Academic literature on the topic 'Medical care Utilization Victoria Melbourne'

Background Responsibilities of critical care nurses for management of mechanical ventilation may differ among countries. Organizational interventions, including weaning protocols, may have a variable impact in settings that differ in nursing autonomy and interdisciplinary collaboration. Objective To characterize the role of Australian critical care nurses in the management of mechanical ventilation. Methods A 3-month, prospective cohort study was performed. All clinical decisions related to mechanical ventilation in a 24-bed, combined medical-surgical adult intensive care unit at the Royal Melbourne Hospital, a university-affiliated teaching hospital in Melbourne, Victoria, Australia, were determined. Results Of 474 patients admitted during the 81-day study period, 319 (67%) received mechanical ventilation. Death occurred in 12.5% (40/319) of patients. Median durations of mechanical ventilation and intensive care stay were 0.9 and 1.9 days, respectively. A total of 3986 ventilation and weaning decisions (defined as any adjustment to ventilator settings, including mode change; rate or pressure support adjustment; and titration of tidal volume, positive end-expiratory pressure, or fraction of inspired oxygen) were made. Of these, 2538 decisions (64%) were made by nurses alone, 693 (17%) by medical staff, and 755 (19%) by nurses and staff in collaboration. Decisions made exclusively by nurses were less common for patients with predominantly respiratory disease or multiple organ dysfunction than for other patients. Conclusions In this unit, critical care nurses have high levels of responsibility for, and autonomy in, the management of mechanical ventilation and weaning. Revalidation of protocols for ventilation practices in other clinical contexts may be needed.

Objective: To provide a biography of G Vernon Davies who took up a career in old age psychiatry in 1955 at the age of 67 at Mont Park Hospital in an era when there few psychiatrists working in the field. Conclusion: In the 1950s and 1960s, Vernon Davies worked as an old age psychiatrist and published papers containing sensible practical advice informed by contemporary research and experience, broadly applicable to both primary and secondary care, presented in a compassionate and empathetic manner. His clinical research in old age psychiatry resulted in the first doctoral degree in psychiatry awarded at the University of Melbourne at the age of 79. Before commencing old age psychiatry, he served in the Australian Army Medical Corps as a Regimental Medical Officer and received the Distinguished Service Order. He spent 3 years as a medical missionary in the New Hebrides before settling at Wangaratta where he worked as a physician for over 30 years. He contributed to his local community in a broad range of activities. Vernon Davies is an Australian pioneer of old age psychiatry.

Clinical Registries are established to provide a clinically credible means for monitoring and benchmarking healthcare processes and outcomes, to identify areas for improvement, and drive strategies for improving patient care. Clinical Registries are used to assess changes in clinical practice, appropriateness of care and health outcomes over time. The American Heart Association Policy Statement in April 2011 called for expanding the application for existing and future Clinical Registries, with well-designed Clinical Registry programs. Concurrently, in Australia, and similarly within the United States and United Kingdom, there has been an increased focus on performance measurement for quality and patient safety. Within Victoria, the Victorian Clinical Governance Policy Framework outlines clinical effectiveness as one of the four domains of Clinical Governance As Clinical Registries evaluate effectiveness and safety of patient care by measuring patient outcomes compared with peers, the use of Clinical Registries data to improve a health service’s quality of care seems intuitive. A mixed methods approach was utilised, involving (1) semi-structured interviews and (2) documentation audit in this study conducted at Austin Health, a major tertiary teaching hospital in North-Eastern metropolitan Melbourne, affiliated with the University of Melbourne and various research institutes within Austin LifeSciences. Although many studies have highlighted the benefits of data collected via individual Clinical Registries, [5,6] the level of voluntary medical staff participation in Clinical Registries at a health service level is yet to be established. The aim of this study was to document the level of medical staff involvement for Clinical Registries within a major tertiary teaching hospital, and the level of reporting into Quality Committees within the organisation. This study demonstrates that along with a very high level of medical staff participation in Clinical Registries, there is a lack of systematic reporting of Registries data into quality committees beyond unit level, and utilisation of such data to reflect upon practice and drive quality improvement. Abbreviations: CREPS – Centre for Excellence in Patient Safety; CSU – Clinical Services Unit; HOU – Heads of Unit; VASM – Victorian Audit of Surgical Mortality.

e18324 Background: Discussion of cancer cases at multi-disciplinary meetings (MDMs) for treatment planning is expected standard care in Australia. There has been rapid uptake of MDMs in the last 10 - 15 years and in the state of Victoria approximately 70% of cancer cases are discussed. MDMs have strong support from medical staff and we investigated their motivation in attending MDMs. Methods: Over 12 months, Austin Health in Melbourne, Victoria, hosted 452 cancer MDMs discussing 5943 patients. MDMs covered 15 tumour areas: 11 solid tumour, one lymphoma and three haematological. Over a 4-week period, medical staff attending MDMs were surveyed and asked to rank what they valued most about cancer MDMs, over and above the benefits for patients. Results: Responses were received from 84% of the 285 medical staff surveyed, which included consultants as well as trainees (registrars and fellows). For 75% of respondents the highest ranking was given to multi-disciplinary communication, 9% gave the highest ranking to quality assurance and governance, 5% ongoing learning for consultants, 5% collegiate relationships, 2% learning and teaching for non-consultant staff, 2% peer support 1% job satisfaction and 1% clinical trials engagement. Similar results were obtained for consultant staff and for registrars / fellows. For consultant medical staff, if multidisciplinary communication was excluded, 44% of respondents gave the highest ranking to quality assurance and governance, 23% to collegiate relationships, 20% ongoing learning for consultants, 10% peer support and 3% clinical trials engagement. Conclusions: When we asked doctors what they valued most about attending cancer MDMs, besides the benefits for patients, communication between disciplines was clearly the most valued aspect. The benefits for quality and governance was the next most valued, then collegiate relationships and peer support, and ongoing learning.

Background On 26 July 2016, Victoria began a large study of HIV pre-exposure prophylaxis, called PrEPX, that involved the creation of around 2600 appointments over 3 months across multiple sites in Melbourne, Australia. At this time, the Melbourne Sexual Health Centre (MSHC) appeared to have a larger demand on its services. The aim of the present study was to determine whether this apparent increase in demand was substantially different from other demand fluctuations. Methods: Patients presenting to the MSHC from 2014 to 2016 were reviewed. Demographic characteristics, sexual risks and sexually transmitted infection diagnoses were extracted from the clinical database. Results: There were 115522 walk-in presentations for care and a rise in presentations in the week following the launch of the PrEPX study, but at least six similar peaks occurred that year. The peak coinciding with the launch of PrEPX was only apparent for men who have sex with men. There was a substantial increase in the proportion of patients who could not be seen (i.e. triaged out), from 10% in the week before PrEPX to 22.2% in the second week after, but this was primarily due to staff absences. At the time of the PrEPX study, data were collected on the duration of symptoms for common conditions and found no significant (P>0.29) change in the average duration of symptoms compared with that seen before the PrEPX launch. Conclusions: The increase in the number of medical consultations required for the PrEPX study did not result in excessive demand for public sexual health services.

Introduction Understanding the economic impact of managing allogeneic hematopoietic stem cell transplant (HSCT) recipients with cytomegalovirus (CMV) is important for future planning within institutional transplant programs. CMV remains the most frequent viral infection following HSCT of which the clinical impact on transplant outcomes has been well described. However, much less is known about the impact of CMV on health resource utilisation, re-admissions and hospital costs. In addition to antiviral therapy, there are nursing, medical and pharmacy costs to consider. We therefore undertook a study to evaluate the clinical and economic burden of CMV infection following HSCT in a large Australian transplant centre operating under a universal health care system. Methods A retrospective single centre study at the Royal Melbourne Hospital, Melbourne, Australia was performed on all consecutive allogeneic HSCT recipients between January 2015 to December 2017. CMV pre-emptive monitoring using quantitative CMV plasma viral load was performed twice weekly from time of transplant to 100 days or longer in the presence of graft versus host disease. Clinically significant CMV (csCMV) was defined as patients receiving anti-CMV treatment, often with a plasma CMV viral load >400 IU/ml. Throughout the study period, the first line anti-CMV therapy was ganciclovir; either as oral valganciclovir for outpatient management in asymptomatic patients or IV ganciclovir as an inpatient for patients with concerns about oral absorption. Second-line therapy was IV foscarnet. Hospital costing data for the first and subsequent re-admissions for the first 12 months were obtained from the business intelligence unit. Financial year costing was available for FY2015/2016 to FY2017/2018. Ethics was approved by the Melbourne Health Human Ethics Review Committee (HREC 2017.368). Results A total of 255 patients underwent alloHSCT with a median age of 51 years (IQR 40-59) with the most common underlying diagnoses being AML (41%), ALL (11%) and MDS (11%) (Table 1). Thirty-one percent of transplants used myeloablative conditioning, 54% had unrelated donors and 3% had an umbilical cord source. Pre-transplant recipient CMV seropositivity was 62% (n=158), of whom 139 had detectable CMV viremia and 104 (40.8%) experienced clinically significant CMV (csCMV). The median duration of CMV treatment was 33 days (IQR 21-63). Re-admission to hospital within the first 12 months of HSCT occurred in 78.4%. There was a greater number of admissions observed in csCMV patients compared to no csCMV (median 3 vs 2 admissions, p=0.001) with the duration of admitted days within the first 12 months being significantly greater in csCMV patients compared to no csCMV (median 65 vs 36 days, p<0.00001). The mean total cost of treating patients with csCMV for the first 12 months compared to the total cost for patients not requiring CMV treatment was A$196,822 (US$147,616) and A$114503 (US $85,877) (p<0.0001), respectively. Therefore the crude attributable mean cost of treating csCMV was A$82,319 (US$61,739) per patient for the first 12 months of HSCT. The greatest significant contributory costs were from pharmacy A$17,807 (US$13,355), nursing A$16,944 (US$12,708) and medical A$5,898 (US$4,423). Conclusions The health care cost and resource utilisation of treating CMV infection following an allogeneic HSCT is substantial and places a heavy burden on limited health resources. In this study, patients experiencing csCMV had an increased number and longer total duration of admissions days compared to patients who did not require CMV treatment. Interventions aimed at reducing the burden of CMV in alloHSCT recipients are required. Disclosures Yong: Merck Ltd: Honoraria. Bajel:AbbVie: Membership on an entity's Board of Directors or advisory committees, Other: travel funding. Ritchie:Sanofi: Honoraria; Novartis: Honoraria; Imago: Research Funding; Beigene: Research Funding; Takeda: Research Funding; BMS: Research Funding; Pfizer: Consultancy; Amgen: Consultancy, Honoraria, Research Funding. Slavin:Merck Ltd: Honoraria, Research Funding.

Objective The aim of the present study was to try to understand the breadth and comprehensiveness of a regional operating model (ROM) developed within the Victorian Department of Health’s North West Metropolitan Region office in Melbourne, Australia. Methods A published literature search was conducted, with additional website scanning, snowballing technique and expert consultation, to identify existing operating models. An analytical grid was developed covering 16 components to evaluate the models and assess the exhaustiveness of the ROM. Results From the 34 documents scoped, 10 models were identified to act as a direct comparator to the ROM. These concerned models from Australia (n = 5) and other comparable countries (Canada, UK). The ROM was among the most exhaustive models, covering 13 of 16 components. It was one of the few models that included intersectoral actions and levers of influence. However, some models identified more precisely the planning tools, prioritisation criteria and steps, and the allocation mechanisms. Conclusions The review finds that the ROM appears to provide a wide coverage of aspects of planning and integrates into a single model some of the distinctive elements of the other models scoped. What is known about the topic? Various jurisdictions are moving towards a population-based approach to manage public services with regard to the provision of individual medical and social care. Various models have been proposed to guide the planning of services from a population health perspective. What does this paper add? This paper assesses the coverage of attributes of operating models supporting a population health planning approach to the management of services at the regional or local level. It provides a scoping of current models proposed to organise activities to ensure an integrated approach to the provision of services and compares the scoped models to a model recently implemented in Victoria, Australia. What are the implications for practitioners? This paper highlights the relative paucity of operating models describing in concrete terms how to manage medical and social services from a population perspective and encourages organisations that are accountable for securing population health to clearly articulate their own operating model. It outlines strengths and potential gaps in current models.

Background Increasing pressure on the emergency department (ED) throughout the world has meant the introduction of innovative ways of working. One such innovation is the advanced practice physical therapist (APP) acting as a primary contact practitioner. There has been little research into the role beyond identifying patient satisfaction with management, cost-effectiveness, and time efficiency. In order to give further support and assist in development of an APP service in the ED, an increased exploration of patient caseload demographics, resource utilization, and management outcomes is needed. Objectives The purpose of this study was to provide quantitative data regarding patient demographics, time efficiency, resource utilization, and management outcomes to examine the APP role in the ED. Design This was a prospective observational study of practice. Setting The study was conducted in a single ED in Melbourne, Australia. Method Data collection was conducted over a 6-month period. Patient demographics and diagnoses, assessment times, hospital resource utilization, and discharge destinations were recorded. Results One thousand seventeen patients (45% female; median age=34 years, interquartile range=25–52) were managed by the APPs; 89% had conditions triaged as not serious or life threatening, and 97% had musculoskeletal pathologies, with the most common diagnosis being fracture or dislocation. Four-hour length-of-stay targets were met in 95% of the patients. Forty-six percent of the patients seen were managed independently, without any support from medical colleagues. The most frequent discharge destination was a referral back to the primary care physician or to hospital outpatient clinics. When comparing similar diagnostic groups, the APPs were significantly more time-efficient than ED physicians in their patient management. Conclusions This study described in detail the caseload managed by the APP in the ED and identified the role as a valuable asset to an ED, managing a great deal of their caseload independently, safely, and time efficiently.

Abstract Background and Aims The detection of sequence variants and copy number changes can improve diagnosis, inform prognosis and guide treatment in patients with bone marrow failure syndromes (BMFS). We aimed to establish and prospectively assess the impact of comprehensive genomic evaluation on diagnostic categorisation and clinical outcomes in patients with genomically uncharacterised BMFS. Methods Eligible patients were recruited from four participating institutions across Victoria, Australia. Inclusion criteria were (i) age >3 months (ii) clinicopathological diagnosis or suspicion of either acquired aplastic anaemia (AA), inherited BMFS, hypoplastic myelodysplastic syndrome (hMDS) or a BMFS with marrow hypoplasia/aplasia not able to be definitively categorised. Patients initially underwent 90-gene targeted sequencing (Peter MacCallum Cancer Centre PanHaem and Myeloid Amplicon next generation sequencing [NGS] panels) for rapid turnaround of accredited results for clinical decision-making. In addition, whole exome sequencing (WES), whole genome copy number analysis, NGS T-cell receptor β (TRB) repertoire assessment and longitudinal monitoring of selected mutations by digital droplet PCR (ddPCR) were performed. All patients received pre-test counselling and assessment. Genomic results were reviewed in centralised multidisciplinary case conferences including the treating clinician, molecular haematopathologists, medical scientists, clinical geneticists and genetic counsellors. Results 100 patients were enrolled. Median age was 25 years (range 3 months - 80 years); 39% were under 18 years. Detection of sequence variants or copy number abnormalities led to or confirmed a diagnosis of either an inherited or acquired BMFS in 36 patients. In 17 patients a diagnosis of an inherited BMFS was positively made by detection of pathogenic sequence variants or copy number changes in FANCA(1 patient [pt]), FANCM(1 pt), FANCI(1 pt), RAD51C(1 pt), HAX1(1 pt), SBDS(1 pt), DNAJC21(1 pt), RPS19(5 pts), RPL35A(1 pt), TERT(1 pt), TINF2(1 pt) and SAMD9L(1 pt). In five patients the clinical BMFS was considered undifferentiated without a clear candidate gene suspected on phenotypic features prior to genomic evaluation. Importantly, an established diagnosis of AA was altered to an inherited BMFS by genomic characterisation in two patients (SAMD9L, FANCA). In 19 patients pathogenic sequence variants or copy number changes were detected either leading to or confirming a diagnosis of an acquired BMFS (paroxysmal nocturnal haemoglobinuria, hMDS or AA). Pathogenic sequence variants were detected in TET2(n=5), RUNX1(n=4), ASXL1(n=3), PIGA(n=3), DNMT3A(n=3),CBL(n=2), and BCOR/IDH2/SF3B1/SRSF2/TP53/U2AF1(n=1 each). Sequencing-detected copy number abnormalities included loss of chromosome 7 (n=6), losses on chromosome 5q (n=2) and copy number loss of ETV6(n=2). Longitudinal monitoring of an acquired truncating RUNX1 mutation by ddPCR resulted in one patient undergoing allogeneic bone marrow transplant for a progressively rising allelic burden. There was a trend towards more restricted TRB diversity in patients with genomically-defined acquired BMFS versus inherited BMFS (normalised Shannon index ≤0.85, 36.4% vs 0%, p=0.09). Conclusion We have established and evaluated a model of comprehensive multimodal genomic characterisation and multidisciplinary care for 100 patients with BMFS. Our results demonstrate a significant contribution to diagnostic categorisation and patient care in this area of clinical need. Disclosures Lieschke: CSL Behring Australia: Consultancy. Tam:Janssen: Honoraria, Research Funding; Gilead: Honoraria; AbbVie: Honoraria, Research Funding; Pharmacyclics: Honoraria, Travel funding; Pharmacyclics: Honoraria; Beigene: Honoraria, Other: Travel funding; Roche: Honoraria; Beigene: Honoraria, Other: Travel funding; Gilead: Honoraria; Roche: Honoraria; AbbVie: Honoraria, Research Funding.

BACKGROUND: There are few reports of the use of the lidocaine 5% patch (L5%P) for neuropathic pain (NP) in the cancer patient. Within a comprehensive cancer centre, L5%P has been prescribed by the Pain and Palliative Care Service (Peter McCallum Cancer Centre, East Melbourne, Victoria, Australia) for selected patients with NP since 2001.OBJECTIVE: To retrospectively audit the use of L5%P within a comprehensive cancer centre.METHODS: All L5%P prescriptions up to January 2009 were listed and patient medical records were searched to determine neuropathic pain syndromes treated, the presence of allodynia, previous analgesic medications, treatment duration and outcome.RESULTS: L5%P was prescribed for 97 patients, most frequently for persistent postsurgical NP (n=26), postherpetic neuralgia (n=24) and cancer-related NP (n=18). Six patients had no history of cancer and two patients never applied L5%P. Reviewers classed L5%P analgesic efficacy as ‘potent’ in 38% of patients with postherpetic neuralgia, 35% of patients with postsurgical pain, 27% of patients with NP after other treatments for cancer and 12% of patients with NP attributed to cancer alone. Allodynia featured in at least 60% of patients. Where allodynia was present, the efficacy of L5%P was assessed as ‘potent’ in 38% and ‘partial’ in 24%, but ‘ineffective’ in 26%, and ‘causing worse pain’ in 3.4% of patients. Treatment duration extended longer than one month in 52 patients, longer than two months in 29 patients and longer than one year in 13 patients. Therapy was ceased due to skin irritation in seven patients. The outcomes in relation to other reports are discussed.CONCLUSION: The present data support trials of L5%P for cancer patients with NP syndromes associated with allodynia.

The aim of the research was to analyse the organisational dynamics surrounding a health care reform implementation process associated with the introduction of coordinated care, which is an Australian Government initiative to introduce structural changes to the funding and delivery of health-care in response to rising health care costs. A longitudinal case study of an implementation team was studied. This included the perceptions and experiences of individuals and institutions within hospitals, the general practice community and Divisions of General Practice. Furthermore, the case study explored organisational structures, decision-making processes and management systems of the Project and included an examination of the difficulties and conflicts that ensued. The broader context of health care reform was also considered. The study found that an effective change management strategy requires clarity around the definition of primary task in health care delivery, particularly when the task is complex and the environment uncertain. This requires a management and support structure able to accommodate the tensions that exists between providing care and managing cost, in a changing and complex system. The case study indicated that where tensions were not managed the functions of providing care and managing costs became disconnected, undermining the integrity of the task and impacting on the effective facilitation of the change process and hence, the capacity of stakeholders to embrace the model of co-ordinated care. Moreover, the micro dynamics of the project team seemed to parallel the macro dynamics of the broader system where economic and health care provision imperatives clash. Through its close analysis of change dynamics, the study provides suggestions for the improved engagement of stakeholders in health care change.

Most of the time, people of all different ages and with all sorts of mental illnesses go to the same place to see a doctor, get medicines, or participate in counseling. That is, they go to mental health clinics or the office of a mental health professional that provides treatments for a number of different illnesses. Most young people who have psychosis get their medical care and treatment in a hospital, clinic, or doctor’s office. In these places, the doctors and other mental health professionals may have taken special classes about how to help young people with psychosis, but that may not be their only focus. They may see people with other illnesses too. However, in some places around the world, there are special clinics that are for people in the early stages of psychosis. These types of specialized programs have been developed recently, since the 1990s. These programs have a number of different types of mental health professionals, including psychiatrists, psychologists, nurses, social workers, counselors, and others. In some programs, mental health professionals and doctors in training may rotate through the clinic spending several months at a time training in the clinic. Some programs, like the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Victoria, Australia, operate within the framework of a youth health service. Such youth services treat all sorts of mental health issues in young people. Other programs are located primarily in adult mental health facilities. Such programs may offer classes or group meetings just for people who recently developed psychosis and other classes or group meetings especially for the families of these young people. Typically, these programs provide someone with 2–3 years of treatment. They usually do a full evaluation of the patient every few months and keep track of how he or she is doing. If the patient needs more care afterwards, they help him or her find another program for longer-term care. In this chapter, we list some of these clinics located in various parts of the world and describe what these specialized early psychosis programs provide.