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Objective: To evaluate the difference in proportion of patients receiving antimicrobials within one hour of sepsis recognition at sepsis-related Medical Emergency Team (MET) calls, without or with a sepsis-credentialed pharmacist. Design: Retrospective pre and post-intervention study. Setting: Single centre tertiary referral hospital. Participants: Patients admitted to the General Medicine Unit who had a sepsis-related MET call 24 hrs per day, and all other units from 17:00-08:00 hrs from August 2019 to Jan 2020 in the pre-intervention cohort and Aug 2020 to Jan 2021 for the post-intervention cohort. Interventions: Pharmacists attended MET calls to assist selection of antimicrobials, collaboratively prescribe with the medical officers, ensure supply, provide advice on dosing calculations, reconstitution, and administration. The pre-intervention cohort (Aug 2019-Jan 2020) did not have credentialed pharmacists' involvement at MET calls. Outcome Measures: Proportion of patients who received antimicrobials within one hours of MET call. Results: There were 97 sepsis-related MET calls in the pre-intervention cohort and 110 sepsis-related MET calls in the post-intervention cohort. A significantly higher proportion of patients received antimicrobials within one hour with pharmacist involvement, compared to control (81.3% vs 59.7%, P  = .0006). A reduction in median time to antimicrobial administration (43 min vs 54 min, P  = .017) was observed. Conclusion: Sepsis-related MET calls with pharmacist involvement experienced a greater proportion of patients receiving antimicrobials within one hour of sepsis recognition, and a reduction in median time to antimicrobial administration. These results provide support for routine pharmacist involvement at MET calls to assist patients receiving medications in a timely and efficient manner., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study explores the experiences of nurses that provide 'complex', generalist healthcare in hospital settings. Complex care is described as care for patients experiencing acute issues additional to multimorbidity, ageing or psychosocial complexity. Nurses are the largest professional group of frontline healthcare workers and patients experiencing chronic conditions are overrepresented in acute care settings. Research exploring nurses' experiences of hospital-based complex care is limited, however. This study aims to add to what is known currently. Four 'complex care' nurses undertook in-depth semistructured interviews and their narratives were analysed using the conceptual framework of complex adaptive phenomenology. Two overarching themes constituting the 'essence' of complex care nursing were identified: Contextual factors and attribute/value-based elements. Creating meaningful patient outcomes and feeling part of a team were experienced as fulfilling, whereas time constraints, institutional settings and systemic barriers to comprehensive caregiving diminished the experience of providing complex care. Overall, work meaning presented as a dynamic phenomenon, shaped by personal and professional values, local settings and systemic factors. It is recommended that more expansive research be undertaken to explore the experience of complex care for nurses. Such knowledge can contribute to initiatives that draw a skilled, effective and engaged hospital-based complex care nursing workforce., (© 2024 The Authors. Nursing Inquiry published by John Wiley & Sons Ltd.)

Background: The COVID-19 pandemic created systemic challenges in patient care delivery., Aim: To evaluate the impact on pharmacist activities during pharmacist participation in ward rounds via telehealth, compared to physical attendance., Method: A single-centre, retrospective cohort study conducted from 18th Aug through 26th Oct 2020. Patients admitted to COVID and non-COVID general medical teams were included. Pharmacists attended ward rounds via telehealth for COVID teams; physical attendance continued for non-COVID teams. Telehealth involved pharmacists interacting with clinicians and patients virtually via videoconferencing whilst stationed remotely on the ward. Routine clinical pharmacy activities during telehealth ward rounds were compared to those during face-to-face ward rounds using comparative statistics., Results: Among the 1230 patients included (762 COVID, 468 non-COVID), pharmacist participation in telehealth ward rounds demonstrated significantly more documented activities compared with face-to-face rounds (mean 6.7 vs 4.9 per patient per day, p < 0.001). The telehealth cohort exhibited a higher number of orders placed via pharmacy-partnered medication charting (3.0 vs 2.4 per patient per day, p < 0.001), medication orders verified (2.3 vs 1.1, p < 0.001), and documented pharmacy notes (0.6 vs 0.2, p < 0.001). No significant difference was observed in medication requests processed (0.4 vs 0.4, p = 738), whilst non-COVID patients had more discharge prescription items generated (0.3 vs 0.7, p < 0.001)., Conclusion: Pharmacist involvement in medical ward rounds via telehealth enabled the ongoing provision of advanced clinical pharmacy services to inpatients in isolation rooms during the COVID-19 pandemic. This approach resulted in a greater number of pharmacy activities during telehealth ward rounds compared to standard in-person attendance., (© 2024. Crown.)

The ever-increasing prevalence of chronic conditions over the last half century has gradually altered the demographic of patients admitted to acute care settings; environments traditionally associated with episodic care rather than chronic and complex healthcare. In consequence, the lifeworld of the hospital medical doctor often entails healthcare for a complex, multi-morbid, patient cohort. This paper examines the experience of providing complex healthcare in the pressurised and fast-paced acute care setting. Four medical doctors from two metropolitan health services were interviewed and their data were analysed using a combinatorial framework of phenomenology and complexity theory. The horizon of complex care revealed itself as dynamic, expansive, immersive, and relational, entailing a specialised kind of practice that is now common in acute care settings. Yet this practice has made inroads largely without heralding the unique nature and potential of its ground. Herein lies opportunity for complex care clinicians to expand notions of health and illness, and to shape research, practice, and system design, for a future in which care for health complexity is optimised, irrespective of care settings., (© 2024. The Author(s).)

Increasingly, complexity science concepts are informing health care design and practice. The present paper describes the implementation of early complexity science principles in a Complex Care Program with the aim of strengthening the provision of integrated care. Grounded in cybernetic network theory, Stafford Beers Viable Systems Model [1] provided the guiding principles for the programs redesign. The Viable Systems Model with its broadly applicable principles [1], is now the conceptual model of information management in the program. Beers framework has enabled a relatively small number of clinicians to coordinate care for a large cohort of patients with significant clinical complexity, and a multitude of providers, in the community setting., Competing Interests: The authors have no competing interests to declare., (Copyright: 2021 The Author(s).)

Introduction: The population is ageing, with increasing health and supportive care needs. For older people, complex chronic health conditions and frailty can lead to a cascade of repeated hospitalisations and further decline. Existing solutions are fragmented and not person centred. The proposed Being Your Best programme integrates care across hospital and community settings to address symptoms of frailty., Methods and Analysis: A multicentre pragmatic mixed methods study aiming to recruit 80 community-dwelling patients aged ≥65 years recently discharged from hospital. Being Your Best is a codesigned 6-month programme that provides referral and linkage with existing services comprising four modules to prevent or mitigate symptoms of physical, nutritional, cognitive and social frailty. Feasibility will be assessed in terms of recruitment, acceptability of the intervention to participants and level of retention in the programme. Changes in frailty (Modified Reported Edmonton Frail Scale), cognition (Mini-Mental State Examination), functional ability (Barthel and Lawton), loneliness (University of California Los Angeles Loneliness Scale-3 items) and nutrition (Malnutrition Screening Tool) will also be measured at 6 and 12 months., Ethics and Dissemination: The study has received approval from Monash Health Human Research Ethics Committee (RES-19-0000904L). Results will be disseminated through peer-reviewed journals, conference and seminar presentations., Trial Registration Number: ACTRN12620000533998; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The Victorian Emergency Minimum Dataset (VEMD) collects administrative and clinical data for all presentations to Victorian public ED. The present study aimed to examine the level of agreement between the VEMD data and the medical record for a sample of patients coded as having acute cardiovascular conditions (acute coronary syndrome, stroke and transient ischaemic attack [TIA]) and unspecified chest pain in the VEMD., Methods: Six months of data provided to the VEMD from a large metropolitan hospital was obtained, and a random sample of 10% of cases (n = 310) were selected for review. Data for eight VEMD items were compared for concordance to data recorded in the ED medical record., Results: Complete concordance between the VEMD and medical records for all eight items was observed only for 101 (33%) presentations. Overall, the least concordant variables were those with a high number of coding options: usual type of accommodation (76%), referral pattern (84%) and primary diagnosis (85%). The concordance of the VEMD primary diagnosis varied when examined as individual codes (range 75%-100%) and when combined (acute coronary syndrome = 94%, stroke or TIA = 85% and chest pain unspecified = 75%). The level of agreement for some items improved when VEMD codings were combined., Conclusion: When compared to the medical record, our data suggest there is likely variation in the accuracy of some VEMD items, and suggests a larger prospective validation of the VEMD is warranted. For researchers using existing VEMD data, combining of some codes may be necessary., (© 2019 Australasian College for Emergency Medicine.)

Objective: This study compared the prevalence of homelessness in consecutive patients presenting to a metropolitan hospital ED measured via a prospective housing screen with the prevalence of homelessness determined via retrospective audit of hospital data. Factors that altered the odds of patients being homeless and service outcomes that differed were examined for screened patients., Methods: All patients presenting to the ED during a 7 day period in 2017 were invited to complete a housing screen. A retrospective audit of all ED presentations during the same period also occurred. Demographic (e.g. age, gender), clinical (e.g. reason for presentation, ED presentation history) and arrival mode (e.g. time, how arrived) predictors of homeless status were examined alongside care outcomes (e.g. ED length of stay, admission and 28 day re-presentation)., Results: Of 1208 presenting patients, 504 were prospectively screened and 7.9% were homeless. This compared with 0.8% of ED presentations coded as homeless in the Victorian Emergency Minimum Dataset and 2.3% of the 704 non-screened patients identified as homeless using Victorian Emergency Minimum Dataset Usual Accommodation alongside primary diagnosis and registration address. Within the screened sample, homeless patients were more likely to be male, arrive by emergency ambulance/with police, have a psychosocial diagnosis, and be frequent presenters. Re-presentation within 28 days occurred for 43% of homeless and 15% of not-homeless patients., Conclusions: Hospital ED administrative data substantially under-recognises the prevalence of homelessness in presenting patients. Standardised use of brief housing screens could improve identification of and provision of support to this often highly vulnerable population., (© 2019 Australasian College for Emergency Medicine.)

Background: Meaningful partnering with patients is advocated to enhance care delivery. Little is known about how this is operationalised at the point of care during hospital ward rounds, where decision-making concerning patient care frequently occurs., Objective: Describe participation of patients, with differing preferences for participation, during ward rounds in acute medical inpatient services., Methods: Naturalistic, multimethod design. Data were collected using surveys and observations of ward rounds at two hospitals in Melbourne, Australia. Using convenience sampling, a stratified sample of acute general medical patients were recruited. Prior to observation and interview, patient responses to the Control Preference Scale were used to stratify them into three groups representing diverse participation preferences: active control where the patient makes decisions; shared control where the patient prefers to make decisions jointly with clinicians; and passive control where the patient prefers clinicians make decisions., Results: Of the 52 patients observed over 133 ward rounds, 30.8% (n=16) reported an active control preference for participation in decision-making during ward rounds, 25% (n=13) expressed shared control preference and 44.2% (n=23) expressed low control preference. Patients' participation was observed in 75% (n=85) of ward rounds, but few rounds (18%, n=20) involved patient contribution to decisions about their care. Clinicians prompted patient participation in 54% of rounds; and in 15% patients initiated their own participation. Thematic analysis of qualitative observation and patient interview data revealed two themes, supporting patient capability and clinician-led opportunity , that contributed to patient participation or non-participation in ward rounds., Conclusions: Participation in ward rounds was similar for patients irrespective of control preference. This study demonstrates the need to better understand clinician roles in supporting strategies that promote patient participation in day-to-day hospital care., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: To systematically review the available evidence about hospital discharge communication practices and identify which practices were preferred by patients and healthcare providers, improved patient and provider satisfaction, and increased patients' understanding of their medical condition., Data Sources: OVID Medline, Web of Science, ProQuest, PubMed and CINAHL plus., Study Selection: Databases were searched for peer-reviewed, English-language papers, published to August 2016, of empirical research using quantitative or qualitative methods. Reference lists in the papers meeting inclusion criteria were searched to identify further papers., Data Extraction: Of the 3489 articles identified, 30 met inclusion criteria and were reviewed., Results of Data Synthesis: Much research to date has focused on the use of printed material and person-based discharge communication methods including verbal instructions (either in person or via telephone calls). Several studies have examined the use of information technology (IT) such as computer-generated and video-based discharge communication practices. Utilizing technology to deliver discharge information is preferred by healthcare providers and patients, and improves patients' understanding of their medical condition and discharge instructions., Conclusion: Well-designed IT solutions may improve communication, coordination and retention of information, and lead to improved outcomes for patients, their families, caregivers and primary healthcare providers as well as expediting the task for hospital staff., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Objective: This study aimed to quantify the rate of transfer of care or overstay from cellulitis management in the emergency short stay unit (ESSU) and to identify risk factors during initial assessment associated with transfer of care or overstay., Methods: A retrospective cohort study was conducted including cellulitis patients diagnosed with and admitted to the ESSU at a metropolitan adult tertiary referral centre. Data abstracted included patient demographics, comorbidities, initial investigations and initial vital signs. Transfer of care or overstay were defined as inpatient admission or a stay in ESSU >28 h, respectively., Results: Of the 451 included patients, 157 (34.8%) met the criteria for transfer of care or overstay. These criteria included admission to hospital inpatient units (115 patients, 73.2%) and patients who overstayed the ESSU time period (42 patients, 26.8%). Variables independently associated with transfer of care or overstay were obesity (adjusted odds ratio [OR] 4.33; 95% confidence interval [CI] 1.38-15.59), i.v. drug use (adjusted OR 2.15; 95% CI 1.03-4.51), white blood cell count (adjusted OR 1.09; 95% CI 1.02-1.16 per 1 × 10 9 /L increase) and C-reactive protein (adjusted OR 1.004; 95% CI 1.00-1.01 per 1 mg/L increase)., Conclusions: Transfer of care or overstay after admission to ESSU was high among patients with cellulitis. Variables independently associated with transfer of care or overstay were obesity, i.v. drug use, elevated white blood cell count and elevated C-reactive protein. Awareness of these variables can inform appropriate guidelines for ESSU admission, potentially improving patient flow and reducing length of stay in the ED and hospital., (© 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Objective: To determine the prevalence of resuscitation orders and Advance Care Plans, and the relationship with Medical Emergency Team (MET) calls., Methods: A point prevalence review of patient records at five Victorian hospital services., Results: One thousand nine hundred and thirty-four patient records were reviewed, and 230 resuscitation orders and 15 Advance Care Plans found. Significantly, more resuscitation orders were found at public hospitals. Patients admitted to private hospitals were older, with shorter admissions. A further 24 orders were written following MET calls for 97 patients. Only 16% of patients aged 80+ years had a resuscitation order written within 24 hours of admission., Conclusion: Fewer resuscitation orders were written at admission for older adults than might be expected if goals of care and resuscitation outcome are considered. MET continue to have a prominent role in end-of-life care. Consideration and documentation about treatment plans are needed early in an admission to avoid burdensome and futile resuscitation events., (© 2016 AJA Inc.)

Objective: to profile the trajectory of, and risk factors for, functional decline in older patients in the 30 days following Emergency Department (ED) discharge., Methods: prospective cohort study of community-dwelling patients aged ≥65 years, discharged home from a metropolitan Melbourne ED, 31 July 2012 to 30 November 2013. The primary outcome was functional decline, comprising either increased dependency in personal activities of daily living (ADL) or in skills required for living independently instrumental ADL (IADL), deterioration in cognitive function, nursing home admission or death. Univariate analyses were used to select risk factors and logistic regression models constructed to predict functional decline., Results: at 30 days, 34.4% experienced functional decline; with 16.7% becoming more dependent in personal ADL, 17.5% more dependant in IADL and 18.4% suffering deterioration in cognitive function. Factors independently associated with decline were functional impairment prior to the visit in personal ADL (Odds Ratio [OR] 3.21, 95% confidence interval [CI] 2.26-4.53) or in IADL (OR 6.69, 95% CI 4.31-10.38). The relative odds were less for patients with moderately impaired cognition relative to those with normal cognition (OR 0.38, 95% CI 0.19-0.75). There was a 68% decline in the relative odds of functional decline for those with any impairment in IADL who used an aid for mobility (OR 0.32, 95% CI 0.14-0.7)., Conclusion: older people with pre-existing ADL impairment were at high risk of functional decline in the 30 days following ED presentation. This effect was largely mitigated for those who used a mobility aid. Early intervention with functional assessments and appropriate implementation of support services and mobility aids could reduce functional decline after discharge., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com)

Background: an emergency department (ED) visit is a sentinel event for an older person, with increased likelihood of adverse outcomes post-discharge including early re-presentation., Objectives: to determine factors associated with early re-presentation., Methods: prospective cohort study conducted in the ED of a large acute Melbourne tertiary hospital. Community-dwelling patients ≥65 years were interviewed including comprehensive assessment of cognitive and functional status, and mood. Logistic regression was used to identify risk factors for return within 30 days., Results: nine hundred and fifty-nine patients, median age 77 years, were recruited. One hundred and forty patients (14.6%) re-presented within 30 days, including 22 patients (2.3%) on ≥2 occasions and 75 patients (7.8%) within 7 days. Risk factors for re-presentation included depressive symptoms, cognitive impairment, co-morbidity, triaged as less urgent (ATS 4) and attendance in the previous 12 months, with a decline in risk after 85 years of age. Logistic regression identified chronic obstructive pulmonary disease (OR 1.78, 95% CI 1.02-3.11), moderate cognitive impairment (OR 2.07, 95% CI 1.09-3.90), previous ED visit (OR 2.11, 95% CI 1.43-3.12) and ATS 4 (OR 2.34, 95% CI 1.10-4.99) as independent risk factors for re-presentation. Age ≥85 years was associated with reduced risk (OR 0.81, 95% CI 0.70-0.93)., Conclusion: older discharged patients had a high rate of early re-presentation. Previously identified risk factors-increased age, living alone, functional dependence and polypharmacy-were not associated with early return in this study. It is not clear whether these inconsistencies represent a change in patient case-mix or strategies implemented to reduce re-attendance. This remains an important area for future research., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: A partnered medication review and charting model involving a pharmacist and medical officer was implemented in the Emergency Short Stay Unit and General Medicine Unit of a major tertiary hospital. The aim of the study was to describe the safety and effectiveness of partnered medication charting in this setting., Methods: A partnered medication review and charting model was developed. Credentialed pharmacists charted pre-admission medications and venous thromboembolism prophylaxis in collaboration with the admitting medical officer. The pharmacist subsequently had a clinical discussion with the treating nurse regarding the medication management plan for the patient. A prospective audit was undertaken of all patients from the initiation of the service., Results: A total of 549 patients had medications charted by a pharmacist from the 14th of November 2012 to the 30th of April 2013. A total of 4765 medications were charted by pharmacists with 7 identified errors, corresponding to an error rate of 1.47 per 1000 medications charted., Conclusions: Partnered medication review and charting by a pharmacist in the Emergency Short Stay and General Medicine unit is achievable, safe and effective. Benefits from the model extend beyond the pharmacist charting the medications, with clinical value added to the admission process through early collaboration with the medical officer. Further research is required to provide evidence to further support this collaborative model., (Copyright © 2015. Published by Elsevier Ltd.)

This article examines the right of pregnant women to determine what will happen to their own bodies and whether their right to autonomy is absolute when refusing treatment which may be consider in their best interests and/or their fetuses'. A theoretical framework is used supported by relevant legal cases to argue that in some instance the rights of women to refuse treatment, most notably caesarean section have been overridden in favour of the fetus. The conclusion from the legal cases is that despite the consequences a woman's rights should not be overridden in favour of the fetus.

In most trials, at least 50% of patients with Graves' disease treated with antithyroid drugs (ATD) relapse after achieving euthyroidism. At present, there are no definitive prognostic parameters available early in treatment to indicate those likely to achieve long-term remission. Because thyrotropin receptor antibodies (TRAb) are specific for Graves' disease, the possibility that their rate of change early in treatment (0 to 6 months) might be such an indicator was explored. TRAb were measured both as thyrotropin binding inhibitory immunoglobulins (TBII) and as thyroid-stimulating antibodies (TSAb) in 85 patients with untreated Graves' disease at 6-month intervals throughout their ATD treatment. The patients in the study were treated for a minimum period of 12 months and were categorized retrospectively into two groups depending on whether or not they remained in remission after ATD treatment. Remission was deemed as reached in patients who remained euthyroid for a minimum period of 15 months after cessation of ATD. The mean initial TBII and TSAb values in the nonremission group were significantly higher than in the remission group (p < 0.001 for both parameters). The rates of fall in mean TBII levels were similar for each group in the first 6 months of treatment, but while they continued to fall in the remission group over the next 6 to 12 months, mean values for the nonremission group plateaued and failed to fall to control levels within that period. These results indicate that changes in TRAb levels, measured either as TBII or TSAb, occur more rapidly in the second 6 months of treatment in patients who ultimately achieve remission than those who do not. If TBII fall to control levels by 12 months, the patient has at least a 70% chance of ultimately achieving remission with ATD treatment alone.

1. Recommendations and decisions concerning treatment should primarily be based on the absolute evaluation of risk and risk reduction and not on calculation of a relative risk situation. 2. The therapeutic benefit in women at low risk should be balanced against possible physical and psychic side effects and submitted to a cost/benefit analysis. 3. The fact that coronary heart disease is rare in young women must not at all be reason for a less consequent treatment and prevention in women with established coronary heart disease.

The release of secretory phospholipase A2 (sPLA2) into the mammalian circulation may contribute to the development of hemorrhagic and inflammatory diseases. sPLA2 has previously been shown to alter the behavior of platelets, leukocytes, and endothelial cells, although the molecular basis for these cellular effects has not been established. Our studies indicate that the inhibition of platelet aggregation by snake, bee venom, and pancreatic sPLA2 is dependent on a plasma cofactor. This cofactor resides within the lipoprotein fraction of plasma, with 54%, 31%, and 11% of the activity present in the high-density lipoprotein (HDL), low-density lipoprotein (LDL), and very low density lipoprotein (VLDL) fractions, respectively. Delipidation of HDL and LDL was associated with the complete loss of platelet-inhibitory activity. Incubation of purified sPLA2 with the HDL fraction of plasma resulted in the time-dependent generation of lysophosphatidylcholine (lysoPC). The formation of lysoPC correlated with the inhibition of platelet aggregation. Purified lysoPC (10 to 100 micrograms/mL) inhibited platelet aggregation and dense granule release induced by thrombin (0.05 U/mL), collagen (1 micrograms/mL), ionophore A23187 (2 mumol/L), ADP (12.5 mumol/L), and adrenaline (3.2 mumol/L). The inhibition of platelet aggregation by lysoPC was dose-dependent and correlated with decreased fibrinogen binding to glycoprotein IIb-IIIa. Our studies indicate that the enzymatic generation of lysoPC from plasma lipoproteins is essential for the sPLA2-mediated inhibition of platelet activation in the presence of albumin. These results raise the possibility that the toxic effects of circulating sPLA2 may be due in part to the generation of the bioactive lysophospholipid, lysoPC.