevalence of hyperglycaemia without previously recognised diabetes mellitus in the emergency department and subsequent management: a retrospective cross-sectional study.

BACKGROUND: Australian hospital data on hyperglycaemia without previously known diabetes are lacking. AIMS: To determine the prevalence of hyperglycaemia without previously recognised diabetes among all patients screened in the emergency department (ED). Secondary aims are to describe the extent of haemoglobin A1c testing for evaluation of new diabetes, adequate glucose monitoring, treatment of significant hyperglycaemia and documented follow-up plans. METHODS: Patients presenting to ED at the Alfred (tertiary hospital in Melbourne) have undergone screening random plasma glucose (RPG) with their first plasma biochemistry since 2015. Of the 16 268 adults screened from July to December 2015, a retrospective, cross-sectional study was undertaken evaluating those with hyperglycaemia (RPG >7.8 mmol/L) but without previously recognised diabetes as determined from coding data. After patient records were reviewed to correct for coding errors, a nested cohort of 200 such patients were further evaluated. Glucose monitoring was deemed adequate if undertaken for ≥48 h. Significant hyperglycaemia (RPG >11 mmol/L) was considered appropriately treated if insulin/hypoglycaemic agents were prescribed. Documented follow-up plans were acceptable if found in the discharge summary. RESULTS: Among all patients screened, 1178 had hyperglycaemia without coded diabetes. After adjusting for coding errors, the prevalence was 5.2%. Within the nested cohort, only 7.5% had a follow-up haemoglobin A1c ordered, 9.5% underwent adequate glucose monitoring, 6.5% had appropriate treatment of significant hyperglycaemia and 2% had documentation of a follow-up plan. CONCLUSIONS: Hyperglycaemia without previously recognised diabetes is commonly seen and justifies ED screening. However, management of newly detected hyperglycaemia in these patients is suboptimal and requires improvement.

Opportunities to improve influenza vaccination rates in general medical inpatients.

Influenza vaccination is an important preventative health measure. A significant proportion of general medical inpatients meets indications for annual inactivated influenza vaccination (IIV), as recommended by the Australian National Immunisation Programme. This study explores opportunities to provide IIV to eligible general medical inpatients and associated barriers.

United we stand, divided we conquer: pilot study of multidisciplinary General Medicine Heart Failure Care Program.

BACKGROUND: Heart failure care and education require a multifaceted approach to ensure appropriate transition from inpatient to outpatient care. AIMS: To explore the feasibility of a multidisciplinary heart failure care model, General Medicine Heart Failure Care Program (GM-HFCP), within a General Medical Unit (GMU). METHODS: Prospective non-randomised before-and-after observational quality improvement intervention over a 6-month period was conducted. All consecutive patients admitted to GMU at Alfred Hospital, Melbourne with a diagnosis of acute decompensated heart failure were included. Main outcome measures included changes in rates of pharmacologic prescription, non-pharmacologic ward-based management, patient education and action plan provision after intervention. RESULTS: In total, 108 patients were included (median age 84 (inter-quartile range 80-89) years, 47(44%) females). Significant improvements were noted in non-pharmacologic management for patient education regarding fluid restriction (12-30%, P = 0.04), weight monitoring (10-28%, P = 0.03), heart failure action plan on discharge (4-28%, P = 0.002) and salt restriction (6-32%, P = 0.002). The rates of prescription of heart failure medications remained similar between the pre- and post-implementation periods, particularly in patients with reduced ejection fraction by 'appropriateness of prescription' criteria. There were no differences in inpatient mortality or 30-day readmission rates in both groups. CONCLUSIONS: This prospective observational study demonstrated that it is possible to share the roles of a heart failure nurse amongst members of the multidisciplinary team, with similar rates of delivery of pharmacologic and non-pharmacologic management aspects. However, further innovative improvements are needed to address certain aspects of heart failure care.

A feasibility study of the provision of a personalized interdisciplinary audiovisual summary to facilitate care transfer care at hospital discharge: Care Transfer Video (CareTV).

OBJECTIVE: To assess the feasibility and patient acceptance of a personalized interdisciplinary audiovisual record to facilitate effective communication with patients, family, carers and other healthcare workers at hospital discharge. DESIGN: Descriptive pilot study utilizing a study-specific patient feedback questionnaire conducted from October 2013 to June 2014. SETTING AND PARTICIPANTS: Twenty General Medical inpatients being discharged from an Acute General Medical Ward in a metropolitan teaching hospital. INTERVENTION: Audiovisual record of a CareTV filmed at the patient's bedside by a consultant-led interdisciplinary team, within 24 h prior to discharge from the ward, provided immediately for the patient to take home. Patient surveys were completed within 2 weeks of discharge. MAIN OUTCOME MEASURES: Technical quality, utilization, acceptability, patient satisfaction and recall of diagnosis, medication changes and post-discharge review arrangements. RESULTS: All patients had watched their CareTV either alone or in the presence of a variety of others: close family, their GP, a medical specialist, friends or other health personnel. Participating patients had good understanding of the video content and recall of their diagnosis, medication changes and post-discharge plans. Patient feedback was overwhelmingly positive. CONCLUSIONS: In the context of a General Medical Unit with extensive experience in interdisciplinary bedside rounding and teamwork, CareTV is simple to implement, inexpensive, technically feasible, requires minimal staff training and is acceptable to patients. The results of this pilot study will inform and indicate the feasibility of conducting a larger randomized control trial of the impact of CareTV on patient satisfaction, medication adherence and recall of key information, and primary healthcare provider satisfaction.

Prevalence, associations, and risk factors for orthostatic hypotension in medical, surgical, and trauma inpatients: an observational cohort study.

BACKGROUND: Orthostatic hypotension (OH) is prevalent in hospitalized elderly patients. It is defined as a reduction in systolic blood pressure (SBP) of at least 20 mmHg and/or diastolic blood pressure (DBP) of at least 10 mmHg within 3 minutes of standing from a lying position. This observational cohort study describes the prevalence, association with symptoms, and risk factors for OH in medical, surgical, and trauma wards in a tertiary hospital and the differences in hemodynamic behaviors between OH-positive (OHP) and OH-negative (OHN) patients. METHODS: All 76 patients who were hemodynamically stable and able to stand from 4 hospital wards had noninvasive supine and orthostatic blood pressures (BPs) and pulse rates (PRs) measured over 4 days. RESULTS: Mean age of the 76 patients included in the study was 67.8 ± 19.6 years. Overall prevalence of OH was 23.7% (95% CI: 14.7%-34.8%) with 21.2% (95% CI: 9.0%-38.9%) in medical, 31.8% (95% CI: 13.9%-54.9%) in surgical, and 19.0% (95% CI: 5.4%-41.9%) in trauma wards. OH had no association with symptoms (P â€Š=  .53). We found no differences in age, number of comorbidities, and medication use between the OHN and OHP groups. The two groups displayed very different hemodynamic responses. The OHN group demonstrated a statistically significant compensatory rise in BP and PR over time to orthostatic challenge, while the OHP group displayed the opposite effect with BP. There was no statistically significant compensatory increase in PR over time to standing in the OHP group. CONCLUSIONS: OH is common and mostly asymptomatic. Routine measurements are recommended to detect cases in the hospital setting. Our study did not identify any significant risk factors for OH but rather confirmed the previous finding that underlying impairment in autonomic responses in individuals may have instead contributed to the development of OH.