Quality of acute asthma care: an audit of clinical practice in a Victorian health service.

BACKGROUND: Gaps in the treatment of patients with acute asthma have been repeatedly described in Australia. We conducted a retrospective audit of acute asthma care at a Victorian tertiary institution. AIMS: To describe acute asthma care at a large health network in metropolitan Melbourne, and evaluate the extent to which Emergency Department (ED) care was consistent with National Asthma Council guidelines. METHODS: A retrospective audit was performed of medical records between July 2017 and June 2019. We included adult patients admitted to campuses within the Western Health network in Melbourne, Victoria, where the length of stay was at least 12 h, and the primary discharge diagnosis was asthma. RESULTS: Four hundred and ninety-three admissions were included in the analysis, representing 392 individual patients. Seventy-one percent of patients were female and 27% were current smokers. Ninety-six percent of patients had a prior asthma diagnosis, 63% had a previous hospital presentation and 75% were prescribed an inhaled preventer. In the ED, systemic corticosteroids and inhaled salbutamol were prescribed in 65% and 82% admissions respectively; adjunctive treatments included ipratropium (67% of admissions), magnesium sulfate (30%), adrenaline (11%) and non-invasive ventilation (9%). Overall, ED care was guideline concordant in 59% of admissions. On the wards, treatments prescribed within 24 h of admission included corticosteroids (90% of admissions), salbutamol (84%), ipratropium (64%) and inhaled preventers (63%). The proportion of patients prescribed these treatments, as well as documented follow up (e.g. asthma action plans), varied significantly depending on the treating specialty. CONCLUSION: The emergency treatment of patients with acute asthma frequently deviated from guidelines and there was significant variation in inpatient treatment. Quality improvement initiatives that incorporate structural changes are required to improve asthma care.

Potentially avoidable blood transfusion during trauma resuscitation.

INTRODUCTION: Red blood cell (RBC) transfusion is often essential during trauma resuscitation but is associated with high cost and potential adverse outcomes. This study aimed to determine the incidence of potentially avoidable RBC transfusions (PAT) among adult major trauma patients. MATERIALS AND METHODS: A retrospective review of data collected by Registry on patients presenting between Jan 2006 and Dec 2011 was conducted. Eligible patients received at least 1 unit of RBC in the first 24h following presentation to the Emergency Department (ED). Episodes of PAT were determined according to haemodynamic stability and post-transfusion haemoglobin levels. RESULTS: There were 621 patients included, of whom 224 (36.1%; 95% CI: 32.3-40.0) received PAT. Of them, 132 (58.9%) were haemodynamically stable on arrival and did not require a surgical procedure. Patients with PAT had significantly lower injury severity scores (30 vs 34, p<0.01), higher presenting systolic blood pressure (129 vs 112mm Hg, p<0.01) and a lower frequency of a shock index ≥1 (24.1 vs 65.0%, p<0.01), compared to those without PAT. They also had a significantly lower mortality (13.4 vs 21.7%, p<0.01). CONCLUSIONS: PAT after trauma was common and often delivered to haemodynamically stable patients who did not require surgical procedures. Clinical decision pathways for trauma resuscitation should aim to limit PAT.

Chlamydia detection during the menstrual cycle: a cross-sectional study of women attending a sexual health service.

BACKGROUND: We investigated the detection of chlamydia at different stages of the menstrual cycle. METHODS: Electronic medical records for women attending Melbourne Sexual Health Centre between March 2011 and 31(st) December 2012, who were tested for chlamydia by nucleic acid amplification of high vaginal, cervical, or urinary samples, and who recorded a date of last normal menstrual period (LNMP) between 0-28 days were included in the analysis. Logistic regression was used to calculate adjusted odds ratio (aOR) and 95% confidence intervals (CI) for the association of chlamydia with menstrual cycle adjusted by demographics and behavioural variables. Chlamydia and beta globin load were determined on those with stored samples. RESULTS: Of the 10,017 consultations that included a test for chlamydia and a valid LNMP, there were 417 in which chlamydia was detected. The proportion of samples with chlamydia was greater in the luteal phase (4.8%, 184/3831) than in the follicular phase (3.4%, 233/6816) both in the crude (OR 1.29 95%CI 1.1-1.6, p = 0.01) and adjusted odds ratio (aOR) 1.4 (95%CI 1.1-1.8, p = 0.004). Among women using hormonal contraception, there was no significant association with the luteal phase of the menstrual cycle (aOR 1.3, 95%CI 0.9, 1.8, p = 0.18). Among women not using hormonal contraception, there was a significant association with the luteal phase (aOR 1.6, (95% CI 1.1-2.3, p = 0.007). The chlamydia load was not significantly different in the 329 positive stored samples in weeks 3 and 4 vs weeks 1 and 2 for any site (P>0.12). CONCLUSIONS: The higher detection of chlamydia detection in the luteal phase of the menstrual cycle in only those not taking hormonal contraception suggest that hormonal factors influence chlamydia detection. The absence of a significantly highly chlamydia load in women during the luteal phase raises questions about the mechanism.

Contribution of sexual practices (other than anal sex) to bacterial sexually transmitted infection transmission in men who have sex with men: a cross-sectional analysis using electronic health records.

OBJECTIVE: We quantified the proportion of cases and risk of primary syphilis (PS), urethral chlamydia (UCT) and urethral gonorrhoea (UGC) attributable to sexual practices other than anal sex. METHODS: In this cross-sectional study, electronic records for men who have sex with men (MSM) who attended the Melbourne Sexual Health Centre between July 2002 (for PS) or January 2006 (for UCT and UGC) and October 2012, inclusive, were examined. RESULTS: There were 37 533 eligible consultations; 2374 (6%) of these reported no anal sex. There were 204 PS diagnoses, 673 UCT diagnoses, and 618 UGC diagnoses; 12 (6%), 16 (2%) and 44 (7%) cases, respectively, occurred in consultations where no anal sex was reported in the previous 3 months (PS, UGC) or twelve months (UCT). Among MSM reporting no anal sex, PS was diagnosed in 0.5 cases/100 consultations, UCT was diagnosed in 1.5 cases/100 tests for UCT and UGC was diagnosed in 14 cases/100 tests for UGC. UCT was significantly more common in MSM reporting anal sex (OR 2.18, 95% CI 1.32 to 3.59, p=0.002), but PS (OR 1.07 95% CI 0.6 to 1.93, p=0.82) and UGC (OR 1.28 95% CI 0.92 to 1.79. p=0.14) were not. For MSM reporting anal sex, condom use was protective for all three infections (all p≤0.03). CONCLUSIONS: Our findings suggest that UCT uncommonly occurs from sexual practices other than anal sex; however, these practices contribute significantly to PS and UGC. Successful programmes to control PS and UGC will need strategies, such as frequent testing, in addition to promoting condom use.