A state-wide implementation of a whole of hospital sepsis pathway with a mortality based cost-effectiveness analysis from a healthcare sector perspective.

With global estimates of 15 million cases of sepsis annually, together with a 24% in-hospital mortality rate, this condition comes at a high cost to both the patient and to the health services delivering care. This translational research determined the cost-effectiveness of state-wide implementation of a whole of hospital Sepsis Pathway in reducing mortality and/or hospital admission costs from a healthcare sector perspective, and report the cost of implementation over 12-months. A non-randomised stepped wedge cluster implementation study design was used to implement an existing Sepsis Pathway ("Think sepsis. Act fast") across 10 of Victoria's public health services, comprising 23 hospitals, which provide hospital care to 63% of the State's population, or 15% of the Australian population. The pathway utilised a nurse led model with early warning and severity criteria, and actions to be initiated within 60 minutes of sepsis recognition. Pathway elements included oxygen administration; blood cultures (x2); venous blood lactate; fluid resuscitation; intravenous antibiotics, and increased monitoring. At baseline there were 876 participants (392 female (44.7%), mean 68.4 years); and during the intervention, there were 1,476 participants (684 female (46.3%), mean 66.8 years). Mortality significantly reduced from 11.4% (100/876) at baseline to 5.8% (85/1,476) during implementation (p>0.001). Respectively, at baseline and intervention the average length of stay was 9.1 (SD 10.3) and 6.2 (SD 7.9) days, and cost was $AUD22,107 (SD $26,937) and $14,203 (SD $17,611) per patient, with a significant 2.9 day reduction in length of stay (-2.9; 95%CI -3.7 to -2.2, p<0.01) and $7,904 reduction in cost (-$7,904; 95%CI -$9,707 to -$6,100, p<0.01). The Sepsis Pathway was a dominant cost-effective intervention due to reduced cost and reduced mortality. Cost of implementation was $1,845,230. In conclusion, a well-resourced state-wide Sepsis Pathway implementation initiative can save lives and dramatically reduce the health service cost per admission.

A single institution analysis of low-dose-rate brachytherapy: 5-year reported survival and late toxicity outcomes.

PURPOSE: To report the 5-year biochemical relapse-free survival (BRFS), overall survival (OS), and long-term toxicity outcomes of patients treated with low-dose-rate (LDR) brachytherapy as monotherapy for low- to intermediate-risk prostate cancer. MATERIAL AND METHODS: Between 2004 and 2011, 371 patients were treated with LDR brachytherapy as monotherapy. Of these, 102 patients (27%) underwent transurethral resection of the prostate (TURP) prior to implantation. Follow-up was performed every 3 months for 12 months, then every 6 months over 4 years and included prostate specific antigen evaluation. The biochemical relapse-free survival (BRFS) was defined according to the Phoenix criteria. Acute and late toxicities were documented using the Common Terminology Criteria for Adverse Events version 4.0. The BRFS and OS estimates were calculated using Kaplan-Meier plots. Univariate and multivariate analyses were performed to evaluate outcomes by pre-treatment clinical prognostic factors and radiation dosimetry. RESULTS: The median follow-up of all patients was 5.45 years. The 5-year BRFS and OS rates were 95% and 96%, respectively. The BRFS rates for patients with Gleason score (GS) > 7 and GS ≤ 6 were 96% and 91% respectively (p = 0.06). On univariate analysis, T1 and T2 staging, risk-group classification, and prostate volumes had no impact on survival at 5 years (p > 0.1). Late grade 2 and 3 genitourinary (GU) toxicities were observed in 10% and 5% of patients respectively. Additionally, patients with prior TURP had a greater incidence of late grade 2 or 3 urinary retention (p = 0.001). There were 14 deaths in total; however, none were attributed to prostate cancer. CONCLUSIONS: LDR brachytherapy is an effective treatment option in low- to intermediate-risk prostate cancer patients. We observed low biochemical relapse rates and minimal GU toxicities several years after treatment in patients with or without TURP. However, a small risk of urinary retention was observed in some patients.

The infusion method trial of void vs standard catheter removal in the outpatient setting: a prospective randomized trial.

OBJECTIVE: • To ascertain if filling the bladder with warm normal saline before trial of void (TOV) reduces time to decision of outcome of TOV and time to discharge compared with standard in-dwelling catheter (IDC) removal in the outpatient setting. PATIENTS AND METHODS: • A prospective randomized controlled trial (not blinded) was carried out in the day procedure unit. Randomization was done using computer-generated random numbers. The sample size was calculated based on initial pilot data using α= 0.05 and ß= 0.2 and a clinically important reduction of ≥60 min for time to decision of outcome of TOV (primary outcome measure). • In all, 60 consecutive patients were recruited from two referral sources: presentations of acute urinary retention to the emergency department and patients discharged home after failing TOV postoperatively. • The infusion method group (32 patients) had 300-500 mL warm normal saline infused into the bladder before removing their IDC and the control group (28) had standard IDC removal. • Data were collected and analysed using the two-tailed Mann-Whitney U-test. Statistical significance was set at P < 0.05. RESULTS: • The median time to decision was 135.0 (95% confidence interval CI 95.0-190.0) min in the infusion group and 247.5 (95% CI 189.6-294.1) min in the control group. • Patients undergoing a bladder infusion had a shorter discharge time [180.0 (95% CI 126.0-226.9) min] than patients in the standard-IDC-removal group [262.5 (95% CI 233.8-315.0) min]. • The infusion arm shortened time to decision by 112.5 min (P < 0.001) and time to discharge by 82.5 min (P < 0.001). • Furthermore, patients in the infusion group were 1.56 times more likely to achieve catheter-free state after TOV (risk ratio 1.56, 95% CI 1.03-2.36; P= 0.03). CONCLUSION: • The infusion method for TOV is safe and expeditious, making it ideal for the outpatient setting. This randomized study shows that the infusion method enables a rapid determination of outcome of TOV with a greater chance of success and shortened discharge times.

Creation and validation of a visual macroscopic hematuria scale for optimal communication and an objective hematuria index.

PURPOSE: Macroscopic hematuria is a common symptom and sign that is challenging to quantify and describe. The degree of hematuria communicated is variable due to health worker experience combined with lack of a reliable grading tool. We produced a reliable, standardized visual scale to describe hematuria severity. Our secondary aim was to validate a new laboratory test to quantify hemoglobin in hematuria specimens. MATERIALS AND METHODS: Nurses were surveyed to ascertain current hematuria descriptions. Blood and urine were titrated at varying concentrations and digitally photographed in catheter bag tubing. Photos were processed and printed on transparency paper to create a prototype swatch or card showing light, medium, heavy and old hematuria. Using the swatch 60 samples were rated by nurses and laymen. Interobserver variability was reported using the generalized kappa coefficient of agreement. Specimens were analyzed for hemolysis by measuring optical density at oxyhemoglobin absorption peaks. RESULTS: Interobserver agreement between nurses and laymen was good (kappa = 0.51, p <0.001). Subgroup analysis showed substantial agreement for light hematuria (kappa = 0.71). Overall agreement improved when the moderate (kappa = 0.28) and heavy (kappa = 0.53) hematuria categories were combined (kappa = 0.70). Compared to known blood concentrations the assay of optical density at oxyhemoglobin absorption peaks showed a linear trend. CONCLUSIONS: A simple visual scale to grade and communicate hematuria with adequate interobserver agreement is feasible. The test for optical density at oxyhemoglobin absorption peaks is a new method, validated in our study, to quantify hemoglobin in a hematuria specimen.

Urinary catheter balloons should only be filled with water: testing the myth.

OBJECTIVE: To test the hypothesis that urinary catheter balloons filled with sterile water, saline or glycine have equivalent rates of failure to deflate. MATERIALS AND METHODS: This was an in vitro equivalence study designed to test whether saline or glycine are neither substantially worse nor substantially better than water in terms of balloon-deflation failure rates. Glycine was chosen as the third arm, as it is readily available during endoscopic procedures and would be useful to use in such situations. We hypothesised that balloon-deflation failure rates using saline or glycine were no worse than water by 10%. We calculated the sample size for equivalence testing; 600 catheters were randomized by computer-generated random numbers to receive 10 mL of water, saline or glycine, and then immersed in a heated artificial urine solution for 6 weeks. The catheter balloons were then deflated, noting any failures to deflate and recording the deflation volumes. RESULTS: There was no failure to deflate in all 600 catheters. The median deflation volume for water, saline and glycine was 9.0, 9.2 and 9.1 mL, respectively (P < 0.001 Kruskal-Wallis test). Post-hoc pair-wise comparisons showed that the deflation volume difference between water and saline was significant (P < 0.001), as was that between water and glycine (P < 0.001). The practical implication of this difference is not apparent from this study. CONCLUSIONS: The use of saline or glycine in catheter balloons has an equivalent deflation failure rate to using water, which in this study was zero.

Prioritizing patients for prostatectomy: balancing clinical and psychosocial factors.

BACKGROUND: The aim of this study was to develop a points-based approach to prioritize patients for elective transurethral resection of the prostate and to determine the relative contributions that clinical and psychosocial characteristics should make to a measurement of urgency for surgery. Another objective was to measure the agreement between urologists, other medical practitioners and laypersons in assessing the major determinants of priority. METHODS: A focus group of urologists and epidemiologists developed a standard questionnaire identifying relevant clinical and psychosocial factors in men with benign prostatic hypertrophy. The questionnaire was used to interview 48 men with benign prostatic hypertrophy being placed on waiting lists for transurethral resection of the prostate at four Victorian public hospitals. Individual patient case vignettes were produced using the answers to the interview questions. Members of an assessor panel comprising six laypeople, six non-urologist medical practitioners, and five urologists individually reviewed the vignettes and assigned urgency ratings and rankings to each patient. The urgency ratings and rankings were used to derive weightings for the clinical and psychosocial factors that were then incorporated into a prioritization tool framework. RESULTS: The assessor panel perceived a broad spread of urgency for surgery among the patients. Agreement on rankings and urgency ratings was moderate among assessors. Linear regression showed that the effect of clinical symptoms and psychosocial disturbance held approximately equal-strength independent associations with perceived urgency for all groups of assessors. CONCLUSION: Urologists, non-urologist medical practitioners and laypeople considered the severity of benign prostatic hypertrophy symptoms and any resulting psychosocial disturbance as equally important in establishing priority for transurethral resection of the prostate. New prioritization tools should take both into consideration and weight them equally.