Patient satisfaction with a consumer codesigned lower limb cellulitis leaflet.

Objective This study evaluated whether a consumer codesigned leaflet about the common skin infection cellulitis would improve patient satisfaction. Methods A patient information leaflet was codesigned with consumers incorporating health literacy principles and attached to a new adult lower limb cellulitis management plan launched in three regional Victorian health services. Health service staff were educated to provide the leaflet during hospital care. Patients discharged with a diagnosis of cellulitis in an 8-month period were followed-up via telephone between 31 and 60 days after their discharge. Each patient was asked to provide feedback on the utility of the leaflet (if received) and their overall satisfaction with the information provided to them using a five-point scale (with scores of 4 or 5 considered to indicate satisfaction). Results In all, 81 of 127 (64%) patients (or carers) were contactable, consented to the study and answered the questions. Of these, 27% (n = 22) reported receiving, accepting and reading the leaflet. The proportion of patients who were satisfied with the information provided to them about cellulitis was 100% for those who received the leaflet, compared with 78% for those who did not receive the leaflet (95% confidence interval 4.8-34%; P = 0.02). Conclusion The provision of a consumer codesigned leaflet increased patient satisfaction with the information received about cellulitis. Real-world strategies to embed the delivery of such resources are required to ensure that more patients receive the benefit. What is known about the topic? There are known deficiencies in the information provided to patients about the common skin condition cellulitis. There is little published evaluation of strategies to address these knowledge deficiencies. What does this paper add? This study evaluated a simple strategy to address patient knowledge deficiencies on cellulitis. It highlights that pertinent information delivered in an accessible way can significantly increase patient satisfaction with the information provided to them. What are the implications for practitioners? These findings are a timely reminder for practitioners that even a simple intervention, such a providing a hard copy information leaflet, can improve patient satisfaction. A national repository of similar consumer codesigned materials would be valuable and could minimise existing duplication of effort in resource development across health sectors. Real-world strategies to embed the delivery of such resources is required to ensure that more patients receive the benefit.

Impact of time to first antimicrobial dose on length of stay and 30-day hospital readmission in patients with lower limb cellulitis.

OBJECTIVES: There have been efforts to promote timely antimicrobial administration for patients with sepsis, but the importance for other infections is uncertain. This study analysed whether time to first antimicrobial dose (TFAD) in patients with lower limb cellulitis influenced outcome measures such as acute length of stay (LOS) in hospital and 30-day hospital readmission rates for cellulitis. METHODS: Medical records of patients admitted with lower limb cellulitis or erysipelas over a 15-month period (1 May 2019 to 30 November 2019 and 1 March 2020 to 31 October 2020) were reviewed. Patients requiring intensive care unit (ICU) admission were excluded. The TFAD was the difference (in minutes) between the emergency department triage time and the time that the antimicrobial was first recorded as administered. Analysis included log-transformed linear regression (for LOS) and logistic regression (for 30-day readmission with cellulitis), controlling for confounders where possible. RESULTS: The study included 282 patients with lower limb cellulitis. The median TFAD was 177 min (interquartile range, 98-290 min). Linear regression suggested a weak association between TFAD and LOS (P = 0.05; adjusted R2 = 0.01), which was non-significant after adjusting for confounders (P = 0.18). There were too few patients readmitted within 30 days with cellulitis for meaningful analysis. CONCLUSION: After controlling for confounders, no association between increased TFAD and increased acute LOS was identified for patients with lower limb cellulitis who did not require ICU admission (i.e. without septic shock). Conclusions could not be made for 30-day readmission rates for cellulitis.

Sustainability of antimicrobial stewardship programs in Australian rural hospitals: a qualitative study.

Objective The aim of this study was to explore the features of sustainable antimicrobial stewardship (AMS) programs in Australian rural hospitals and develop recommendations on incorporating these features into rural hospitals' AMS programs. Methods Lead AMS clinicians with knowledge of at least one AMS program sustained for >2 years in a health service in rural Australia were recruited to the study. A series of interviews was conducted and the transcripts analysed thematically using a framework method. Results Fifteen participants from various professional disciplines were interviewed. Key features that positively affected the sustainability of AMS programs in rural hospitals included a hospital executive who provided strong governance and accountability, dedicated resources, passionate local champions, area-wide arrangements and adaptability to engage in new partnerships. Challenges to building AMS programs with these features were identified, particularly in engaging hospital executive to allocate AMS resources, managing the burn out of passionate champions and formalising network arrangements. Conclusions Strategies to increase the sustainability of AMS programs in rural hospitals include using accreditation as a mechanism to drive direct resource allocation, explicit staffing recommendations for rural hospitals, greater support to develop formal network arrangements and a framework for integrated AMS programs across primary, aged and acute care. What is known about the topic? AMS programs facilitate the responsible use of antimicrobials. Implementation challenges have been identified for rural hospitals, but the sustainability of AMS programs has not been explored. What does this paper add? Factors that positively affected the sustainability of AMS programs in rural hospitals were a hospital executive that provided strong governance and accountability, dedicated resources, network or area-wide arrangements and adaptability. Challenges to building AMS programs with these features were identified. What are the implications for practitioners? Recommended actions to boost the sustainability of AMS programs in rural hospitals are required. These include using accreditation as a mechanism to drive direct resource allocation, explicit staffing recommendations for rural hospitals, greater support to develop network arrangements and support to create integrated AMS programs across acute, aged and primary care.

Using telehealth to improve access to hepatitis C treatment in the direct-acting antiviral therapy era.

Introduction: One-third of the Australian population lives outside major cities and this group has worse health outcomes. Telehealth is becoming an accepted way to improve patient access to specialist healthcare. Over 200,000 Australian's have hepatitis C virus (HCV) and new treatments are very effective and well tolerated. We aim to demonstrate that HCV treatment utilising telehealth support for care delivery has cure rates similar to onsite care in clinical trials. We also report length of consultation and calculate reductions in travel and carbon output. Methods: Patient demographic, clinical, and treatment outcome data were collected prospectively from hospital software and analysed retrospectively. This was an audit of all patients treated for HCV in one year from a single tertiary hospital that included telehealth in their care delivery. Results: Sustained virological response was achieved in 51/52 (98%) patients with completed treatment courses, and 51/58 (88%) of those who had a planned telehealth consultation as part of their management. A median of 634 km of patient travel was saved per telehealth consultation. Discussion: We found that a telehealth-supported outreach programme for patients in regional Australia with HCV produced similar outcomes to clinical trials. There was a considerable saving in time and cost for the patients and significant environmental benefit through the reduction in carbon footprint associated with travel to distant specialist health services. We conclude that telehealth facilitated outreach is a feasible and effective way to access HCV treatment and cure in regional Australia.

Similarities and differences in antimicrobial prescribing between major city hospitals and regional and remote hospitals in Australia.

Many regional and remote hospitals (RRHs) do not have the specialist services that usually support antimicrobial stewardship (AMS) programmes in major city hospitals. It is not known if this is associated with higher rates of inappropriate antimicrobial prescribing. The aim of this study was to identify similarities and differences in antimicrobial prescribing patterns between major city hospitals and RRHs in Australia. The Australian Hospital National Antimicrobial Prescribing Survey (H-NAPS) datasets from 2014, 2015 and 2016 (totalling 47,876 antimicrobial prescriptions) were analysed. The antimicrobial prescribed, indications for use, documentation of indication, recording of a review date and assessment of the appropriateness of prescribing were evaluated. Overall, inappropriate prescribing of antimicrobials was higher in RRHs than in major city hospitals (24.0% vs. 22.1%; P<0.001). Compared with major city hospitals, inappropriate prescribing of ceftriaxone was higher in RRHs (33.9% vs. 27.6%; P<0.001), as was inappropriate prescribing for cellulitis (25.7% vs. 19.0%; P≤0.001). A higher rate of inappropriate prescribing was noted for some high-risk infections in RRHs compared with major city hospitals, including Gram-positive bacteraemia with sepsis (12.6% vs. 6.5%; P=0.004), empiric therapy for sepsis (26.0% vs. 12.0%; P<0.001) and endocarditis (8.2% vs. 2.7%; P=0.02). To the authors' knowledge, this is the largest study to date comparing antimicrobial prescribing of RRHs with major city hospitals. A key finding was that antimicrobial prescribing was more frequently inappropriate for some high-risk infections treated in RRHs. Targeted strategies that support appropriate antimicrobial prescribing in RRHs are required.

Meeting the challenge for effective antimicrobial stewardship programs in regional, rural and remote hospitals - what can we learn from the published literature?

INTRODUCTION: Antimicrobial resistance (AMR) has been recognised as an urgent health priority, both nationally and internationally. Australian hospitals are required to have an antimicrobial stewardship (AMS) program, yet the necessary resources may not be available in regional, rural or remote hospitals. This review will describe models for AMS programs that have been introduced in regional, rural or remote hospitals internationally and showcase achievements and key considerations that may guide Australian hospitals in establishing or sustaining AMS programs in the regional, rural or remote hospital setting. METHODS: A narrative review was undertaken based on literature retrieved from searches in Ovid Medline, Scopus, Web of Science and the grey literature. 'Cited' and 'cited by' searches were undertaken to identify additional articles. Articles were included if they described an AMS program in the regional, rural or remote hospital setting (defined as a bed size less than 300 and located in a non-metropolitan setting). RESULTS: Eighteen articles were selected for inclusion. The AMS initiatives described were categorised into models designed to address two different challenges relating to AMS program delivery in regional, rural and remote hospitals. This included models to enable regional, rural and remote hospital staff to manage AMS programs in the absence of on-site infectious diseases (ID) trained experts. Non-ID doctor-led, pharmacist-led and externally led initiatives were identified. Lack of pharmacist resources was recognised as a core barrier to the further development of a pharmacist-led model. The second challenge was access to timely off-site expert ID clinical advice when required. Examples where this had been overcome included models utilising visiting ID specialists, telehealth and hospital network structures. Formalisation of such arrangements is important to clarify the accountabilities of all parties and enhance the quality of the service. Information technology was identified as a facilitator to a number of these models. The variance in availability of information technology between hospitals and cost limits the adoption of uniform programs to support AMS. CONCLUSION: Despite known barriers, regional, rural and remote hospitals have implemented AMS programs. The examples highlighted show that difficulty recruiting ID specialists should not inhibit AMS programs in regional, rural and remote hospitals, as much of the day-to-day work of AMS can be done by non-experts. Capacity building and the strengthening of networks are core features of these programs. Descriptions of how Australian regional, rural and remote hospitals have structured and supported their AMS programs would add to the existing body of knowledge sourced from international examples. Research into AMS programs predominantly led by GPs and nursing staff will provide further possible models for regional, rural and remote hospitals.

Hepatitis B among immigrants from Myanmar: Genotypes and their clinical relevance.

Hepatitis B virus (HBV) from 76 adult immigrants in Australia from Myanmar was characterized to determine the prevalence of different HBV genotypes and subgenotypes. A mutational analysis was then performed to determine the presence of clinically significant mutations and correlate them to clinical outcomes. Initial genotyping revealed 68 patients with genotype C (89.5%) and eight patients with genotype B (10.5%). Phylogenetic analysis revealed the large majority of the genotype C infections were of subgenotype C1 (67/68). Sequencing of the HBV polymerase gene (and overlapping surface gene) revealed no mutations associated with antiviral resistance. HBV surface gene mutations were detected in 10 patients with subgenotype C1. HBV BCP/PC sequencing was obtained for 71/76 (93%) patients. BCP and/or PC mutations were identified in 57/71 (80%) of PCR positive patients. Treatment had been commenced for 15/76 (18%) patients, a further 26 untreated patients were in a stage of disease where HBV treatment would be considered standard of care. It was identified that genotype C1 is the predominant sub-genotype in this population. Genotype C is known to be associated with increased risk of development of HCC. This highlights the need for screening for HCC given the potential for the development of liver cancer. It was also identified that people with HBV were potentially not receiving optimal therapy in a timely fashion.

Improvements in patient care: videoconferencing to improve access to interpreters during clinical consultations for refugee and immigrant patients.

OBJECTIVE: To demonstrate the suitability of accessing interpreters via videoconference for medical consultations and to assess doctor and patient perceptions of this compared with either on-site or telephone interpreting. METHODS: We assessed the suitability and acceptability of accessing interpreters via videoconference during out-patient clinical consultations in two situations: (i) when the doctor and patient were in a consulting room at a central hospital and the interpreter sat remotely; and (ii) when the doctor, patient and interpreter were each at separate sites (during a telehealth consultation). The main outcome measures were patient and doctor satisfaction, number of problems recorded and acceptability compared with other methods for accessing an interpreter. RESULTS: Ninety-eight per cent of patients were satisfied overall with the use of an interpreter by video. When comparing videoconference interpreting with telephone interpreting, 82% of patients thought having an interpreter via video was better or much better, 15% thought it was the same and 3% considered it worse. Compared with on-site interpreting, 16% found videoconferencing better or much better, 58% considered it the same and 24% considered it worse or much worse. CONCLUSIONS: The present study has demonstrated that accessing an interpreter via videoconference is well accepted and preferred to telephone interpreting by both doctors and patients.

Using stool antigen to screen for Helicobacter pylori in immigrants and refugees from high prevalence countries is relatively cost effective in reducing the burden of gastric cancer and peptic ulceration.

OBJECTIVES: Refugees and immigrants from developing countries settling in industrialised countries have a high prevalence of Helicobacter pylori (H. pylori). Screening these groups for H. pylori and use of eradication therapy to reduce the future burden of gastric cancer and peptic ulcer disease is not currently recommended in most countries. We investigated whether a screening and eradication approach would be cost effective in high prevalence populations. METHODS: Nine different screening and follow-up strategies for asymptomatic immigrants from high H. pylori prevalence areas were compared with the current approach of no screening. Cost effectiveness comparisons assumed population prevalence's of H. pylori of 25%, 50% or 75%. The main outcome measure was the net cost for each cancer prevented for each strategy. Total costs of each strategy and net costs including savings from reductions in ulcers and gastric cancer were also calculated. RESULTS: Stool antigen testing with repeat testing after treatment was the most cost effective approach relative to others, for each prevalence value. The net cost per cancer prevented with this strategy was US$111,800 (assuming 75% prevalence), $132,300 (50%) and $193,900 (25%). A test and treat strategy using stool antigen remained relatively cost effective, even when the prevalence was 25%. CONCLUSIONS: H. pylori screening and eradication can be an effective strategy for reducing rates of gastric cancer and peptic ulcers in high prevalence populations and our data suggest that use of stool antigen testing is the most cost effective approach.

The limitations of polymerase chain reaction in the setting of possible recurrent tuberculosis: 2 instructional cases.

The interpretation of a positive result for Mycobacterium tuberculosis by nucleic acid amplification such as polymerase chain reaction (PCR) can be challenging. We present 2 cases that illustrate the limitations of tuberculosis PCR on respiratory secretions in previously treated patients, even years after the previous disease episode.

Hospitalised adult patients with pandemic (H1N1) 2009 influenza in Melbourne, Australia.

OBJECTIVE: To describe the case characteristics and outcomes of patients hospitalised with pandemic (H1N1) 2009 influenza infection during the first 2 months of the epidemic. DESIGN, PARTICIPANTS AND SETTING: Prospective case series of 112 patients admitted to seven hospitals in Melbourne with laboratory-confirmed pandemic (H1N1) 2009 influenza between 1 May and 17 July 2009. MAIN OUTCOME MEASURES: Details of case characteristics, risk factors for severe disease, treatment and clinical course. RESULTS: Of 112 hospitalised patients, most presented with cough (88%) and/or fever (82%), but several (4%) had neither symptom. A quarter of female patients (15) were pregnant or in the post-partum period. Patients presenting with multifocal changes on chest x-ray had significantly longer hospital lengths of stay, and were more likely to require intensive care unit admission. Thirty patients required admission to an intensive care unit, and three died during their acute illness. The median length of intensive care admission was 10.5 days (interquartile range, 5-16 days). CONCLUSIONS: This study highlights risk factors for severe disease, particularly pregnancy. Clinical and public health planning for upcoming influenza seasons should take into account the spectrum and severity of clinical infection demonstrated in this report, and the need to concentrate resources effectively in high-risk patient groups.