COVID-19 (Omicron strain) hospital admissions from a virtual ward - who required further care?

BACKGROUND: The COVID-19 virtual ward was created to provide care for people at home with COVID-19. Given this was a new model of care, little was known about the clinical characteristics and outcomes of patients requiring admission to hospital from the virtual ward platform. The aims were to characterise hospital admission volume, patient epidemiology, clinical characteristics, and outcome from a virtual ward in the setting of an Omicron (BA.1, BA.2) outbreak. METHODS: A retrospective observational study was performed for all virtual ward patients admitted from 1st January 2022 to 25th March 2022 (over 16 years old). Epidemiological, clinical and laboratory data was reviewed on all patients who required hospital admission. RESULTS: A total of 7021 patients were cared for on the virtual ward over the study period with 473 referred to hospital for assessment. Twenty-six (0.4%) patients were admitted to hospital during their care on the ward. Twenty-two (84.6%) admissions were COVID-19 related. Fifty three percent of the hospitalised patients were fully vaccinated and 11 had received prior therapeutics for COVID-19. Shortness of breath was the most common reason for escalation to hospital. Chest pain was the second most common reason and the most common diagnosis after investigation was non-cardiac chest pain. CONCLUSIONS: Few patients required admission from the virtual ward in the setting of the Omicron variant (BA.1, BA.2) as a direct result of COVID-19 disease and virtual ward care. Shortness of breath and chest pain were the most common symptoms driving further clinical care.

Infection control behaviours, intra-household transmission and quarantine duration: a retrospective cohort analysis of COVID-19 cases.

OBJECTIVES: To study COVID-19 (Delta Variant) cases and close contacts co-located within households. Focusing on epidemiology of transmission of COVID-19, quarantine duration and utilisation of infection control behaviours under a telehealth model of care in an elimination setting. METHODS: A retrospective cohort analysis examined household spread of infection, duration of quarantine and change in PCR CT value during illness. A survey explored infection control behaviours used by household members during isolation and quarantine. RESULTS: The cohort was 141 individuals in 35 households. Thirty-seven were index cases, and 48 became positive during quarantine, most within 10 days. Whole-household infection occurred in 12 households with multiple members. Behaviours focused on fomite transmission reduction rather than preventing aerosol transmission. The median duration of close contact household quarantine was 25 days. The majority of COVID-19 cases were de-isolated after 14 days with no evidence of further community transmission. CONCLUSION: Intrahousehold transmission was not universal and, if it occurred, usually occurred quickly. Behaviours utilised focused on fomites, suggesting a need for improved education regarding the potential utilisation of strategies to prevention the transmission of aerosols. Households experienced long durations of home-based quarantine. IMPLICATIONS FOR PUBLIC HEALTH: The impact of long quarantine durations must be considered, particularly where most community benefit from quarantine is achieved within 10 days from exposure in the setting of the Delta Variant. Education of households regarding aerosol risk reduction is a potential strategy in the household setting of individuals at risk of disease progression.

A Virtual Ward Model of Care for Patients With COVID-19: Retrospective Single-Center Clinical Study.

BACKGROUND: COVID-19 has necessitated the implementation of innovative health care models in preparation for an influx of patients. A virtual ward model delivers clinical care remotely to patients in isolation. We report on an Australian cohort of patients with COVID-19 treated in a virtual ward. OBJECTIVE: The aim of this study was to describe and evaluate the safety and efficacy of a virtual ward model of care for an Australian cohort of patients with COVID-19. METHODS: Retrospective clinical assessment was performed for 223 patients with confirmed COVID-19 treated in a virtual ward in Brisbane, Australia, from March 25 to May 15, 2020. Statistical analysis was performed for variables associated with the length of stay and hospitalization. RESULTS: Of 223 patients, 205 (92%) recovered without the need for escalation to hospital care. The median length of stay in the virtual ward was 8 days (range 1-44 days). In total, 18 (8%) patients were referred to hospital, of which 6 (33.3%) were discharged after assessment at the emergency department. Furthermore, 12 (5.4%) patients were admitted to hospital, of which 4 (33.3%) required supplemental oxygen and 2 (16.7%) required mechanical ventilation. No deaths were recorded. Factors associated with escalation to hospital care were the following: hypertension (odds ratio [OR] 3.6, 95% CI 1.28-9.87; P=.01), sputum production (OR 5.2, 95% CI 1.74-15.49; P=.001), and arthralgia (OR 3.8, 95% CI 1.21-11.71; P=.02) at illness onset and a polymerase chain reaction cycle threshold of ≤20 on a diagnostic nasopharyngeal swab (OR 5.0, 95% CI 1.25-19.63; P=.02). CONCLUSIONS: Our results suggest that a virtual ward model of care to treat patients with COVID-19 is safe and efficacious, and only a small number of patients would potentially require escalation to hospital care. Further studies are required to validate this model of care.

Dextrose Prolotherapy Versus Control Injections in Painful Rotator Cuff Tendinopathy.

OBJECTIVE: To compare the effect of dextrose prolotherapy on pain levels and degenerative changes in painful rotator cuff tendinopathy against 2 potentially active control injection procedures. DESIGN: Randomized controlled trial, blinded to participants and evaluators. SETTING: Outpatient pain medicine practice. PARTICIPANTS: Persons (N=73) with chronic shoulder pain, examination findings of rotator cuff tendinopathy, and ultrasound-confirmed supraspinatus tendinosis/tear. INTERVENTIONS: Three monthly injections either (1) onto painful entheses with dextrose (Enthesis-Dextrose), (2) onto entheses with saline (Enthesis-Saline), or (3) above entheses with saline (Superficial-Saline). All solutions included 0.1% lidocaine. All participants received concurrent programmed physical therapy. MAIN OUTCOME MEASURES: Primary: participants achieving an improvement in maximal current shoulder pain ≥2.8 (twice the minimal clinically important difference for visual analog scale pain) or not. Secondary: improvement in the Ultrasound Shoulder Pathology Rating Scale (USPRS) and a 0-to-10 satisfaction score (10, completely satisfied). RESULTS: The 73 participants had moderate to severe shoulder pain (7.0±2.0) for 7.6±9.6 years. There were no baseline differences between groups. Blinding was effective. At 9-month follow-up, 59% of Enthesis-Dextrose participants maintained ≥2.8 improvement in pain compared with Enthesis-Saline (37%; P=.088) and Superficial-Saline (27%; P=.017). Enthesis-Dextrose participants' satisfaction was 6.7±3.2 compared with Enthesis-Saline (4.7±4.1; P=.079) and Superficial-Saline (3.9±3.1; P=.003). USPRS findings were not different between groups (P=.734). CONCLUSIONS: In participants with painful rotator cuff tendinopathy who receive physical therapy, injection of hypertonic dextrose on painful entheses resulted in superior long-term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline. These differences could not be attributed to a regenerative effect. Dextrose prolotherapy may improve on the standard care of painful rotator cuff tendinopathy for certain patients.

A case of Mycoplasma pneumoniae-associated encephalomyelitis in a 16-year-old female presenting to an adult teaching hospital.

We report a rare cause of encephalitis that is not often described in the adult clinical setting. Our case was a 16-year-old female who presented with a clinical picture of viral encephalitis; however, magnetic resonance imaging showed a demyelinating lesion of the left frontal lobe. In this age group, differential diagnoses of acute demyelination encephalomyelitis and multiple sclerosis were entertained. Further investigations demonstrated positive Mycoplasma pneumoniae serology. As a result, a diagnosis of Mycoplasma pneumoniae-associated encephalitis was made based on a process of exclusion.

Community-associated methicillin-resistant Staphylococcus aureus endocarditis 'down under': case series and literature review.

Infective endocarditis is a common complication of Staphylococcus aureus bacteraemia, but literature reports of community-associated methicillin-resistant S. aureus (CA-MRSA) endocarditis are relatively uncommon and mostly comprise intravenous drug users (IVDUs) with the USA300 strain. We report 5 cases of CA-MRSA endocarditis in previously healthy young Australian adults, 4 in IVDUs. Morbidity was high with frequent septic emboli; 3 patients required cardiac surgery and 1 patient died. Typing revealed the 2 most common Australian strains, the Panton-Valentine leukocidin (PVL)-positive ST93 (Queensland) strain and the PVL-negative ST1 (WA-MRSA-1) strain.

The paradox of readmission: effect of a quality improvement program in hospitalized patients with heart failure.

BACKGROUND: Congestive heart failure (CHF) is an increasingly common condition associated with significant hospital resource utilization. Initiating better disease management at the time of initial hospital admission has the potential to reduce readmissions. OBJECTIVE: To evaluate the impact of a multifaceted quality improvement program on 12-month hospital utilization in patients admitted to hospital with CHF. DESIGN: Prospective longitudinal study comparing baseline and intervention cohorts. PARTICIPANTS: All consecutive patients with CHF discharged alive from 3 metropolitan hospitals during the baseline (October 1, 2000 to April 17, 2001) and intervention (February 15, 2002 to August 31, 2002) study periods. Active prospective case-finding identified 220 baseline and 235 intervention participants; full data was available on 197 baseline and 219 intervention participants. INTERVENTIONS: Education and performance feedback for hospital and primary care practitioners; clinical decision support tools; individualized, guideline-based treatment plans; patient education and self-management support; and improved hospital-community integration. MEASUREMENTS: Twelve-month all-cause hospital readmission, 12-month mortality, readmission-free survival, heart failure-specific readmission, and total hospital days over 12 months. RESULTS: Intervention patients had a higher rate of all-cause readmission (odds ratio [OR] = 1.65; 95% confidence interval [CI] = 1.10-2.46) but a trend to reduction in mortality (OR = 0.68; 95% CI = 0.44-1.07). There was no difference in frequency of hospitalizations per year, number of hospital days, or the composite outcome of death or readmission. CONCLUSIONS: The intervention improved care processes and may have reduced mortality, but at the cost of higher readmission rates. Better understanding of intervention components, intensity, and targeting may optimize the effectiveness of disease management programs.

The use of cusum analysis in the early detection and management of hospital bed occupancy crises.

OBJECTIVE: To assess the value of cusum analysis in hospital bed management. DESIGN: Comparative analysis of medical patient flows, bed occupancy, and emergency department admission rates and access block over 2 years. SETTING: Internal Medicine Services and Emergency Department in a teaching hospital. INTERVENTIONS: Improvements in bed use and changes in the level of available beds. MAIN OUTCOME MEASURES: Average length of stay; percentage occupancy of available beds; number of patients waiting more than 8 hours for admission (access block); number of medical patients occupying beds in non-medical wards; and number of elective surgical admissions. RESULTS: Cusum analysis provided a simple means of revealing important trends in patient flows that were not obvious in conventional time-series data. This prompted improvements in bed use that resulted in a decrease of 9500 occupied bed-days over a year. Unfortunately and unexpectedly, after some initial improvement, the levels of access block, medical ward congestion and elective surgical admissions all then deteriorated significantly. This was probably caused by excessive bed closures in response to the initial improvement in bed use. CONCLUSION: Cusum analysis is a useful technique for the early detection of significant changes in patient flows and bed use, and in determining the appropriate number of beds required for a given rate of patient flow.

Optimising care of acute coronary syndromes in three Australian hospitals.

OBJECTIVE: To improve quality of in-hospital care of patients with acute coronary syndromes using a multifaceted quality improvement program. DESIGN: Prospective, before and after study of the effects of quality improvement interventions between October 2000 and August 2002. Quality of care of patients admitted between 1 October 2000 and 16 April 2001 (baseline) was compared with that of those admitted between 15 February 2002 and 31 August 2002 (post-intervention). SETTING: Three teaching hospitals in Brisbane, Australia. STUDY PARTICIPANTS: Consecutive patients (n = 1594) admitted to hospital with acute coronary syndrome [mean age 68 years (SD 14 years); 65% males]. INTERVENTIONS: Clinical guidelines, reminder tools, and educational interventions; 6-monthly performance feedback; pharmacist-mediated patient education program; and facilitation of multidisciplinary review of work practices. MAIN OUTCOME MEASURES: Changes in key quality indicators relating to timing of electrocardiogram (ECG) and thrombolysis in emergency departments, serum lipid measurement, prescription of adjunctive drugs, and secondary prevention. RESULTS: Comparing post-intervention with baseline patients, increases occurred in the proportions of eligible patients: (i) undergoing timely ECG (70% versus 61%; P = 0.04); (ii) prescribed angiotensin-converting enzyme inhibitors (70% versus 60%; P = 0.002) and lipid-lowering agents (77% versus 68%; P = 0.005); (iii) receiving cardiac counselling in hospital (57% versus 48%; P = 0.009); and (iv) referred to cardiac rehabilitation (17% versus 8%; P < 0.001). CONCLUSIONS: Multifaceted approaches can improve care processes for patients hospitalized with acute coronary syndromes. Care processes under direct clinician control changed more quickly than those reliant on complex system factors. Identifying and overcoming organizational impediments to quality improvement deserves greater attention.

Achieving better in-hospital and after-hospital care of patients with acute cardiac disease.

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after-hospital care, patient self-care, and hospital-community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included: clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); educational interventions (seminars, academic detailing); regular performance feedback; patient self-management strategies; and hospital-community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before-after study design to assess program impact, significantly more program patients compared with historical controls received: ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and beta-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. CHF: Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, beta-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P = 0.06) and from 13.4% to 10.1% (P = 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P = 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.

Using clinical indicators in a quality improvement programme targeting cardiac care.

RATIONALE: The Brisbane Cardiac Consortium, a quality improvement collaboration of clinicians from three hospitals and five divisions of general practice, developed and reported clinical indicators as measures of the quality of care received by patients with acute coronary syndromes or congestive heart failure. DEVELOPMENT OF INDICATORS: An expert panel derived indicators that measured gaps between evidence and practice. Data collected from hospital records and general practice heart-check forms were used to calculate process and outcome indicators for each condition. Our indicators were reliable (kappa scores 0.7-1.0) and widely accepted by clinicians as having face validity. Independent review of indicator-failed, in-hospital cases revealed that, for 27 of 28 process indicators, clinically legitimate reasons for withholding specific interventions were found in <5% of cases. IMPLEMENTATION AND RESULTS: Indicators were reported every 6 months in hospitals and every 10 months in general practice. To stimulate practice change, we fed back indicators in conjunction with an education programme, and provided, when requested, customized analyses to different user groups. Significant improvement was seen in 17 of 40 process indicators over the course of the project. LESSONS LEARNED AND FUTURE PLANS: Lessons learnt included the need to: (i) ensure brevity and clarity of feedback formats; (ii) liberalize patient eligibility criteria for interventions in order to maximize sample size; (iii) limit the number of data items; (iv) balance effort of indicator validation with need for timely feedback; (v) utilize more economical methods of data collection and entry such as scannable forms; and (vi) minimize the burden of data verification and changes to indicator definitions. Indicator measurement is being continued and expanded to other public hospitals in the state, while divisions of general practice are exploring lower-cost methods of ongoing clinical audit. CONCLUSION: Use of clinical indicators succeeded in supporting clinicians to monitor practice standards and to realize change in systems of care and clinician behaviour.