Complexity of surgery and treatment burden in patients with peritoneal malignancy is not determined by addition of hyperthermic intraperitoneal chemotherapy.

BACKGROUND: This study describes surgical and quality of life outcomes in patients with peritoneal malignancy treated by cytoreductive surgery (CRS) alone compared with a subgroup treated with CRS and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: Peritoneal malignancy patients undergoing surgery between 2017 and 2023 were included. The cohort was divided into patients treated by CRS and HIPEC and those treated by CRS without HIPEC (including CRS only or maximal tumour debulking (MTB)). Main outcomes included surgical outcomes, survival, and quality of life. Groups were compared using non-parametric tests and log-rank test was used to compare survival curves. RESULTS: 403 had CRS and HIPEC, 25 CRS only and 15 MTB. CRS and HIPEC patients had a lower peritoneal carcinomatosis index (12.0 vs. 17.0 vs. 35.0; P < 0.001) and longer surgical operative time (9.3 vs. 8.3 vs. 5.2 h; P < 0.001), when compared to CRS only and MTB, respectively. No other significant difference between groups was observed. CONCLUSIONS: The optimal management of selected patients with resectable peritoneal malignancy incorporates a combined strategy of CRS and HIPEC. When HIPEC is not utilized, due to significant residual disease or comorbidity precluding safe delivery, CRS alone is associated with good outcomes. Hospital stay and complications are acceptable but not significantly different to the CRS and HIPEC group. CRS alone is a complex intervention requiring comparable resources with good outcomes. In view of our findings 'intention to treat' with CRS and HIPEC should be the basis for resource allocation and funding.

Delivering complex surgical services: lessons learned from the evolution of a specialised pelvic exenteration centre.

Pelvic exenteration (PE) is a potentially curative, ultra-radical surgical procedure for the treatment of advanced pelvic tumours, which involves surgical resection of multiple pelvic organs. Delivering such a complex low-volume, high-cost surgical program presents a number of unique health management challenges, and requires an organisation-wide approach involving both clinical and administrative teams. In contrast to the United Kingdom and France, where PE services have been historically decentralised, a centralised approach was developed early on in Australia and New Zealand (ANZ) with referral of these complex patients to a small number of quaternary centres. The PE program at the authors' institution was established in 1994 and has since evolved into the highest volume PE centre in the ANZ region and the largest single institution experience globally. These achievements have required navigation of specific funding and management issues, supported from inception by a proactive and collaborative relationship with hospital administration and management. The comprehensive state-wide quaternary referral model that has been developed has subsequently been successfully applied to other complex surgical services at the authors' institution, as well as by more recently established PE centres in Australia. This article aims to summarise the authors' experience with establishing and expanding this service and the lessons learned from a health management perspective.

Surgical outcomes and cost analysis of a multi-specialty robotic-assisted surgery caseload in the Australian public health system.

This study aims to compare surgical outcomes and in-hospital cost between robotic-assisted surgery (RAS), laparoscopic and open approaches for benign gynaecology, colorectal and urological patients and to explore the association between cost and surgical complexity. This retrospective cohort study included consecutive patients undergoing RAS, laparoscopic or open surgery for benign gynaecology, colorectal or urological conditions between July 2018 and June 2021 at a major public hospital in Sydney. Patients' characteristics, surgical outcomes and in-hospital cost variables were extracted from the hospital medical records using routinely collected diagnosis-related groups (DRG) codes. Comparison of the outcomes within each surgical discipline and according to surgical complexity were performed using non-parametric statistics. Of the 1,271 patients included, 756 underwent benign gynaecology (54 robotic, 652 laparoscopic, 50 open), 233 colorectal (49 robotic, 123 laparoscopic, 61 open) and 282 urological surgeries (184 robotic, 12 laparoscopic, 86 open). Patients undergoing minimally invasive surgery (robotic or laparoscopic) presented with a significantly shorter length of hospital stay when compared to open surgical approach (P < 0.001). Rates of postoperative morbidity were significantly lower in robotic colorectal and urological procedures when compared to laparoscopic and open approaches. The total in-hospital cost of robotic benign gynaecology, colorectal and urological surgeries were significantly higher than other surgical approaches, independent of the surgical complexity. RAS resulted in better surgical outcomes, especially when compared to open surgery in patients presenting with benign gynaecology, colorectal and urological diseases. However, the total cost of RAS was higher than laparoscopic and open surgical approaches.

Sydney Local Health District's Integrated Response to the COVID-19 Pandemic: A Descriptive Study.

Introduction: Sydney Local Health District (SLHD) is a local health district in the state of New South Wales in Australia responsible for providing health services to the centre and inner west of the Sydney metropolitan area. SLHD adopted, during the COVID-19 pandemic, an integrated virtual and community care approach to manage quarantine and protect the health and wellbeing of the population. Description: The case study describes the roles of the different agencies and teams in the first six months of the pandemic across four key functions of 1) rapid screening and testing; 2) reaching the community; 3) effective quarantine and ongoing care; and 4) infrastructure, pathology and staff education. Discussion: The "whole of system" approach proved to be an effective method of delivering care that reduced community anxiety, improved and created relationships between existing and new internal and external stakeholders, and changed the community and health sector's perspective on the importance of virtual care. Conclusion: This case study describes the importance of well-integrated, decentralised and funded public health system in response to the COVID-19 pandemic.

rpavirtual: Key lessons in healthcare organisational resilience in the time of COVID-19.

The COVID-19 pandemic is an unfolding crisis which is continually testing the resilience of healthcare organisations. In this context, a key requirement for executives, managers and frontline staff is continually adapting, learning and coping with complexity under pressure to deliver high quality and safe care. Sydney Local Health District has responded to the COVID-19 crisis, in part, through the pivoting of rpavirtual, a newly established virtual health service, to deliver an innovative model of care in a clinically rigorous and safe manner. Through reviewing the rapid evolution of rpavirtual's purpose, implementation challenges and impact, we investigate how it has displayed resilience and derive key lessons for health organisations.

Understanding for whom, how and why Sydney Local Health District's Integrated Response was Effective in Addressing COVID-19: A Critical Realist Qualitative Study.

INTRODUCTION: Australia has been comparatively effective in preventing the transmission of COVID-19. The Sydney Local Health District [SLHD] used a "whole of health" integrated approach to respond to the pandemic. The aim of this study was to understand for whom, how and why this response worked, to inform a sustainable system transformation. METHODS: A critical realist qualitative study was conducted with 20 purposively selected key informants. Data were collected through in-depth interviews and analysed using thematic analysis guided by abduction and retroduction. The five strategies of the WHO integrated people-centred health services framework was used to guide the overall study. RESULTS: An enabling environment of a strong governance, emergency preparedness, a committed and adaptable workforce, and a strong core infrastructure underpinned SLHD's effective response. With a culture of embracing innovation, the district adapted virtual care to effectively quarantine people through their special health accommodation, and coordinate care across tertiary and community services. The established interagency relationships prior to the pandemic, enabled service directors to quickly integrate their services, which empowered and engaged the community [and staff], working across relevant sectors to provide care "where the people are"; reaching marginalised populations, and reducing community transmission. DISCUSSION AND CONCLUSION: The SLHD's progress towards a 'whole of health' approach, empowered and enabled the district to effectively work within and across sectors to address the pandemic in a people-centred manner. Sustaining the contextual conditions and mechanisms, that facilitated effective integration, will be beneficial beyond the pandemic.

Pfizer/BioNtech BNT162b2: adverse events and insights from an Australian mass vaccination clinic for COVID-19.

The Pfizer/BioNtech BNT162b2 is a major vaccine used in the Australian COVID-19 immunisation programme. We report on BNT162b2 safety in the observation period in a dedicated vaccination clinic linked to a quaternary teaching hospital. We performed a retrospective review of medical records for 57 842 vaccinations, and describe the model of care and adverse event rate at the clinic during its first 2 months of operation. A total of 243 adverse events following immunisation (0.42% of total vaccine doses) were recorded in the immediate observation period post-vaccination, which were predominantly immunisation stress-related responses. Of the 110 patients who experienced an adverse event with their first dose of the vaccine, 90% returned for their second dose of the vaccine, with 87% not reporting any further adverse reaction with the subsequent dose. Nineteen (0.03% of total doses) people were reviewed for an allergic reaction, of which 10 (53%) reported a history of prior allergies. A female predominance was present in both total adverse reactions (70%) and allergic vaccine reactions (79%). Only two patients experienced anaphylaxis (0.003% of total doses), in keeping with low rates of adverse reactions to the BNT162b2 vaccine in the current literature. Overall, the present study reinforces the safety of BNT162b2 in the Australian population, describes vaccination completion rates after adverse events and identifies predisposing factors for rare allergic reactions to the vaccine.

Design and implementation of flexible advanced training in rheumatology: report of a pilot programme.

BACKGROUND: Training in medicine is highly demanding and coincides with critical life tasks including relationship development, childbearing and rearing. The rigid requirements of training programmes risk precluding successful achievement of these extracurricular roles, forcing choices between work and other life commitments. Flexible employment structures that facilitate the development of high-quality physicians are needed. AIM: To assess the outcomes of 2 novel flexible training positions in Rheumatology. METHODS: The clinical department, trainees and senior administration designed flexible, part-time advanced training positions in rheumatology. We sought to deliver excellent training, supervision and support while ensuring safe, efficient clinical service delivery within existing systems and cultures. Barriers to implementation were actively identified. We rejected job share arrangements in favour of independent part-time positions anchored to departmental education, clinical and trainee needs. The outcomes of these positions have been determined through regular trainee meetings, clinic activity and costs. RESULTS: Trainees achieved all training requirements, reported high levels of job satisfaction, strong professional development, improved work-life balance and reduction of stress. Outpatient events increased and waiting times have decreased. We estimate that increased rebatable outpatient services have rendered the positions cost neutral. CONCLUSION: Flexible training positions can enhance clinical departments while enabling high-quality training for junior doctors. Further work should consider longer term outcomes and application to different clinical and training settings.

Relational Quality Between the RN and Nursing Assistant: Essential for Teamwork and Communication.

OBJECTIVE: Nurse (RN) and nursing assistant (NA) relational quality was examined along with associations between relational quality and evaluations of teamwork and communication. BACKGROUND: RN and NA teams constitute the primary nursing care delivery method, and the quality of their relationship affects system capacity for improving patient outcomes; adverse events are linked to communication and teamwork breakdowns. METHODS: RN (N = 889) and NA (263) relational quality was examined using a cross-sectional secondary analysis from system assessment with the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture. RESULTS: RN and NA perceived relational quality indicated significant differences in teamwork and safety grade ratings, with both groups reporting perceived teamwork as high when patient safety grade was low. CONCLUSIONS: This study supports the benefits of improving the RN-NA teamwork-communication relationship. An enhanced RN-NA relational quality can be used by nurse leaders to optimize patient care delivery outcomes.

The Virtual Care Experience of Patients Diagnosed With COVID-19.

Virtual models of care are seen as a sustainable solution to the growing demand for health care. This paper analyses the experience of virtual care among patients diagnosed with COVID-19 in home isolation or health hotel quarantine using a patient-reported experience questionnaire. Results found that patients respond well to virtual models of care during a pandemic. Lessons learned can inform future developments of virtual care models.

Virtual Health Care for Community Management of Patients With COVID-19 in Australia: Observational Cohort Study.

BACKGROUND: Australia has successfully controlled the COVID-19 pandemic. Similar to other high-income countries, Australia has extensively used telehealth services. Virtual health care, including telemedicine in combination with remote patient monitoring, has been implemented in certain settings as part of new models of care that are aimed at managing patients with COVID-19 outside the hospital setting. OBJECTIVE: This study aimed to describe the implementation of and early experience with virtual health care for community management of patients with COVID-19. METHODS: This observational cohort study was conducted with patients with COVID-19 who availed of a large Australian metropolitan health service with an established virtual health care program capable of monitoring patients remotely. We included patients with COVID-19 who received the health service, could self-isolate safely, did not require immediate admission to an in-patient setting, had no major active comorbid illness, and could be managed at home or at other suitable sites. Skin temperature, pulse rate, and blood oxygen saturation were remotely monitored. The primary outcome measures were care escalation rates, including emergency department presentation, and hospital admission. RESULTS: During March 11-29, 2020, a total of 162 of 173 (93.6%) patients with COVID-19 (median age 38 years, range 11-79 years), who were diagnosed locally, were enrolled in the virtual health care program. For 62 of 162 (38.3%) patients discharged during this period, the median length of stay was 8 (range 1-17) days. The peak of 100 prevalent patients equated to approximately 25 patients per registered nurse per shift. Patients were contacted a median of 16 (range 1-30) times during this period. Video consultations (n=1902, 66.3%) comprised most of the patient contacts, and 132 (81.5%) patients were monitored remotely. Care escalation rates were low, with an ambulance attendance rate of 3% (n=5), emergency department attendance rate of 2.5% (n=4), and hospital admission rate of 1.9% (n=3). No deaths were recorded. CONCLUSIONS: Community-based virtual health care is safe for managing most patients with COVID-19 and can be rapidly implemented in an urban Australian setting for pandemic management. Health services implementing virtual health care should anticipate challenges associated with rapid technology deployments and provide adequate support to resolve them, including strategies to support the use of health information technologies among consumers.

Detailed cost of robotic-assisted surgery in the Australian public health sector: from implementation to a multi-specialty caseload.

BACKGROUND: A barrier to the uptake of robotic-assisted surgery (RAS) continues to be the perceived high costs. A lack of detailed costing information has made it difficult for public hospitals in particular to determine whether use of the technology is justified. This study aims to provide a detailed description of the patient episode costs and the contribution of RAS specific costs for multiple specialties in the public sector. METHODS: A retrospective descriptive costing review of all RAS cases undertaken at a large public tertiary referral hospital in Sydney, Australia from August 2016 to December 2018 was completed. This included RAS cases within benign gynaecology, cardiothoracic, colorectal and urology, with the total costs described utilizing various inpatient costing data, and RAS specific implementation, maintenance and consumable costs. RESULTS: Of 211 RAS patients, substantial variation was found between specialties with the overall median cost per patient being $19,269 (Interquartile range (IQR): $15,445 to $32,199). The RAS specific costs were $8828 (46%) made up of fixed costs including $4691 (24%) implementation and $2290 (12%) maintenance, both of which are volume dependent; and $1848 (10%) RAS consumable costs. This was in the context of 37% robotic theatre utilisation. CONCLUSIONS: There is considerable variation across surgical specialties for the cost of RAS. It is important to highlight the different cost components and drivers associated with a RAS program including its dependence on volume and how it fits within funding systems in the public sector.

Control of COVID-19 in Australia through quarantine: the role of special health accommodation (SHA) in New South Wales, Australia.

BACKGROUND: The first COVID-19 cases were diagnosed in Australia on 25 January 2020. Initial epidiemiology showed that the majority of cases were in returned travellers from overseas. One aspect of Public Health response was to introduce compulsory 14 day quarantine for all travellers returning to New South Wales (NSW) by air or sea in Special Health Accommodation (SHA). We aim to outline the establishment of a specialised health quarantine accommodation service in the context of the COVID-19 pandemic, and describe the first month of COVID-19 screening. METHODS: The SHA was established with a comprehensive governance structure, remote clinical management through Royal Prince Alfred Virtual Hospital (rpavirtual) and site management with health care workers, NSW Police and accommodation staff. RESULTS: From 29 March to 29 April 2020, 373 returning travellers were admitted to the SHA from Sydney Airport. 88 (26.1%) of those swabbed were positive for SARS-CoV 2. The day of diagnosis of COVID-19 varied from Day 1 to Day 13, with 63.6% (n = 56) of these in the first week of quarantine. 50% of the people in the SHA were referred to rpavirtual for ongoing clinical management. Seven people required admission to hospital for ongoing clinical care. CONCLUSION: The Public Health response to COVID-19 in Australia included early and increased case detection through testing, tracing of contacts of confirmed cases, social distancing and prohibition of gatherings. In addition to these measures, the introduction of mandated quarantine for travellers to Australia was integral to the successful containment of COVID-19 in NSW and Australia through the prevention of transmission locally and interstate from returning travellers.

Understanding the peer, manager, and system influence on patient safety.

A unique view of the Hospital Survey on Patient Safety Culture.

Research as the gatekeeper: introduction ofrobotic-assisted surgery into the public sector.

Objective Within Australia, robotic-assisted surgery (RAS) has largely been undertaken within the private sector, and predominately based within urology. This is rapidly developing, with RAS becoming increasingly prevalent across surgical specialties and within public hospitals. At this point in time there is a need to consider how this generation of the technology can be appropriately and safely introduced into the public health system given its prohibitive costs and lack of high-level long-term evidence. Methods This paper describes a unique approach used to govern the establishment of a new RAS program within a large public tertiary referral hospital in Australia. This included the creation of a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. Results Taking this novel approach, both benefits and challenges were encountered. Although initially there was a trade-off of activity to enable time for the research program to be developed, it was found the model strengthened patient safety in introducing the technology, fostered a breadth of surgical speciality involvement, ensured uniformity of data collection and, in the longer term, will enable a significant contribution to be made to the evidence regarding the appropriateness of RAS being used across several surgical specialties. Conclusions There is potential for this comprehensive governance framework to be transferred to other public hospitals commencing or with existing RAS programs and to be applied to the introduction of other new and expensive surgical technology. What is known about the topic? RAS is rapidly evolving and becoming increasingly prevalent across surgical specialities in major public hospitals. Consequently, it is important that this new technology is safely and appropriately implemented into the public health system. What does this paper add? This article describes the benefits and implementation challenges of a novel RAS approach, including a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. What are the implications for practitioners? This comprehensive governance framework can be transferred to other public hospitals introducing, or already using, new and expensive surgical technology.

Surveillance methods to detect the impact of a significant cold chain breach.

In January 2015, a significant cold chain breach on a postnatal ward in a tertiary hospital in Sydney, Australia was noted to have been occurring since August 2013. Surveillance, amongst the 1178 mothers and 1178 babies affected, for vaccine-preventable diseases (VPDs) and adverse events following immunisation (AEFIs) using linkage with a notifiable diseases database was subsequently undertaken; no directly related instances of VPDs or AEFIs were detected. We evaluate this novel systematic surveillance method which has not been previously reported to determine whether it is effective in determining the impact of cold chain breaches on an individual and population level. The recommendation for revaccination of the affected mothers and subsequent surveillance was resource-intensive and future studies related to such incidents should focus on detailing the resources used to allow the costs versus benefits of such systematic surveillance to be determined.

Quality of delivery of "right@home": Implementation evaluation of an Australian sustained nurse home visiting intervention to improve parenting and the home learning environment.

BACKGROUND: Home visiting programs are implemented in high income countries to improve outcomes for families with young children. Significant resources are invested in such programs and high quality evaluations are important. In the context of research trials, implementation quality is often poorly reported and, when reported, is variable. This paper presents the quality of implementation of the right@home program, a sustained nurse home visiting intervention trialled in Australia, and delivered in a 'real world' context through usual child and family health services. right@home is structured around the core Maternal Early Childhood Sustained Home-visiting (MECSH) program, which is a salutogenic, child focused prevention model. METHOD: At each visit right@home practitioners completed a checklist detailing the client unique identifier, date of contact and activities undertaken. These checklists were collated to provide data on intervention dose, retention to program completion at child age 2 years, and visit content, which were compared with the program schedule. Quality of family-provider relationship was measured using the Session Rating Scale. Exploratory factor analysis was conducted to identify clusters of activities and allow qualitative assessment of concordance between program aims and program delivery. RESULTS: Of 363 intervention families offered the program, 352 (97·0%) commenced the program and 304 (87·3%) completed the program to child age 2 years. 253 of 352 (71·9%) families who commenced the program received more than 75 percent of scheduled visits including at least one antenatal visit. Families rated the participant-practitioner relationship highly (mean 39.4/40). The factor analysis identified six antenatal and six postnatal components which were concordant with the program aims. CONCLUSIONS: The right@home program was delivered with higher adherence to program dose, schedule and content, and retention than usually reported in other home visiting research. Program compliance may have resulted from program design (visit schedule, dose, content and delivery flexibility) that was consistent with family aims.