Widespread implementation of a low-cost telehealth service in the delivery of antenatal care during the COVID-19 pandemic: an interrupted time-series analysis.

BACKGROUND: Little evidence is available on the use of telehealth for antenatal care. In response to the COVID-19 pandemic, we developed and implemented a new antenatal care schedule integrating telehealth across all models of pregnancy care. To inform this clinical initiative, we aimed to assess the effectiveness and safety of telehealth in antenatal care. METHODS: We analysed routinely collected health data on all women giving birth at Monash Health, a large health service in Victoria (Australia), using an interrupted time-series design. We assessed the impact of telehealth integration into antenatal care from March 23, 2020, across low-risk and high-risk care models. Allowing a 1-month implementation period from March 23, 2020, we compared the first 3 months of telehealth integrated care delivered between April 20 and July 26, 2020, with conventional care delivered between Jan 1, 2018, and March 22, 2020. The primary outcomes were detection and outcomes of fetal growth restriction, pre-eclampsia, and gestational diabetes. Secondary outcomes were stillbirth, neonatal intensive care unit admission, and preterm birth (birth before 37 weeks' gestation). FINDINGS: Between Jan 1, 2018, and March 22, 2020, 20 031 women gave birth at Monash Health during the conventional care period and 2292 women gave birth during the telehealth integrated care period. Of 20 154 antenatal consultations provided in the integrated care period, 10 731 (53%) were delivered via telehealth. Overall, compared with the conventional care period, no significant differences were identified in the integrated care period with regard to the number of babies with fetal growth restriction (birthweight below the 3rd percentile; 2% in the integrated care period vs 2% in the conventional care period, p=0·72, for low-risk care models; 5% in the integrated care period vs 5% in the conventional care period, p=0·50 for high-risk care models), number of stillbirths (1% vs 1%, p=0·79; 2% vs 2%, p=0·70), or pregnancies complicated by pre-eclampsia (3% vs 3%, p=0·70; 9% vs 7%, p=0·15), or gestational diabetes (22% vs 22%, p=0·89; 30% vs 26%, p=0·06). Interrupted time-series analysis showed a significant reduction in preterm birth among women in high-risk models (-0·68% change in incidence per week [95% CI -1·37 to -0·002]; p=0·049), but no significant differences were identified in other outcome measures for low-risk or high-risk care models after telehealth integration compared with conventional care. INTERPRETATION: Telehealth integrated antenatal care enabled the reduction of in-person consultations by 50% without compromising pregnancy outcomes. This care model can help to minimise in-person interactions during the COVID-19 pandemic, but should also be considered in post-pandemic health-care models. FUNDING: None.

The Role of Local Public Health Units in Enhancing Outbreak Response in Residential Aged Care Facilities.

Local public health units offer a place-based response to disease threats impacting populations in its catchment. This place-based response can be further strengthened when local public health units (LPHUs) collaborate with local stakeholders, in particular health services, to protect the more vulnerable population. We describe the approaches taken by a newly formed LPHU in southeast metropolitan Victoria, Australia in COVID-19 outbreak management impacting residential aged care facilities (RACFs) in its catchment, throughout the different phases of the pandemic. These collaborative and flexible approaches ensured that public health actions met the demand and needs of stakeholders. Approaches included the development of prioritization and risks matrices, refining known processes such as outbreak management team membership and redefining roles of the LPHU as capacity of stakeholder evolved.

Achieving COVID-19 vaccination equity in South Eastern Metropolitan Victoria, Australia: a population-based study.

Background: We describe COVID-19 first and second vaccine uptake across Local Government Areas (LGAs) in Victoria using southeast metropolitan Melbourne catchment as a case study. We explore key policy and implementation strategies that contributed to equitable uptake. Methods: Population level data within the South East Public Health Unit (SEPHU) was used to compare trends in COVID-19 vaccination first and second dose uptake for each of the 11 LGAs in year 2021. Changes in vaccination uptake over the year were reviewed against social and public health measures used during the COVID-19 pandemic in Victoria and strategies in the SEPHU vaccination program. Findings: By September 2021, 57% of the eligible population in the least disadvantaged LGA, Bayside, had received their second dose vaccination compared to 32% in the most disadvantaged LGA, Greater Dandenong. By end of 2021, the gap had narrowed with 95% in Bayside and 92% in Greater Dandenong having received their second dose. The increase in vaccination uptake for both LGAs was bimodal. Government policies on vaccine eligibility and the opening of mass vaccination sites preceded the first peak in vaccination uptake. Strong community engagement, addressing misinformation, providing culturally appropriate vaccination services and mass outbreaks preceded the second peak in vaccination uptake. Interpretation: Vaccine equity across culturally and economically diverse populations can be achieved through a combination of robust, targeted community engagement, mass deployment of appropriate workforce, vaccination services tailored to cultural needs and sensitivities and accessibility to mass vaccination sites on a backdrop of state-wide policies that incentivise vaccination. Funding: None.

Streamlining elective surgery care in a public hospital: the Alfred experience.

OBJECTIVE: To evaluate the effectiveness of redesigning and streamlining perioperative services. DESIGN: A before-and-after evaluation, with retrospective analysis of de-identified administrative data. SETTING: A major tertiary hospital, Melbourne, Australia. PARTICIPANTS: Patients undergoing elective surgery, February 2005 - February 2010. INTERVENTION: Implementing a process redesign to streamline clinical pathways for elective surgery, with a focus on the patient journey from referral to discharge, and establishing a separate, dedicated elective surgery facility. MAIN OUTCOME MEASURES: Numbers of patients waiting beyond national recommended waiting times for elective surgery; hospital-initiated postponement (HIP) rates for elective surgery; and lengths of stay (LOS), both combined and for specific diagnostic-related groups. RESULTS: The clinical process redesign resulted in a sustained downward trend in the number of elective surgery patients waiting longer than national recommended maximum waiting times. HIP rates were reduced to 1% in the dedicated elective surgery facility, and there was a significant reduction in the combined LOS, as well as the LOS for the most common surgical procedures (P < 0.001). CONCLUSIONS: Clinical process redesign of perioperative services and collocation of a separate elective surgery centre improved (i) timeliness of care for elective surgery patients and (ii) key indicators (LOS and HIP rates) for planned elective admissions.

Breaking the chain of transmission within a tertiary health service: An approach to contact tracing during the COVID-19 pandemic.

BACKGROUND: Tertiary referral health service. INTERVENTION(S): An approach to hospital based contact tracing is described along with tools employed to streamline the process and including the development of an outbreak management team (OMT) for each contact trace. RESULTS: Forty-one OMTs occurred, involving 23 HCW and 18 patient index cases. The total furloughed HCWs arising from these contact traces was 383, with individual contact traces furloughing a mean (range) of 10 (0-80) HCWs. Importantly, 15 furloughed HCWs subsequently became COVID-19 positive during their 14-day isolation period, showing the importance of the contact tracing process and the ability to remove workers from the workplace before they become infectious. CONCLUSIONS: A standardised, streamlined contact tracing procedure in healthcare settings ensures any impacts of COVID-19 positive cases are consistently managed. This response framework may be of use to other health services and help reduce the transmission of COVID-19 in the workplace.

Coronavirus testing in women attending antenatal care.

BACKGROUND: Universal screening has been proposed as a strategy to identify asymptomatic individuals infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and mitigate transmission. AIM: To investigate the rate of positive tests among pregnant women in Melbourne, Australia. METHODS: We performed a cross-sectional prevalence study at three maternity hospitals (one tertiary referral hospital and two secondary maternities) in Melbourne, Australia. SARS-CoV-2 testing was offered to all pregnant women attending face-to-face antenatal visits and to those attending the hospital with symptoms of possible coronavirus disease, between 6th and 19th of May 2020. Testing was performed by multiplex-tandem polymerase chain reaction (PCR) on combined oropharyngeal and nasopharyngeal swabs. The primary outcome was the proportion of positive SARS-CoV-2 tests. FINDINGS: SARS-CoV-2 testing was performed in 350 women, of whom 19 had symptoms of possible COVID-19. The median maternal age was 32 years (IQR 28-35 years), and the median gestational age at testing was 33 weeks and four days (IQR 28 weeks to 36 weeks and two days). All 350 tests returned negative results (p̂=0%, 95% CI 0-1.0%). CONCLUSION: In a two-week period of low disease prevalence, the rate of asymptomatic coronavirus infection among pregnant women in Australia during the study period was negligible, reflecting low levels of community transmission.

Redesigning emergency patient flow with timely quality care at the Alfred.

OBJECTIVES: The 4 h National Emergency Access Target was introduced in 2011. The Alfred Hospital in Melbourne implemented a hospital-wide clinical service framework, Timely Quality Care (TQC), to enhance patient experience and care quality by improving timeliness of interventions and investigations through the emergency episode and admission to discharge in 2012. We evaluated TQC's effect on achieving the National Emergency Access Target and associated safety and quality indicators. METHODS: Retrospective analysis with piecewise regression of 215 125 ED attendances before/after implementation, November 2009 to August 2013; with comparison of proportions of patients discharged, admitted or transferred from ED within 4 h of arrival; left at risk; unplanned ED re-attendances up to 28 days; ED length of stay; and in-hospital mortality. RESULTS: The percentage of patients admitted, discharged or transferred within 4 h rose from 60% in 2010, to 74% in 2013. Median ED length of stay decreased significantly. Rate of unplanned ED re-presentations decreased by 27%, 22% and 17% within 24 h, 48 h and 7 days, respectively; and patient numbers leaving at risk halved from 8% to 4%. Mortality for admitted patients declined from 3.5% to 2.2%. All results were statistically significant. CONCLUSIONS AND FUTURE DIRECTIONS: TQC resulted in improvement in timeliness of care for emergency patients without compromising safety and quality. Success is attributed to effective engagement of stakeholders with a hospital-wide approach to redesigning the care pathway and establishing a new set of principles that underpin care from the time of ED arrival.

Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia.

OBJECTIVE: To examine the response of the Victorian State Trauma System to the February 2009 bushfires. DESIGN AND SETTING: A retrospective review of the strategic response required to treat patients with bushfire-related injury in the first 72 hours of the Victorian bushfires that began on 7 February 2009. Emergency department (ED) presentations and initial management of patients presenting to the state's adult burns centre (The Alfred Hospital [The Alfred]) were analysed, as well as injuries and deaths associated with the fires. RESULTS: There were 414 patients who presented to hospital EDs as a result of the bushfires. Patients were triaged at the emergency scene, at treatment centres and in hospital. National and statewide burns disaster plans were activated. Twenty-two patients with burns presented to the state's burns referral centres, of whom 18 were adults. Adult burns patients at The Alfred spent 48.7 hours in theatre in the first 72 hours. There were a further 390 bushfire-related ED presentations across the state in the first 72 hours. Most patients with serious burns were triaged to and managed at burns referral centres. Throughout the disaster, burns referral centres continued to have substantial surge capacity. CONCLUSIONS: Most bushfire victims either died, or survived with minor injuries. As a result of good prehospital triage and planning, the small number of patients with serious burns did not overload the acute health care system.