Beliefs and attitudes of drug and alcohol clinicians when considering referral of Aboriginal clients to involuntary drug and alcohol treatment: A qualitative study.

INTRODUCTION: Involuntary drug and alcohol treatment occurs in many countries and its role is often controversial. This can be a particular concern in relation to First Nations or other culturally distinct populations. This study explores beliefs and attitudes of drug and alcohol clinicians when considering referral of Aboriginal Australians to involuntary drug and alcohol treatment in New South Wales (NSW), Australia. METHODS: The Involuntary Drug and Alcohol Treatment program (IDAT) is legislated by the NSW Drug and Alcohol Treatment Act 2007. There are two IDAT units-in urban (Sydney, four beds) and regional NSW (Orange, eight beds). NSW Health drug and alcohol clinicians who had referred clients to IDAT between 2016 and 2018 were invited to participate in a semi-structured 1:1 interview. Eleven clinicians (n = 2, male) from six local health districts (urban through to remote) agreed to participate. A descriptive qualitative analysis of responses was conducted. RESULTS: Two key themes summarised the beliefs and attitudes that clinicians reported influencing them when considering referral of Aboriginal Australians to involuntary drug and alcohol treatment in NSW: (i) dilemma between saving someone's life and being culturally safe; and (ii) need for holistic wrap-around care. DISCUSSION AND CONCLUSIONS: Almost all clinicians were worried that being in IDAT would further erode their Aboriginal client's autonomy and be retraumatising. Strategies are needed to support the involvement of Aboriginal-specific services in IDAT processes and ensure local support options for clients on discharge. Future research should examine the effectiveness, acceptability and feasibility of involuntary drug and alcohol treatment programs.

The impact of Indigenous-led programs on alcohol-related criminal incidents: a multiple baseline design evaluation.

OBJECTIVES: To evaluate the impact of a multi-component, Aboriginal-led strategy to reduce alcohol-related criminal incidents for Aboriginal people in four rural/remote communities in New South Wales (NSW), Australia. METHODS: A retrospective multiple baseline design (MBD), using interrupted time series analysis of routinely collected crime data. RESULTS: A statistically significant reduction in alcohol-related criminal incidents was observed in one community for both victims of crime (parameter estimate -0.195; p≤0.01) and persons of interest (parameter estimate -0.282; p≤0.001). None of the analyses show level shifts, meaning there were no measurable changes immediately post the introduction of the Breaking the Cycle (BTC) programs. CONCLUSIONS: It is not possible to conclude that the program was effective independently of any other community factors, because the statistically significant result was not observed across multiple communities. The statistically significant result in one community has clear practical benefits in that community: a sustained impact over two years would reduce Aboriginal victims of alcohol-related crime from an estimated 56 incidents per annum to 36, and reduce Aboriginal persons of interest in alcohol-related crime from an estimated 68 alcohol-related person of interest (POI) per annum to 40. IMPLICATIONS FOR PUBLIC HEALTH: The statistically and practically meaningful result in Community 1 highlights the potential of multi-component, Aboriginal-led strategies to reduce alcohol-related criminal incidents. Earlier engagement with researchers, to identify best-evidence strategies to reduce alcohol harms and to facilitate the use of prospective evaluation designs, would help translate the positive outcome in one community across multiple communities.

'It sort of has the feel of being at home': Mixed-methods evaluation of a pilot community-based palliative end-of-life service in a regional setting.

OBJECTIVE: To evaluate the acceptability and effectiveness of a small community-based hospice on the end-of-life experiences of patients and families. METHODS: Mixed-methods study. DESIGN: Patient admission data were used to assess utilisation of the hospice. Open-ended interviews with hospice patients and their families/carers were used to understand the emotional effects of the service. SETTING: A small palliative end-of-life hospice in a rural town in NSW, Australia, during a 12-month trial period that began in March 2019. Data were collected in October-November 2019. PARTICIPANTS: Patients, families and carers who used the hospice during the trial period, as well as staff working at the hospice. MAIN OUTCOME MEASURE(S): Quantitative measures included the number of patients admitted to the hospice, the average length of stay and the overall occupancy rate of the hospice. Quantitative interviews were used to explore the experiences of patients and families who used the hospice, and whether the hospice met their end-of-life needs. RESULTS: During the trial, 58 patients were admitted to the hospice. The majority of admissions were less than 7 days. Two patients and nine family members were interviewed about their experiences, and six staff completed interviews. Experiences were consistently positive, with the community setting of the hospice contributing to a peaceful and home-like end-of-life experience. Interviewees described meaningful relationships with staff, a pleasant physical environment and the comprehensive care provided were key elements of this experience. CONCLUSION: This model, embedding end-of-life care within a residential aged care facility, facilitated a positive end-of-life experience for residents of this regional community. The development of local models to meet local needs is essential to enabling people nearing the end of life to remain in their location of choice, and ensure that their needs are met at this vulnerable time.

'Empowering clinicians in smaller sites': A qualitative study of clinician's experiences with a rural Virtual Paediatric Feeding Clinic.

OBJECTIVE: To explore the experiences of 'spoke site' allied health and child and family health clinicians in the provision of care through a pilot 'hub and spoke' model Virtual Paediatric Feeding Clinic (VPFC) outreach service. DESIGN: The study was qualitative, with data from virtual interview transcripts analysed using thematic analysis. SETTING: Orange Health Service ('hub site') and seven community health centres within the Western NSW Local Health District ('spoke sites'). PARTICIPANTS: Nine 'spoke site' clinicians (from dietetics, speech pathology, occupational therapy and child and family health nursing), who had participated in the pilot clinic. INTERVENTIONS: Participants took part in a semi-structured interview with a member of the research team. MAIN OUTCOME MEASURES: Spoke site clinicians experiences and perceptions of the VPFC. RESULTS: Four key themes emerged: (1) impact of the VPFC on 'spoke site' clinicians, (2) benefits for clients and families, (3) perceptions of the virtual model of care and (4) VPFC service challenges. CONCLUSION: The expansion of an existing interdisciplinary Paediatric Feeding Clinic into a virtual service demonstrates the use of technology to bridge a gap in healthcare. Clinicians reported benefits not only for families, but for their own knowledge and confidence in provision of care and reduced professional isolation through connection with discipline-specific colleagues.

Managing Complex Healthcare Change: A Qualitative Exploration of Current Practice in New South Wales, Australia.

PURPOSE: As the cost of healthcare continues to rise, healthcare organizations internationally are seeking long-term solutions to eradicate inefficiency, achieve value-based healthcare, and minimize hospital inpatient services. This requires transformational change in healthcare organizations, and associated change management and leadership capability at multiple levels. Despite the critical need for effective change leadership and management in healthcare, limited evidence exists that this currently occurs in addition to the capability and capacity for managing change in health systems. METHODS: Semi-structured interviews were undertaken with 16 healthcare managers and leaders at a range of levels in nine healthcare organizations across the public health system of one Australian state (New South Wales), including metropolitan, regional and rural geographical areas. Thematic content analysis was undertaken with the emergent data. RESULTS: Four key themes emerged from the data: 1) lack of adoption of frameworks and methods for change management for any scope or scale of change, 2) inadequate resources for delivering, managing and leading change, 3) insufficient leadership, capacity and capability in managing change, and 4) the need for support and culture that supports change at all levels of the system. CONCLUSION: Ensuring dedicated resources for change and sufficient capacity and capability amongst health professionals and managers at every level in a health system are required for effective management of change. An enabling culture for change, supported by adequate education and training in change leadership and management are critical in order for the benefits of health service and system changes to be realised.

Patterns of emergency department use in rural and metropolitan New South Wales from 2012 to 2018.

OBJECTIVE: To explore the patterns of and investigate the factors associated with rises in emergency department presentations in rural and metropolitan New South Wales from 2012 to 2018. DESIGN: A retrospective descriptive study of de-identified data from the New South Wales Emergency Department Data Collection. SETTING: New South Wales, Australia. PARTICIPANTS: All individuals presenting to 99 New South Wales emergency departments, which continuously reported to the Emergency Department Data Collection between 2012 and 2018. A total of 2 166 449 presentations recorded throughout New South Wales in 2012 (rural 786 278; metropolitan 1 380 171) and 2 477 192 in 2018 (rural 861 761; metropolitan 1 615 431). MAIN OUTCOME MEASURES: Total emergency department presentations, plus Poisson regression modelled annual changes in emergency department presentations over the period 2012-2018. RESULTS: Growth in emergency department presentations outpaced population growth in both rural and metropolitan New South Wales between 2012 and 2018. The patterns of age-standardised rates of presentations were broadly similar between rural and metropolitan areas, with highest rates observed in the youngest (0-4 years) and oldest (85+ years) cohorts. The rural sample also displayed a distinct third peak in ages 15-39 years, and rates were higher across all age groups. Rural New South Wales displayed disproportionately higher emergency department presentations in the two most deprived socio-economic status quintiles. While rural New South Wales displayed significant reductions in triage category 5 (non-urgent cases) over time, the relative proportion remained approximately double that of metropolitan sites. CONCLUSIONS: There are differences between rural and metropolitan emergency department presentations relating to demographic factors, triage levels, acuity and admissions. Detailed local investigations are required to determine specific contextual issues that impact on emergency department demand.

'We walked side by side through the whole thing': A mixed-methods study of key elements of community-based participatory research partnerships between rural Aboriginal communities and researchers.

OBJECTIVES: To advance the rural practice in working with Aboriginal communities by (a) identifying the extent of community partners' participation in and (b) operationalising the key elements of three community-based participatory research partnerships between university-based researchers and Australian rural Aboriginal communities. DESIGN: A mixed-methods study. Quantitative survey and qualitative one-on-one interviews with local project implementation committee members and group interviews with other community partners and project documentation. SETTING: Three rural Aboriginal communities in New South Wales. PARTICIPANTS: Thirty-seven community partners in three community-based participatory research partnerships of which 22 were members of local project implementation committees and 15 were other community partners who implemented activities. INTERVENTION: Community-based participatory research partnerships to develop, implement and evaluate community-based responses to alcohol-related harms. MAIN OUTCOMES MEASURES: Community partners' extent of and experiences with participation in the community-based participatory research partnership and their involvement in the development and implementation processes. RESULTS: Community partners' participation varied between communities and between project phases within communities. Contributing to the community-based participatory research partnerships were four key elements of the participatory process: unique expertise of researchers and community-based partners, openness to learn from each other, trust and community leadership. CONCLUSION: To advance the research practice in rural Aboriginal communities, equitable partnerships between Aboriginal community and research partners are encouraged to embrace the unique expertise of the partners, encourage co-learning and implement community leadership to build trust.

A stepped wedge trial of efficacy and scalability of a virtual clinical pharmacy service (VCPS) in rural and remote NSW health facilities.

BACKGROUND: Medication errors are a leading cause of mortality and morbidity. Clinical pharmacy services provided in hospital can reduce medication errors and medication related harm. However, few rural or remote hospitals in Australia have a clinical pharmacy service. This study will evaluate a virtual clinical pharmacy service (VCPS) provided via telehealth to eight rural and remote hospitals in NSW, Australia. METHODS: A stepped wedge cluster randomised trial design will use routinely collected data from patients' electronic medical records (n = 2080) to evaluate the VCPS at eight facilities. The sequence of steps is randomised, allowing for control of potential confounding temporal trends. Primary outcomes are number of medication reconciliations completed on admission and discharge. Secondary outcomes are length of stay, falls and 28 day readmissions. A cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA) will be conducted. The CEA will answer the question of whether the VCPS is more cost-effective compared to treatment as usual; the CBA will consider the rate of return on investing in the VCPS. A patient experience measure (n = 500) and medication adherence questionnaire (n = 100 pre and post) will also be used to identify patient responses to the virtual service. Focus groups will investigate implementation from hospital staff perspectives at each site. Analyses of routine data will comprise generalised linear mixed models. Descriptive statistical analysis will summarise patient experience responses. Differences in medication adherence will be compared using linear regression models. Thematic analysis of focus groups will identify barriers and facilitators to VCPS implementation. DISCUSSION: We aim to demonstrate the effectiveness of virtual pharmacy interventions for rural populations, and inform best practice for using virtual healthcare to improve access to pharmacy services. It is widely recognised that clinical pharmacists are best placed to reduce medication errors. However, pharmacy services are limited in rural and remote hospitals. This project will provide evidence about ways in which the benefits of hospital pharmacists can be maximised utilising telehealth technology. If successful, this project can provide a model for pharmacy delivery in rural and remote locations. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) -ACTRN12619001757101 Prospectively registered on 11 December 2019. Record available from: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378878&isReview=true.

The process of change for people with cognitive impairment in a residential rehabilitation program for substance problems: a phenomenographical analysis.

Cognitive impairment is prevalent among people with substance problems and a factor affecting retention in treatment. Empirical phenomenography was used to systematically explore how people with cognitive impairment viewed a novel residential rehabilitation program - Project RE PIN - designed with cognitive compensatory behaviour change activities and from a strengths-based approach. Twelve participants took part in semi-structured interviews and cross-case analysis identified the overarching theme of change. Key program elements were the safe environment, structured routines, modified psycho-educational material and staff support. Critical changes that participants attributed to the program were in dealing with their own and others' emotions, experiencing daily life without drugs or alcohol and reframing their self-view. Fear and anxiety about relapse were common and few participants had strategies or support to cope in the future. This study demonstrates that program activities changed participants' thoughts, feelings and behaviours about themselves and their substance use. The results indicate that RE-PIN's modified content and processes can benefit people with cognitive impairments in treatment. The study highlights that some treatment users may be vulnerable to resumption of drug use despite gains made during a residential program and their desire to remain substance-free.

Correction to: The development of a healing model of care for an Indigenous drug and alcohol residential rehabilitation service: a community-based participatory research approach.

Upon publication of the original article (Munro et al., 2017), the authors noticed the following errors.

Understanding remote Aboriginal drug and alcohol residential rehabilitation clients: Who attends, who leaves and who stays?

INTRODUCTION AND AIMS: Aboriginal residential rehabilitation services provide healing for Aboriginal people who misuse substances. There is limited available research that empirically describes client characteristics of these services. This study examined 5 years of data of a remote Aboriginal residential rehabilitation service. DESIGN AND METHODS: Retrospective analysis of 329 client admissions to Orana Haven Drug and Alcohol Rehabilitation Centre from 2011 to 2016. Multinomial and binary logistic regressions were conducted to identify trends in the data. RESULTS: There were 66 admissions recorded annually, of which most identified as Aboriginal (85%). Mean length of stay was 56 days, with one in three (36%) discharging within the first month. A third (32%) completed, 47% self-discharged and 20% house-discharged from the program. Client age significantly increased over time (P = 0.03), with most aged from 26 to 35. Older clients were significantly more likely to readmit (P < 0.002) and stay longer than 90 days (P = 0.02). Most clients were referred from the criminal justice system, significantly increasing from 79% (2011-2012) to 96% (2015-2016) (P < 0.001) and these clients were more likely to self-discharge (P < 0.01). Among a subset of clients, most (69%) reported concerns with polysubstance use and half (51%) reported mental illness. DISCUSSION AND CONCLUSIONS: The current study makes a unique contribution to the literature by empirically describing the characteristics of clients of a remote Aboriginal residential rehabilitation service to more accurately tailor the service to the client's needs. Key recommendations include integrating these empirical observations with staff and client perceptions to co-design a model of care, standardise data collection, and routinely following-up clients to monitor treatment effectiveness.

The development of a healing model of care for an Indigenous drug and alcohol residential rehabilitation service: a community-based participatory research approach.

BACKGROUND: Given the well-established evidence of disproportionately high rates of substance-related morbidity and mortality after release from incarceration for Indigenous Australians, access to comprehensive, effective and culturally safe residential rehabilitation treatment will likely assist in reducing recidivism to both prison and substance dependence for this population. In the absence of methodologically rigorous evidence, the delivery of Indigenous drug and alcohol residential rehabilitation services vary widely, and divergent views exist regarding the appropriateness and efficacy of different potential treatment components. One way to increase the methodological quality of evaluations of Indigenous residential rehabilitation services is to develop partnerships with researchers to better align models of care with the client's, and the community's, needs. An emerging research paradigm to guide the development of high quality evidence through a number of sequential steps that equitably involves services, stakeholders and researchers is community-based participatory research (CBPR). The purpose of this study is to articulate an Indigenous drug and alcohol residential rehabilitation service model of care, developed in collaboration between clients, service providers and researchers using a CBPR approach. METHODS/DESIGN: This research adopted a mixed methods CBPR approach to triangulate collected data to inform the development of a model of care for a remote Indigenous drug and alcohol residential rehabilitation service. RESULTS: Four iterative CBPR steps of research activity were recorded during the 3-year research partnership. As a direct outcome of the CBPR framework, the service and researchers co-designed a Healing Model of Care that comprises six core treatment components, three core organisational components and is articulated in two program logics. The program logics were designed to specifically align each component and outcome with the mechanism of change for the client or organisation to improve data collection and program evaluation. CONCLUSION: The description of the CBPR process and the Healing Model of Care provides one possible solution about how to provide better care for the large and growing population of Indigenous people with substance misuse issues. [corrected].

"I just feel comfortable out here, there's something about the place": staff and client perceptions of a remote Australian Aboriginal drug and alcohol rehabilitation service.

BACKGROUND: The need for effective, culturally safe residential rehabilitation services for Aboriginal people is widely acknowledged, however the combination of treatment components that is optimally effective, is not well defined. Most existing Aboriginal residential rehabilitation research has focused on describing client characteristics, and largely ignored the impact of treatment and service factors, such as the nature and quality of therapeutic components and relationships with staff. METHODS: This qualitative study was undertaken as part of a three-year mixed methods community-based participatory research (CBPR) project that aimed to empirically describe a remote Aboriginal drug and alcohol rehabilitation service. Researchers utilised purposive sampling to conduct 21 in-depth, semi-structured interviews. The interviews used a 'research yarning' approach, a form of culturally appropriate conversation that is relaxed and narrative-based. The interview transcripts were thematically coded using iterative categorization. The emerging themes were then analysed from an Interpretative Phenomenological Analysis, focusing on how participants' lived experiences before and during their admission to the service shaped their perceptions of the program. RESULTS: A total of 12 clients (mean age 35 years, SD 9.07, 91% Aboriginal) and 9 staff (2 female, 7 male, mean age 48 years, SD 8.54, 67% Aboriginal) were interviewed. Five themes about specific program components were identified in the interview data: healing through culture and country; emotional safety and relationships; strengthening life skills; improved wellbeing; and perceived areas for improvement. This research found that Aboriginal drug and alcohol residential rehabilitation is not just about length of time in treatment, but also about the culture, activities and relationships that are part of the treatment process. CONCLUSION: This study highlights that cultural elements were highly valued by both clients and staff of a remote Aboriginal residential rehabilitation service, with the country or location being fundamental to the daily practice of, and access to, culture. Developing reliable and valid assessments of the program components of culture and treatment alliance would be valuable, given this study has reinforced their perceived importance in achieving positive treatment outcomes. Further, strengthening the aftercare program, as part of an integrated model of care, would likely provide greater support to clients after discharge.

Effect of evacuation and displacement on the association between flooding and mental health outcomes: a cross-sectional analysis of UK survey data.

BACKGROUND: Extensive flooding occurred during the winter of 2013-14 in England. Previous studies have shown that flooding affects mental health. Using data from the 2013-14 Public Health England National Study of Flooding and Health, we compared the prevalence of symptoms of depression, anxiety, and post-traumatic stress disorder between participants displaced by flooding and those flooded, but not displaced, 1 year after flooding. METHODS: In this multivariable ordinal regression analysis, we collected data from a cross-sectional survey collected 1 year after the flooding event from flood-affected postcodes in five counties in England. The analysis was restricted to individuals whose homes were flooded (n=622) to analyse displacement due to flooding. The primary outcome measures were depression (measured by the PHQ-2 depression scale) and anxiety (measured by the two-item Generalised Anxiety Disorder [GAD]-2 anxiety scale), and post-traumatic stress disorder (measured by the Post-Traumatic Stress Disorder Checklist [PCL]-6 scale). We adjusted analyses for recorded potential confounders. We also analysed duration of displacement and amount of warning received. FINDINGS: People who were displaced from their homes were significantly more likely to have higher scores on each scale; odds ratio (OR) for depression 1·95 (95% CI 1·30-2·93), for anxiety 1·66 (1·12-2·46), and for post-traumatic stress disorder 1·70 (1·17-2·48) than people who were not displaced. The increased risk of depression was significant even after adjustment for severity of flooding. Scores for depression and post-traumatic stress disorder were higher in people who were displaced and reported receiving no warning than those who had received a warning more than 12 h in advance of flooding (p=0·04 for depression, p=0·01 for post-traumatic stress disorder), although the difference in anxiety scores was not significant. INTERPRETATION: Displacement after flooding was associated with higher reported symptoms of depression, anxiety, and post-traumatic stress disorder 1 year after flooding. The amount of warning received showed evidence of being protective against symptoms of the three mental illnesses studied, and the severity of flooding might be the reason for some, but not all, of the differences between the groups. FUNDING: National Institute for Health Research Health Protection Research Units (HPRU) in Emergency Preparedness and Response at King's College London, Environmental Change and Health at the London School of Hygiene and Tropical Medicine, and Evaluation of Interventions at the University of Bristol, Public Health England.

Cut fossil fuel links and curb burden on the NHS.

At a time when the NHS is struggling to meet demand, it is easy to regard the health impact of climate change as less urgent than the immediate needs of patients. However, action now to limit the effects of climate change would also reduce demands on the health service and help us to meet the healthcare needs of future generations.

Riding the rural radio wave: The impact of a community-led drug and alcohol radio advertising campaign in a remote Australian Aboriginal community.

OBJECTIVE: Aboriginal people experience a higher burden of disease as a consequence of drug and alcohol (D&A) abuse. Although media campaigns can be a popular tool for disseminating health promotion messages, evidence of the extent to which they reduce the impact of substance abuse is limited, especially for rural Aboriginal communities. This paper is the first to examine the impact a locally designed D&A radio advertising campaign for Aboriginal people in a remote community in Western NSW. DESIGN: A post-intervention evaluation. SETTING: The radio campaign was implemented in Bourke, (population 2465, 30% Aboriginal). PARTICIPANTS: Fifty-three community surveys were completed. MAIN OUTCOME MEASURE(S): The self-reported level of awareness of the campaign and the number of self-referrals to local D&A workers in the intervention period. RESULTS: Most respondents (79%) reported they listen to radio on a daily basis, with 75% reporting that they had heard one or more of the advertisements. The advertisement that was remembered best contained the voice of a respected, local person. There was one self-referral to local health services during the intervention timeframe. CONCLUSION: The community-led radio advertising campaign increased community awareness of substance abuse harms, but had limited impact on formal help-seeking. This paper highlights the value of radio as a commonly used, trusted and culturally relevant health promotion medium for rural communities, especially when engaging local respected Aboriginal presenters.

The Need to Move from Describing to Evaluating the Effectiveness of Indigenous Drug and Alcohol Residential Rehabilitation Services: A Systematic Review.

BACKGROUND AND OBJECTIVES: Despite the importance of Indigenous drug and alcohol residential rehabilitation, the knowledge supporting these services is limited. This paper aims to: (i) identify the research output related to Indigenous drug and alcohol residential rehabilitation services; (ii) classify identified studies according to their methodology; and (iii) describe key characteristics of clients and services, and critique the research methods. METHODS: A PRISMA compliant search of 10 electronic databases for studies of Indigenous drug and alcohol residential rehabilitation services from Australia, United States, Canada and New Zealand, published between 1 January 2000 and 28 March 2016, was conducted. RESULTS: Of the 38 relevant studies, 20 were service descriptions, one was a thesis, 16 described treatment or client characteristics and one was a pre/post evaluation. No systematic reviews or the development or evaluation of measures was identified, with reviewed studies found to be of relatively low methodological quality. CONCLUSION: There are few published studies on Indigenous drug and alcohol residential rehabilitation services, an average of one paper per annum internationally, and only one treatment outcome evaluation. Three key features of the reviewed papers included (i) studied services were mostly located in regional areas; (ii) services provided multi-component programs, with little alignment between the models of care of other services; and (iii) the majority used qualitative, rather than quantitative methods. Client outcomes will likely improve if future research can establish best-practice, culturally acceptable models of care and increase the application of evidence-based, culturally validated quantitative evaluation measures to complement existing qualitative research.

Bacterial-Fungal Interactions Including Quorum Sensing, Between 2 Opportunistic Pathogens, Resulting in Post-Traumatic Sepsis in a Child Presenting With a Closed Femoral Fracture.

Pseudomonas aeruginosa and Candida albicans (are opportunistic pathogens that cause systemic infections in immune-suppressed patients. They show important bacterial-fungal interactions including quorum sensing. This involves cell signaling to communicate between the cells of their own colony and the cells of rival microbes or the host. It is thought that this phenomenon is vital in the potential competition and virulence of the organisms. We report a case of a previously healthy 2-year-old boy, where an accidental injury had been sustained resulting in a closed fracture of femur. He subsequently developed sepsis related to co-infection by C. albicans and P. aeruginosa. Trauma may result in a transient immune-suppression and predispose to sepsis caused by opportunistic microorganisms. They can engage in bacterial-fungal interaction. Clinicians should consider invasive co-infection when initial cultures show evidence for only 1 pathogen.