Physiological status during emergency department care : relationship with inhospital death after clinical deterioration

OBJECTIVE: To examine the relationship between patient physiological status in the emergency department (ED) and inhospital mortality after rapid response team (RRT) or cardiac arrest team (CAT) activations within 72 hours of emergency admission to medical or surgical wards. DESIGN, SETTING AND PARTICIPANTS: A multisite, retrospective, cohort study of 660 randomly selected (220 patients per site) adult medical or surgical patients who were admitted from the ED during 2012 and who had had an RRT or CAT activation within 72 hours of admission, at three hospitals in Melbourne, Australia. MAIN OUTCOME MEASURE: Inhospital mortality. RESULTS: There were 825 RRT activations (for 634 patients) and 42 CAT activations (for 35 patients). The median time to the first RRT or CAT activation was 18.8 hours and was significantly shorter in patients who died in hospital (14.6 v 20.6 hours, P=0.036). Compared with survivors, patients who died were more likely to have at least one observation meeting RRT criteria during their ED stay (45.9% v 34.8%; P=0.029): tachypnoea (21.1% v 13.4%, P=0.039), hypotension (20.2% v 11.8%, P=0.018), hypoxaemia (8.3% v 3.1%, P=0.001) and altered conscious state (6.2% v 1.3%, P=0.001) were more common in patients who died. The risk-adjusted odds ratio (OR) for inhospital death was highest for patients with an altered conscious state during their ED stay (OR, 4.633; 95% CI, 1.365-15.728; P=0.014). CONCLUSIONS: In patients who needed an RRT or CAT activation within the first 72 hours of emergency admission to medical or surgical wards, there was a strong association between physiological derangement during ED care and inhospital death.

Nutritional management of gastrointestinal surgical patients in Victoria's public hospitals

Aim: Poor nutritional status has negative effects on post-operative outcomes, further compounded by surgical stress and fasting, places gastrointestinal surgery patients at high risk of malnutrition. Recent published research has challenged historic surgical nutrition practices; however, changes to practice in Australia have been slow. The aim of this study was to investigate current nutritional management of gastrointestinal surgery patients and compare this with the best practice guidelines, while exploring enablers to implementation of best practice. Methods: A 30-question telephone survey was developed to explore demographics and nutritional management of gastrointestinal surgical patients during pre-admission, inpatient stay and post-operative care. Forty-one gastrointestinal surgery dietitians were identified and contacted from 31 public hospitals in Victoria, Australia, and invited to participate. Results: Twenty-five dietitians participated in the survey (response rate 61%). Very few dietitians (12%) were funded for pre-admission clinics or outpatient clinics, and, overwhelmingly, dietitians reported not being involved in nutritional decision-making, and reported feeling unsatisfied with current nutritional management of patients. Despite half the hospitals reporting following best practice guidelines, only 22% implemented guidelines completely. There was no correlation observed between dietitian experience, department size or full-time equivalents allocated to surgery and nutritional intervention; however, the presence of a care pathway made a significant difference to the dietitian's overall satisfaction with dietetic care (P = 0.002). Conclusions: Current nutritional management of gastrointestinal surgery patients in Victorian hospitals is far from best practice. The implementation of a care pathway is the most effective way of ensuring best practice nutritional management of gastrointestinal surgical patients.

Multicenter randomized controlled trial of a home walking intervention after outpatient cardiac rehabilitation on health-related quality of life in women

BACKGROUND: Poor health-related quality of life (HRQL) has been shown to be predictive of adverse outcomes in cardiac patients. As women with coronary heart disease have been shown to have lower HRQL than men with coronary heart disease, women are at greater risk of a poor clinical outcome. This study tested the effect of a 12-week home walking intervention after completion of outpatient cardiac rehabilitation (OCR) on HRQL and maintenance of physical activity among women. DESIGN: Multicenter two-group randomized trial. METHODS: After completion of OCR, participants were randomly allocated to the intervention or usual care groups. The outcomes were HRQL (assessed using the MacNew Heart Disease HRQL instrument) and self-reported physical activity (assessed using the Stages of Change model of exercise behavior) at 3, 6, and 12 months after OCR. RESULTS: Seventy-two women were randomized to the intervention and 81 to usual care. Attrition was greater in the treatment group (13 vs. 1%). HRQL scores increased relative to the base level in both arms and were significantly higher in the intervention group at 6 months, but not at 3 or 12 months. Maintenance of physical activity declined over time in both groups, however, this decline was significantly reduced among women in the intervention group. CONCLUSION: HRQL improved in both groups, but seemed to increase earlier among women in the intervention group. As maintenance of physical activity was higher among women in the intervention group, this minimal intervention could be used to facilitate women's progression from supervised to independent exercise.

Association between participation in outpatient cardiac rehabilitation and self-reported receipt of lifestyle advice from a healthcare provider: results of a population-based cross-sectional survey

We test the hypothesis that the odds of self-reported receipt of lifestyle advice from a health care provider will be lower among outpatient cardiac rehabilitation (OCR) nonattendees and nonreferred patients compared to OCR attendees. Logistic regression was used to analyse cross-sectional data provided by 65% (4971/7678) of patients aged 20 to 84 years discharged from public hospitals with a diagnosis indicating eligibility for OCR between 2002 and 2007. Among respondents, 71% (3518) and 55% (2724) recalled advice regarding physical activity and diet, respectively, while 88% (592/674) of smokers recalled quit advice. OCR attendance was low: 36% (1764) of respondents reported attending OCR, 11% (552) did not attend following referral, and 45% (2217) did not recall being invited. The odds of recalling advice regarding physical activity and diet were significantly lower among OCR nonattendees compared to attendees (OR 0.34, 95% CI 0.21, 0.56 and OR 0.33, 95% CI 0.25, 0.44, resp.) and among nonreferred respondents compared to OCR attendees (OR 0.10, 95% CI 0.07, 0.15 and OR 0.17, 95% CI 0.14, 0.22, resp.). Patients hospitalised for coronary heart disease should be referred to OCR or a suitable alternative to improve recall of lifestyle advice that will reduce the risk of further coronary events.

Prevalence of mental health disorders in inflammatory bowel disease: an Australian outpatient cohort

BACKGROUND: This study aimed to characterize prevalence of anxiety and depressive conditions and uptake of mental health services in an Australian inflammatory bowel disease (IBD) outpatient setting.

METHODS: Eighty-one IBD patients (39 males, mean age 35 years) attending a tertiary hospital IBD outpatient clinic participated in this study. Disease severity was evaluated according to the Manitoba Index. Diagnosis of an anxiety or depressive condition was based upon the Mini-International Neuropsychiatric Interview and the Hospital Anxiety and Depression Scale.

RESULTS: Based on Hospital Anxiety and Depression Scale subscale scores >8 and meeting Mini-International Neuropsychiatric Interview criteria, 16 (19.8%) participants had at least one anxiety condition, while nine (11.1%) had a depressive disorder present. Active IBD status was associated with higher prevalence rates across all anxiety and depressive conditions. Generalized anxiety was the most common (12 participants, 14.8%) anxiety condition, and major depressive disorder (recurrent) was the most common depressive condition reported (five participants, 6.2%). Seventeen participants (21%) reported currently seeking help for mental health issues while 12.4% were identified has having at least one psychological condition but not seeking treatment.

CONCLUSION: We conclude that rates of anxiety and depression are high in this cohort, and that IBD-focused psychological services should be a key component of any holistic IBD service, especially for those identified as having active IBD.

Trends in referral to outpatient cardiac rehabilitation in the Hunter Region of Australia, 2002-2007

BACKGROUND: Cardiac rehabilitation (CR) is an underutilized evidence-based treatment. We described trends in referral to outpatient CR (OCR) and the factors associated with referral. DESIGN: Cross-sectional survey data provided by Hunter residents aged 20 years or older discharged from public hospitals in the region between 2002 and 2007 with an OCR eligible diagnosis were extracted from the Hunter New England Heart and Stroke Register database. METHODS: Trends in referral were determined using the chi test for trend. Factors associated with referral were examined using multiple logistic regression. RESULTS: Sixty-five percent (4971 of 7678) of patients provided sufficient data for inclusion in the analysis. Approximately half of the patients reported being referred to OCR. No increase over time was observed. Factors associated with referral were age less than 70 years, male sex, being married, urban residence, at least one admission to the tertiary referral hospital for cardiology, at least one admission for acute myocardial infarction, revascularization, no admissions for congestive heart failure, a self-reported history of high cholesterol, and no history of stroke or atrial fibrillation. CONCLUSION: Access to this treatment of proven benefit remained suboptimal despite the provision of new programs and expansion of existing programs. Automatic referral, which is recommended in Australia, should be standard practice.

Cancer diagnosed in the emergency department of a regional health service

OBJECTIVE: Patients diagnosed with cancer in the Emergency Department (ED) have more advanced disease at diagnosis and poorer outcomes. High rates of initial presentation to ED suggest potential problems with access to care. The aim of this project was to interpret findings in regional/rural Victoria and explore implications for practice.

DESIGN: Cross-sectional study linking two independent data sets.

SETTING: Regional city of Geelong and surrounding rural areas in south-west Victoria.

PARTICIPANTS: All newly diagnosed cancer patients in 2009.

MAIN OUTCOME MEASURES: Number of cancer patients diagnosed in the ED.

RESULTS: One in five newly diagnosed cancer patients present to ED 6 months prior to cancer diagnosis. One in 10 is diagnosed as a result of their ED visit. Patients presenting to ED were older, more often men and from disadvantaged areas. Symptoms on presentation included chest complaints, bowel obstruction, abdominal pain, anaemia and generalised weakness. Cancer diagnosed in the ED is associated with advanced stage and shorter survival.

CONCLUSION: Reasons for presentation to ED would be multifactorial and include complex cases with coexisting symptoms making diagnosis difficult. The general public appear to have a low level of awareness of alternative primary care services or difficulty accessing such information. Some of the changes towards reducing the number of patients presenting to ED will include patient education.