The Western Australian experience of COVID-19 after the borders reopened: evaluation of public health modelling predictions.

BACKGROUND: Western Australia (WA) serves as a unique global case study on the impact of coronavirus disease 2019 (COVID-19) on an isolated, prepared and highly vaccinated population. This study builds upon the study performed by House et al. through an extended data set. AIM: To examine the impact of COVID-19 at the only quaternary hospital in WA following the border opening from 3 March to 17 July 2022. PARTICIPANTS: A total of 257 adults were admitted with COVID-19 under either respiratory or the intensive care unit (ICU). OUTCOMES: Admission numbers, disease severity, ICU admission, prevalence of COVID-19 deterioration risk factors, length of stay and mortality. RESULTS: A total of 257 patients were admitted with COVID-19, under respiratory (81.7%) and ICU (18.3%). COVID-19 was the primary reason for admission for 67.7%. Ten patients died during the study, with seven deaths attributed to COVID pneumonitis. COVID-19 severity was 37.4% mild, 37.0% moderate, 18.3% severe and 7.4% critical. Risk factors for requiring ICU included incomplete immunisation status (P = 0.011), chronic kidney disease (P = 0.008) and Aboriginal and Torres Strait Islander (ATSI) ethnicity. The WA Department of Health predicted that the number of hospitalisations and ICU cases were significantly higher than the actual number of cases. CONCLUSION: The number of hospitalisations and ICU COVID-19 cases were significantly less than predicted, likely due to high population vaccination rates prior to border opening. The main risk factors for COVID-19 severity were incomplete immunisation and ATSI ethnicity.

Exploring the advancements of Australian OPAT.

Outpatient parenteral antimicrobial therapy (OPAT) in Australia has evolved from modest beginnings to a well-established health service with proven benefits in patient outcomes. This is a comprehensive review of the current state of art Australian OPAT with vignettes of the types of OPAT models of care, antimicrobial prescribing and antimicrobial use. In addition, we highlight the similarities and differences between OPAT to other countries and describe Australian OPAT experiences with COVID-19 and paediatrics. Australian OPAT continues to advance with OPAT antifungals, novel treatment options and upcoming high-impact research.

The unique COVID-19 experience in Western Australia: lessons learnt.

BACKGROUND: Western Australia (WA) was in a unique position to experience coronavirus disease 2019 (COVID-19) in a highly vaccinated and geographically isolated population. AIM: To describe the COVID-19 Omicron experience at the only quaternary hospital in WA following border opening from 3 March to 11 May 2022. PARTICIPANTS: A total of 158 adults with microbiologically confirmed COVID-19 were admitted to the respiratory or intensive care unit (ICU). OUTCOMES: Admission numbers, disease severity, prevalence of COVID-19 deterioration risk factors, immunisation status, severity of infection, immunosuppression and treatment regimen. RESULTS: One hundred fifty-eight COVID-19-positive patients were admitted to the respiratory ward (n = 123) and the ICU (n = 35) during the study period. COVID-19 infection was the primary admission reason in 32.9% of patients, 51.3% were male and the median age was 62 years. Aboriginal or Torres Strait Islanders (ATSI) were overrepresented (13.3%). Care was predominantly ward based (77.2%). Nearly half of the patients had mild COVID-19 (49.4%). Dexamethasone was the most common treatment provided to patients (58.2%). The median length of stay was 5.8 days (interquartile range, 5-15). Eight patients died during the study period (5.1%), with three of those deaths attributable to COVID-19. CONCLUSIONS: COVID-19 case numbers following WA state border opening were of lower care acuity and disease severity than predicted. Two-thirds of admissions were for other primary diagnoses, with incidental COVID detection. Hospital admissions were overrepresented by partially or unvaccinated patients and by ATSI Australians. An increase in social support along with general and geriatric medicine speciality input were required to treat hospitalised COVID-19 cases in the WA Omicron wave.

A survey of operating theatre staff on the impact of automated medication dispensing systems in operating theatres in an Australian hospital.

There is a lack of published literature investigating the impact of anaesthesia-specific automated medication dispensing systems on theatre staff. This study aimed to investigate the perspectives of theatre staff from multiple disciplines on their experience using anaesthesia stations three years after implementation at our Western Australian quaternary hospital institution. A web-based survey was distributed to 440 theatre staff, which included consultant anaesthetists, anaesthetic trainees, nurses, anaesthetic technicians and pharmacists, and 118 responses were received (response rate 26.8%). Eighty-one percent of the anaesthetic medical staff responders reported that the anaesthesia stations were fit for purpose and 66.67% of the anaesthetic medical staff reported that they were user friendly. Sixty-seven percent of anaesthetic medical staff agreed that controlled medication (e.g. schedule 8 and schedule 4 recordable) transactions were more efficient with the anaesthesia stations, and 66.67% agreed that the anaesthesia stations improved accountability for these transactions. Sixty-seven percent of anaesthetic medical staff preferred to use anaesthesia stations and 21.2% of all the responders preferred a manual medication trolley (P ≤ 0.001). This survey of user experience with anaesthesia stations was found to be predominantly positive with the majority of theatre staff and anaesthetic medical staff preferring anaesthesia stations.

Intravesical hyaluronic acid with chondroitin sulphate to prevent urinary tract infection after spinal cord injury.

CONTEXT/OBJECTIVE: Prevention of urinary tract infection (UTI) after spinal cord injury is an important goal. Intravesical hyaluronic acid with chondroitin sulphate (HA+CS) has been effective in preventing UTI in other settings. We aimed to demonstrate safety and feasibility of a standard treatment course of 7 intravesical HA+CS instillations over 12 weeks, in patients with acute (Arm A) and chronic (Arm B) spinal cord injury (SCI). DESIGN: Follow-up of adverse events, quality of life bladder management difficulty (BMD) and bladder complication (BC) T-scores at baseline (Arm B only), 12 and 24 weeks, and symptomatic urinary tract infection (UTI). RESULTS: Of 33 and 14 individuals screened, 2 and 8 participants were recruited to the study for Arm A and Arm B respectively. Of the 10 participants, 8 completed all 7 instillations. HA+CS commonly caused cloudy urine with urinary sediment which was mild and short-lived. In Arm B, a mean reduction in BMD and BC T-scores was observed from baseline (57.3 and 54.4 respectively), of 6.8 and 4.3 at 12 weeks and 1.6 and 2.8 at 24 weeks, respectively. Four participants with a history of frequent UTI in the prior 12 months did not have UTI in the 24 weeks of the study. CONCLUSIONS: HA+CS was well tolerated. Recruitment was more difficult in early acute SCI; participants with chronic SCI were highly motivated to reduce UTI and manage self-administration without difficulty. Larger case-control or randomized controlled trials in patients with neurogenic bladder from SCI are warranted. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03945110.

Antibiotic allergy labels and optimal antimicrobial stewardship.

BACKGROUND: Although common, antimicrobial allergy labels (AAL) rarely reflect immunologically-mediated hypersensitivity and can lead to poorer outcomes from alternative antimicrobial agents. Antimicrobial stewardship programs are ideally placed to assess AAL early as a means of improving antimicrobial use. AIMS: To quantify the prevalence of AAL in patients referred for antimicrobial stewardship review and assess their impact on antibiotic prescribing, patient mortality, hospital length of stay, readmission and rates of multidrug-resistant infections. METHODS: We conducted a retrospective analysis of adult patients referred for inpatient antimicrobial prospective audit and feedback rounds (PAFR) through an electronic referral system (eReferrals) over a 12-month period in 2015. Outcome data were collected for a period of 36 months following the initial review. RESULTS: Of the 639 patient records reviewed, 630 met inclusion criteria; 103 (16%) had an AAL, of which 82 (13%) had reported allergies to ß-lactam antibiotics. Those with AAL were significantly less likely to be receiving guideline-recommended antimicrobial therapy (50% vs 64%, P = 0.0311); however, there were no significant difference in mortality, hospital length of stay, readmission or increased incidence of multidrug-resistant infections. CONCLUSIONS: Our cohort demonstrated that AAL was associated with reduced adherence to antibiotic guidelines. The lack of association with adverse outcomes may reflect limitations within the study including retrospective cohort study numbers and observational nature, further skewed by high rates of poor documentation. A clear opportunity exists for antimicrobial stewardship programs to incorporate allergy assessment, de-labelling, challenge and referral into these rounds.

Impact of a Review of a Smart Infusion Pump Library in Hematology/Oncology: Tailoring Content to Meet Specialty Needs.

OBJECTIVES: Errors involving chemotherapy or intravenous medications may cause serious patient harm. Dose error reduction software (DERS) for "smart" infusion pumps offers additional safety protection for their administration. Our institution uses DERS software hospital-wide; however, the hematology/oncology areas were noted to have reduced compliance with DERS recommendations. In response, we sought to review the DERS content and survey hematology/oncology end users' satisfaction with the software. METHODS: A multidisciplinary working group was formed to review the current DERS entries for medications, fluids, and blood products. The review included details such as dose, rate, and concentrations. Dose error reduction software compliance was determined using vendor-supplied Continuous Quality Improvement software. An electronic survey assessing clinicians' satisfaction with the current DERS library and any challenges in its use was conducted before and after the review. RESULTS: Ninety-one changes were made to 71 medications by the working group. Compliance with the DERS library went from 81.5% before the review to 87.3% after the review (P = 0.257). Fifty-eight survey responses were received (30 prereview and 28 postreview) with improvements in staff satisfaction with the DERS library (83.3%-92.8%, P < 0.05). Near-miss events changed after the review from 2 to 0, and the number of alerts caused by values outside the DERS library reduced from 8788 before the review to 3383 after the review (P ≤ 0.05). CONCLUSIONS: Review of a hematology/oncology DERS library found improvements that better met the needs of end users. Engagement with relevant stakeholders, in conjunction with ongoing communication and review, is required to improve compliance and satisfaction with DERS.

Adherence to antimicrobial prophylaxis guidelines in cardiac implantable electronic device procedures in two Australian teaching hospitals.

Objective This study investigated antibiotic prophylaxis (AP) guideline adherence and the cardiac implantable electronic device (CIED) infection rate in two major Australian public teaching hospitals. Methods In a retrospective observational study, the medical records of patients who underwent CIED procedures between January and December 2017 were reviewed (Hospital A, n = 400 procedures; Hospital B, n = 198 procedures). Adherence to AP guidelines was assessed regarding drug, dose, timing, route and frequency. Infection was identified using follow-up documentation. Results AP was administered in 582 of 598 procedures (97.3%). Full guideline adherence was observed in 33.9% of procedures (203/598) and differed significantly between Hospitals A and B (47.3% vs 7.1%, respectively; P < 0.001). Common reasons for non-adherence were the timing of administration (42.3% vs 60.6% non-adherent in Hospitals A and B, respectively; P < 0.001) and repeat dosing (19.3% vs 78.8% non-adherent in Hospitals A and B, respectively; P < 0.001). Twenty infections were identified over 626.6 patient-years of follow-up (mean (±s.d.) follow-up 1.0 ± 0.3 years). The infection rate was 3.19 per 100 patient-years (P = 0.99 between hospitals). Two devices were removed due to infection; no patients died from CIED infection. Conclusions Although the rate of serious CIED infection was low, there was evidence of highly variable and suboptimal antibiotic use, and potential overuse of AP. What is known about the topic? Previous Australian studies have revealed high rates of inappropriate surgical AP. CIED infections are potentially life threatening, but can be avoided through effective use of AP. However, prolonged durations of AP in this setting may also result in complications, including Clostridioides difficile infection. What does this paper add? This study, the first to our knowledge to focus specifically on adherence to Australian guidelines for AP in CIED procedures, highlighted several common issues between AP in this setting and surgical and procedural AP more broadly. 'Early' and 'late' dose administration and extended post-procedural AP were common. Only 34% of prescriptions fully adhered to the guidelines; practices varied significantly between the two hospitals. What are the implications for practitioners? There is a clear need for institution-specific antimicrobial stewardship strategies to optimise AP in CIED procedures, aligned with the Antimicrobial Stewardship Clinical Care Standard. Patients are being placed at potentially avoidable risk of both complications of extended durations of AP and CIED infection, although the rate of serious CIED infection was low. A standardised approach to surveillance of CIED infections and prospective multisite audits of AP in CIED procedures using a validated tool, such as the Surgical National Antimicrobial Prescribing Survey, are recommended to better inform evidence-based practice. Potential strategies to optimise guideline adherence include prescribing support in patients with immediate penicillin hypersensitivity or methicillin-resistant Staphylococcus aureus colonisation, optimising the in-patient location of drug administration to promote timely dosing, limiting inappropriate post-procedural prophylaxis and routine S. aureus screening and decolonisation.

An evaluation of automated dispensing cabinets and inventory robots for centralised distribution of medication in an Australian hospital.

ObjectiveIn Australian hospitals, a central distribution system is often utilised to supply medication to clinical areas. This study investigated the impact of automated dispensing cabinets (ADCs) and inventory robots in medication distribution within an Australian hospital.MethodsA prospective observational study of pharmacy technician medication supply to clinical areas was conducted over a 2-week period pre- and post-implementation of ADCs and inventory robots. Information was collected on the time taken to perform all tasks required to provide a weekly medication supply service for medication other than drugs of addiction.ResultsThere was no significant reduction of total duration for medication supply, pre-implementation mean 73.08min versus post-implementation 68.59min (P=0.567). An instance of automation downtime occurred during the post-implementation period for which manual downtime procedures were implemented. Without downtime, a significant reduction in overall time taken was observed, 74.25min versus 63.18min (P=0.019). Pre-restocking medication selection errors were reduced non-significantly after implementation of inventory robots, 11 (0.43%) versus 4 (0.21%) errors (P=0.090).ConclusionsImplementation of ADCs and robots did not significantly reduce the total time to provide a weekly medication supply service when downtime occurred, although a significant reduction was observed when downtime did not occur. Pharmacy medication selection errors were non-significantly lower.What is known about the topic?Australian hospitals are increasingly implementing automated technology such as ADCs and inventory robotics in an attempt to improve efficiency and accuracy of medication supply; however, limited literature is available in an Australian setting.What does this paper add?This paper describes the impact of implementing ADCs in clinical areas (e.g. inpatient wards) and inventory robots in a main store pharmacy on the medication supply process. This paper highlights the benefit of improved efficiency and accuracy in selecting medication in pharmacy for distribution and identifies time to restock the ADCs is significantly increased.What are the implications for practitioners?Implementing ADCs and inventory robotics in Australian hospitals can provide benefits in efficiency and accuracy; however, robust downtime procedures are essential.

Effectiveness of the TightRope® Fixation in Treating Ankle Syndesmosis Injuries: A Critically Appraised Topic.

Clinical Scenario: Ankle fractures are a frequent occurrence, and they carry the potential for syndesmosis injury. The syndesmosis is important to the structural integrity of the ankle joint by maintaining the proximity of the tibia, fibula, and talus. Presently, the gold standard for treating an ankle syndesmosis injury is to insert a metallic screw through the fibula and into the tibia. This technique requires a second intervention to remove the hardware, but also carries an inherent risk of breaking the screw during rehabilitation. Another fixation technique, the Tightrope™, has gained popularity in treating ankle syndesmosis injuries. The TightRope™ involves inserting Fiberwire® through the tibia and fibula, which allows for stabilization of the ankle mortise and normal range of motion. Clinical Question: In patients suffering from ankle syndesmosis injuries, is the Tightrope™ ankle syndesmosis fixation system more effective than conventional screw fixation at improving return to work, pain, and patient-reported outcome measures? Summary of Key Findings: Five studies were selected to be critically appraised. The PEDro checklist was used to score 2 randomized control trials, and the Downs & Black checklist was used to score the cohort study on methodology and consistency. Two systematic reviews were also appraised. All 5 articles demonstrated support for using the TightRope™ fixation. Clinical Bottom Line: There is moderate evidence to support the use of the TightRope™ syndesmosis fixation system, as it provides both clinician- and patient-reported outcomes that are similar to those using the conventional metallic screw, with a shortened time to recover and return to activity. Strength of Recommendation: Grade A evidence exists in support of using the TightRope™ fixation system in place of the metallic screw following ankle syndesmosis injury.

Building on Antimicrobial Stewardship Programs Through Integration with Electronic Medical Records: The Australian Experience.

Antimicrobial stewardship (AMS) is well established in Australian hospitals. Electronic medical record (EMR) implementation has lagged in Australia, with two Healthcare Information and Management Systems Society (HIMSS) Stage 6 hospitals and one Stage 7 hospital as of September 2020. Specific barriers faced by AMS teams with paper-based prescribing and medical records include real-time identification of antimicrobials orders; the ability to prospectively monitor antimicrobial use; and the integration of fundamental point of prescribing AMS principles into routine clinical practice. There are few local guidelines to assist Australian hospitals and AMS teams beyond "out of the box" EMR functionality. EMR implementation has enormous potential to positively impact AMS teams through more efficient workflows and the ability to expand the reach and coverage of AMS activities. There are inevitable limitations associated with EMR implementation that must be considered. In this paper, four Australian hospitals share their experience with EMR roll out, AMS customisation and how they have overcome specific barriers in local AMS practice.

Multi-route antifungal administration in the management of urinary Candida glabrata bezoar.

A 65-year-old lady was admitted with urosepsis and imaging suggesting right sided hydronephrosis secondary to a filling defect consistent with a fungal bezoar. An indwelling urinary catheter and a right percutaneous nephrostomy tube were inserted. Candida glabrata cultured from urine was resistant to fluconazole. Amphotericin B was instilled into the renal pelvis via the nephrostomy tube while intravenous liposomal amphotericin was administered daily along with oral flucytosine. This multi-modal antifungal administration was continued for 14 days. Clinical and biochemical improvement was achieved and repeat imaging showed complete resolution of the filling defects and hydronephrosis.

The role of a Coronavirus disease 2019 pharmacist: an Australian perspective.

The coronavirus disease 2019 (COVID-19) pandemic has greatly impacted healthcare services around the world. Pharmacists are front-line healthcare professionals and integral members of the healthcare team. The deployment of a specialized 'COVID pharmacist' within our institution has demonstrated that the skills of the pharmacist can be adapted, expanded and utilized to alleviate the pressure of doctor shortages, reduce healthcare worker exposure to infected patients, contribute to therapeutic decisions and work collaboratively to tackle the challenges faced during this pandemic. This commentary details an Australian hospital pharmacy response to the COVID-19 pandemic, describing the unique clinical and practical contributions made by a specialized COVID pharmacist in our institution.

Ergometrine stability in postpartum haemorrhage kits: Does temperature and light matter?

BACKGROUND: Postpartum haemorrhage (PPH) kits containing uterotonics are used on obstetric units for the timely management of PPH. Visible discolouration of ergometrine and ergometrine-oxytocin injections was observed in PPH kits stored in medical refrigerators on the obstetric unit at our hospital. AIM: To investigate the stability of ergometrine and ergometrine-oxytocin injections in PPH kits under simulated clinical storage conditions and to determine the potency of ampoules quarantined from PPH kits on our obstetric unit. MATERIAL AND METHODS: Ergometrine and ergometrine-oxytocin injection ampoules were stored exposed to and protected from light at 4°C and room temperature (25°C) for up to three months, and assayed by high-performance liquid chromatography. Stability was based on the time for the ergometrine or oxytocin concentration to fall to 90% of the original concentration (t90 ). The potency of quarantined discoloured ampoules also was determined. RESULTS: Ergometrine was stable at both temperatures for >6 months, when stored protected from light in simulated clinical conditions. When exposed to light, ergometrine was stable for approximately 4 days at 25°C and 10 days at 4°C. Discoloured ergometrine and ergometrine-oxytocin injection ampoules were found to be <90% of the nominal concentration. CONCLUSION: Stability of ergometrine in PPH kits is largely unaffected by temperature fluctuations (at 4°C and 25°C) over 6 months when protected from light. Ergometrine and ergometrine-oxytocin ampoules should be inspected prior to use and any discoloured ampoules discarded.

Early urinary tract infection after spinal cord injury: a retrospective inpatient cohort study.

STUDY DESIGN: Retrospective audit. OBJECTIVES: Examine factors associated with urinary tract infection (UTI), UTI incidence and impact on hospital length of stay (LOS) in new, inpatient adult traumatic spinal cord injury (SCI). SETTING: Western Australian Hospitals managing SCI patients. METHODS: Data on UTIs, bladder management and LOS were obtained from hospital databases and medical records over 26 months. Adherence to staff-administered intermittent catheterisation (staff-IC) was determined from fluid balance charts. RESULTS: Across the cohort (n = 70) UTI rate was 1.1 starts/100 days; UTI by multi-resistant organisms 0.1/100 days. Having ≥1 UTIs compared with none and longer duration of initial urethral indwelling catheterisation (IDC) were associated with longer LOS (p-values < 0.001). For patients with ≥1 UTIs (n = 43/70), longer duration of initial IDC was associated with shorter time to first UTI (1 standard deviation longer [SD, 45.0 days], hazard ratio (HR): 0.7, 95% confidence interval [CI] 0.5-1.0, p-value 0.044). In turn, shorter time to first UTI was associated with higher UTI rate (1 SD shorter [30.7 days], rate ratio (RR): 1.32, 95%CI 1.0-1.7, p-value 0.039). During staff-IC periods (n = 38/70), protocols were followed (85.7% ≤ 6 h apart, 96.1% < 8 h), but 26% of IC volumes exceeded 500 mL; occasional volumes > 800 mL and interruptions requiring temporary IDC were associated with higher UTI rates the following week (odds ratios (ORs): 1.6, 95%CI 1.1-2.3, p-value 0.009; and 3.9, 95%CI 2.6-5.9, p-value < 0.001 respectively). CONCLUSIONS: Reducing initial IDC duration and limiting staff-IC volumes could be investigated to possibly reduce inpatient UTIs and LOS. SPONSORSHIP: None.