Experiences of the SARS-CoV-2 pandemic amongst Australian healthcare workers: from stressors to protective factors.

BACKGROUND: The SARS-CoV-2 pandemic has critically challenged healthcare systems globally. Examining the experiences of healthcare workers (HCWs) is important for optimizing ongoing and future pandemic responses. OBJECTIVES: In-depth exploration of Australian HCWs' experiences of the SARS-CoV-2 pandemic, with a focus on reported stressors vis-à-vis protective factors. METHODS: Individual interviews were performed with 63 HCWs in Australia. A range of professional streams and operational staff were included. Thematic analysis was performed. RESULTS: Thematic analysis identified stressors centred on paucity of, or changing, evidence, leading to absence of, or mistrust in, guidelines; unprecedented alterations to the autonomy and sense of control of clinicians; and deficiencies in communication and support. Key protective factors included: the development of clear guidance from respected clinical leaders or recognized clinical bodies, interpersonal support, and strong teamwork, leadership, and a sense of organizational preparedness. CONCLUSIONS: This study provides insights into the key organizational sources of emotional stress for HCWs within pandemic responses and describes experiences of protective factors. HCWs experiencing unprecedented uncertainty, fear, and rapid change, rely on clear communication, strong leadership, guidelines endorsed by recognized expert groups or individuals, and have increased reliance on interpersonal support. Structured strategies for leadership and communication at team, service group and organizational levels, provision of psychological support, and consideration of the potential negative effects of centralizing control, would assist in ameliorating the extreme pressures of working within a pandemic environment.

Knowledge, perceptions and experiences of nurses in antimicrobial optimization or stewardship in the intensive care unit.

There is an urgent and recognized need for an interprofessional collaborative approach to support global action in addressing antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) refers to systematic approaches for antimicrobial optimization within healthcare organizations. In areas with high antimicrobial utilization such as intensive care units (ICUs), specific roles for nurses in AMS are not clearly defined. This review aimed to identify and to critically evaluate primary studies that examined knowledge, perspectives and experiences of nurses associated with antimicrobial use and optimization in ICUs. A systematic search of Medline, CINAHL, PsychINFO, EMBASE, PubMed, SCOPUS, Cochrane Library and Web of Science databases for primary studies published from 1st January 2000 to 20th March 2020 was performed. A convergent synthesis design was used to synthesize quantitative and qualitative data. Of the 898 studies initially screened, 26 were included. Most (18/26) studies were quantitative. All qualitative studies (6/26) were of high methodological quality. Studies where interventions were used (10/26) identified significant potential for ICU nurses to reduce antimicrobial use, time-to-antibiotic administration, and error rates. Barriers to nursing engagement included knowledge deficits in antimicrobial use, interprofessional dissonance and the culture of deference to physicians. Enhancing education, technology utilization, strong nursing leadership and robust organizational structures that support nurses were perceived as enablers to strengthen their roles in optimizing antimicrobial use. This review showed that nursing initiatives have significant potential to strengthen antimicrobial optimization in ICUs. Barriers and enablers to active engagement were identified.

Aerosol-generating procedures and infective risk to healthcare workers from SARS-CoV-2: the limits of the evidence.

The transmission behaviour of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is still being defined. It is likely that it is transmitted predominantly by droplets and direct contact and it is possible that there is at least opportunistic airborne transmission. In order to protect healthcare staff adequately it is necessary that we establish whether aerosol-generating procedures (AGPs) increase the risk of transmission of SARS-CoV-2. Where we do not have evidence relating to SARS-CoV-2, guidelines for safely conducting these procedures should consider the risk of transmitting related pathogens. Currently there is very little evidence detailing the transmission of SARS-CoV-2 associated with any specific procedures. Regarding AGPs and respiratory pathogens in general, there is still a large knowledge gap that will leave clinicians unsure of the risk to themselves when offering these procedures. This review aimed to summarize the evidence (and gaps in evidence) around AGPs and SARS-CoV-2.

The drivers of antimicrobial use across institutions, stakeholders and economic settings: a paradigm shift is required for effective optimization.

OBJECTIVES: Significant antimicrobial overuse persists worldwide, despite overwhelming evidence of antimicrobial resistance and knowledge that optimization of antimicrobial use will slow the development of resistance. It is critical to understand why this occurs. This study aims to consider the social influences on antimicrobial use within hospitals in Australia, via an in-depth, multisite analysis. METHODS: We used a qualitative multisite design, involving 222 individual semi-structured interviews and thematic analysis. Participants (85 doctors, 79 nurses, 31 pharmacists and 27 hospital managers) were recruited from five hospitals in Australia, including four public hospitals (two metropolitan, one regional and one remote) and one private hospital. RESULTS: Analysis of the interviews identified social relationships and institutional structures that may have a strong influence on antimicrobial use, which must be addressed concurrently. (i) Social relationships that exist across settings: these include the influence of personal risk, hierarchies, inter- and intraprofessional dynamics and sense of futility in making a difference long term in relation to antimicrobial resistance. (ii) Institutional structures that offer context-specific influences: these include patient population factors (including socioeconomic factors, geographical isolation and local infection patterns), proximity and resource issues. CONCLUSIONS: The success of antimicrobial optimization rests on adequate awareness and incorporation of multilevel influences. Analysis of the problem has tended to emphasize individual 'behaviour improvement' in prescribing rather than incorporating the problem of overuse as inherently multidimensional and necessarily incorporating personal, interpersonal and institutional variables. A paradigm shift is urgently needed to incorporate these critical factors in antimicrobial optimization strategies.

Context-sensitive antibiotic optimization: a qualitative interviews study of a remote Australian hospital setting.

BACKGROUND: Antibiotic optimization is an urgent international issue. Regulatory frameworks, including the requirement to have a functioning antimicrobial stewardship (AMS) programme, are now ubiquitous across the hospital sector nationally and internationally. However, healthcare is ultimately delivered in a diverse range of institutional settings and social contexts. There is emerging evidence that implementation of antibiotic optimization strategies may be inappropriate or even counterproductive to attempts to optimize in atypical healthcare settings. AIM: To document the experiences and perspectives of clinical staff in a remote healthcare setting in Australia with respect to antimicrobial use, and strategies for optimization in that environment. METHODS: Semi-structured qualitative interviews were conducted with 30 healthcare professionals, including doctors, nurses and pharmacists, from a remote hospital in Queensland, Australia. FINDINGS: Four themes were identified from the analysis as key challenges to antibiotic optimization: (i) AMS as externally driven, and local knowledge sidelined; (ii) perceptions of heightened local population risks, treatment failure and the subsequent pressure to over-use of antimicrobials; (iii) interprofessional relationship dynamics including medical hierarchical structures perceived as a barrier to AMS; (iv) a clinical workforce dominated by transient locum staff and other process issues were perceived as significant barriers. CONCLUSION: The perceptions of healthcare professionals in this site lead to the conclusion that antimicrobial regulations and practice improvement strategies more generally are unlikely to succeed if they fail to accommodate and respect the context of care, the resource and structural constraints of the setting, and the specificities of particular populations (and subsequent clinical 'know-how').

How do hospital respiratory clinicians perceive antimicrobial stewardship (AMS)? A qualitative study highlighting barriers to AMS in respiratory medicine.

BACKGROUND: Suboptimal antibiotic use in respiratory infections is widespread in hospital medicine and primary care. Antimicrobial stewardship (AMS) teams within hospitals, commonly led by infectious diseases physicians, are frequently charged with optimizing the use of respiratory antibiotics, but there is limited information on what drives antibiotic use in this area of clinical medicine, or on how AMS is perceived. AIM: To explore the perceptions of hospital respiratory clinicians on AMS in respiratory medicine. METHODS: In-depth interviews were conducted with 28 clinicians (13 doctors and 15 nurses) from two hospitals in Australia. Data were analysed thematically using the framework approach. FINDINGS: Four key barriers to the integration of AMS processes within respiratory medicine, from the participants' perspectives, were identified: CONCLUSIONS: AMS processes are introduced in hospitals with established social structures and knowledge bases. This study found that AMS in respiratory medicine challenges and conflicts with many of these dynamics. If the influence of these dynamics is not considered, AMS processes may not be effective in containing antibiotic use in hospital respiratory medicine.

Ebola outbreak preparedness planning: a qualitative study of clinicians' experiences.

OBJECTIVES: The 2014-15 Ebola outbreak in West Africa highlighted the challenges many hospitals face when preparing for the potential emergence of highly contagious diseases. This study examined the experiences of frontline health care professionals in an Australian hospital during the outbreak, with a focus on participant views on information, training and preparedness, to inform future outbreak preparedness planning. STUDY DESIGN: Semi-structured interviews were conducted with 21 healthcare professionals involved in Ebola preparedness planning, at a hospital in Australia. METHODS: The data were systematically coded to discover key themes in participants' accounts of Ebola preparedness. RESULTS: Three key themes identified were: 1) the impact of high volumes of-often inconsistent-information, which shaped participants' trust in authority; 2) barriers to engagement in training, including the perceived relative risk Ebola presented; and finally, 3) practical and environmental impediments to preparedness. CONCLUSIONS: These clinicians' accounts of Ebola preparedness reveal a range of important factors which may influence the relative success of outbreak preparedness and provide guidance for future responses. In particular, they illustrate the critical importance of clear communication and guidelines for staff engagement with, and implementation of training. An important outcome of this study was how individual assessments of risk and trust are produced via, and overlap with, the dynamics of communication, training and environmental logistics. Consideration of the dynamic ways in which these issues intersect is crucial for fostering an environment that is suitable for managing an infectious threat such as Ebola.

Individual care versus broader public health: A qualitative study of hospital doctors' antibiotic decisions.

OBJECTIVES: This study aimed to examine how hospital doctors balance competing concerns around antibiotic use and resistance, with a focus on individual care versus broader public health considerations. METHODS: Sixty-four doctors across two hospitals in Australia participated in semi-structured interviews about their perspectives on antibiotic resistance and prescribing decisions. Results were analysed using the framework approach. RESULTS: The first theme focused on the significance of antimicrobial resistance (AMR) and the role of hospital doctors. Participants did not perceive resistance to be central to clinical decision-making, and externalised the resistance threat. They perceived themselves as separated from the issue of escalating resistance, viewing the key drivers to be overseas use, use in agriculture, and community prescribing. The second theme was around balancing risks. Immediate clinical risks were described as prioritised over long term population risk. Participants described concern around reputational and legal risks, which were perceived to be associated with under-prescribing of antibiotics. Over-prescribing was described by participants to be easier and without perceived immediate risk to them or to patients. CONCLUSION: Hospital doctors perceived antimicrobial resistance as externally produced and described clinical concerns taking precedence in individual antibiotic decisions. These dual processes mean that a population health model has limited traction in the hospital context. The externalisation of resistance leads to a sense of futility in changing practice, which combines with the pressures of acute medicine to prioritise immediate patient outcomes. Such dynamics are leading to antibiotic optimisation as a low or absent priority in hospital clinician antibiotic decision-making.

Optimizing antibiotic usage in hospitals: a qualitative study of the perspectives of hospital managers.

BACKGROUND: Antibiotic optimization in hospitals is an increasingly critical priority in the context of proliferating resistance. Despite the emphasis on doctors, optimizing antibiotic use within hospitals requires an understanding of how different stakeholders, including non-prescribers, influence practice and practice change. AIM: This study was designed to understand Australian hospital managers' perspectives on antimicrobial resistance, managing antibiotic governance, and negotiating clinical vis-à-vis managerial priorities. METHODS: Twenty-three managers in three hospitals participated in qualitative semi-structured interviews in Australia in 2014 and 2015. Data were systematically coded and thematically analysed. FINDINGS: The findings demonstrate, from a managerial perspective: (1) competing demands that can hinder the prioritization of antibiotic governance; (2) ineffectiveness of audit and monitoring methods that limit rationalization for change; (3) limited clinical education and feedback to doctors; and (4) management-directed change processes are constrained by the perceived absence of a 'culture of accountability' for antimicrobial use amongst doctors. CONCLUSION: Hospital managers report considerable structural and interprofessional challenges to actualizing antibiotic optimization and governance. These challenges place optimization as a lower priority vis-à-vis other issues that management are confronted with in hospital settings, and emphasize the importance of antimicrobial stewardship (AMS) programmes that engage management in understanding and addressing the barriers to change.

Barriers to uptake of antimicrobial advice in a UK hospital: a qualitative study.

BACKGROUND: The role of infectious diseases (ID) and clinical microbiology (CM) in hospital settings has expanded in response to increasing antimicrobial resistance, leading to widespread development of hospital antimicrobial stewardship (AMS) programmes, the majority of which include antibiotic approval systems. However, inappropriate antibiotic use in hospitals continues, suggesting potential disjunctions between technical advice and the logics of antibiotic use within hospitals. AIM: To examine the experiences of doctors in a UK hospital with respect to AMS guidance of antibiotic prescribing, and experiences of a verbal postprescription antibiotic approval process. METHODS: Twenty doctors in a teaching hospital in the UK participated in semi-structured interviews about their experiences of antibiotic use and governance. NVivo10 software was used to conduct a thematic content analysis systematically. FINDINGS: This study identified three key themes regarding doctors' relationships with ID/CM clinicians that shaped their antibiotic practices: (1) competing hierarchical influences limiting active consultation with ID/CM; (2) non-ID/CM consultants' sense of ownership over clinical decision-making and concerns about challenges to clinical autonomy; and (3) tensions between evidence-based practice and experiential-style learning. CONCLUSIONS: This study illustrates the importance of examining relations between ID/CM and non-ID/CM clinicians in the hospital context, indicating that AMS models that focus exclusively on delivering advice rather than managing interprofessional relationships may be limited in their capacity to optimize antibiotic use. AMS and, specifically, antibiotic approval systems would likely be more effective if they incorporated time and resources for fostering and maintaining professional relationships.

Long-term weight loss maintenance and management following a VLCD: a 3-year outcome.

BACKGROUND: Effective weight loss treatment is important as obesity has severe health and socioeconomic repercussions. Emerging evidence suggests that rapid initial weight loss results in better long-term weight loss maintenance. This remains controversial and contradicts current recommendations for slower weight loss. AIM: To determine the effect of a very low calorie diet (VLCD) with group-based behaviour therapy on weight loss and long-term weight management by means of a retrospective database analysis. METHODS: Data for this retrospective analysis included participants who embarked on the LighterLife Total VLCD programme between 2007 and 2010, and whose weights at baseline and at least 12 months were available (n = 5965). RESULTS: Data were available for 5965 individuals at 1 year, 2044 at 2 years and 580 at 3 years. At baseline, the majority of individuals were Caucasian (n = 5155), female (n = 5419), ≥ 40 years old (n = 4272), 49% were within the body mass index (BMI) range of 30-35 kg/m(2) while 51% had a BMI > 35 kg/m(2) . The average initial weight of the whole cohort was 99.1 kg (SD 16.6). Initial weight and BMI at entry onto programme, as well as numbers of weeks of weight loss were all significantly associated with weight loss achieved on the first weight loss attempt. Weight lost during the initial weight loss phase was the only factor, which was significantly associated with percentage weight loss maintenance for years 1, 2, and 3. CONCLUSION: The findings of this retrospective analysis suggest that provided a longer term weight loss management programme is adhered to, large amounts of initial weight loss can result in important longer term weight loss maintenance in motivated individuals.

The cost-effectiveness of the LighterLife weight management programme as an intervention for obesity in England.

LighterLife Total is a very low calorie diet total dietary replacement weight reduction programme that provides Foodpacks, behavioural change therapy and group support appropriate for people with a body mass index of 30 kg m(-2) or above. A model was built to assess the cost-effectiveness of LighterLife Total, compared with (i) no treatment, Counterweight, Weight Watchers and Slimming World, as a treatment for obesity in those with a body mass index of 30 kg m(-2) or above, and (ii) no treatment, gastric banding and gastric bypass in those with a body mass index of 40 kg m(-2) or above. Change in body mass index over time was modelled, and prevalence of comorbidities (diabetes, coronary heart disease and colorectal cancer) was calculated. Costs (of intervention and treatment for comorbidities) and quality-adjusted life years were calculated. LighterLife Total was cost-effective against no treatment, Counterweight, Weight Watchers and Slimming World in the 30+ kg m(-2) group (incremental cost-effectiveness ratios: £11 895, £12 453, £12 585 and £12 233, respectively). In the 40+ kg m(-2) group, LighterLife Total was cost-effective against no treatment (incremental cost-effectiveness ratio: £4356), but less effective than gastric banding and bypass.

Coccidioidomycosis in returned Australian travellers.

Coccidioidomycosis is a fungal infection caused by Coccidioides species. The disease has wide clinical presentation and a distinct geographical distribution. We describe two cases of coccidioidomycosis in returned Australian travellers who presented to Nambour Hospital. Knowledge of the international geographical distribution of endemic fungal infections and their clinical manifestations can assist in earlier diagnosis and appropriate management.

Very-low-energy diets and morbidity: a systematic review of longer-term evidence.

Evidence from the literature supports the safe use of very-low-energy diets (VLED) for up to 3 months in supervised conditions for patients who fail to meet a target weight loss using a standard low-fat, reduced-energy approach. There is, however, a need for longer-term outcomes on obesity and associated morbidities following a VLED. The present systematic review aims to investigate longer-term outcomes from studies using VLED, with a minimum duration of 12 months, published between January 2000 and December 2010. Studies conducted in both children and adults, with a mean/median BMI of ≥ 28 kg/m2 were included. PubMed, MEDLINE, Web of Science and Science Direct were searched. Reference lists of studies and reviews were manually searched. Weight loss or prevention of weight gain and morbidities were the main outcomes assessed. A total of thirty-two out of 894 articles met the inclusion criteria. The duration of the studies ranged from 12 months to 5 years. Periods of VLED ranged from 25 d to 9 months. Several studies incorporated aspects of behaviour therapy, exercise, low-fat diets, low-carbohydrate diets or medication. Current evidence demonstrates significant weight loss and improvements in blood pressure, waist circumference and lipid profile in the longer term following a VLED. Interpretation of the results, however, was restricted and conclusions with which to guide best practice are limited due to heterogeneity between the studies. The present review clearly identifies the need for more evidence and standardised studies to assess the longer-term benefits from weight loss achieved using VLED.

Global warming: is weight loss a solution?

The current climate change has been most likely caused by the increased greenhouse gas emissions. We have looked at the major greenhouse gas, carbon dioxide (CO(2)), and estimated the reduction in the CO(2) emissions that would occur with the theoretical global weight loss. The calculations were based on our previous weight loss study, investigating the effects of a low-carbohydrate diet on body weight, body composition and resting metabolic rate of obese volunteers with type 2 diabetes. At 6 months, we observed decreases in weight, fat mass, fat free mass and CO(2) production. We estimated that a 10 kg weight loss of all obese and overweight people would result in a decrease of 49.560 Mt of CO(2) per year, which would equal to 0.2% of the CO(2) emitted globally in 2007. This reduction could help meet the CO(2) emission reduction targets and unquestionably would be of a great benefit to the global health.

Long-term cost-effectiveness of weight management in primary care.

BACKGROUND: As obesity prevalence and health-care costs increase, Health Care providers must prevent and manage obesity cost-effectively. METHODS: Using the 2006 NICE obesity health economic model, a primary care weight management programme (Counterweight) was analysed, evaluating costs and outcomes associated with weight gain for three obesity-related conditions (type 2 diabetes, coronary heart disease, colon cancer). Sensitivity analyses examined different scenarios of weight loss and background (untreated) weight gain. RESULTS: Mean weight changes in Counterweight attenders was -3 kg and -2.3 kg at 12 and 24 months, both 4 kg below the expected 1 kg/year background weight gain. Counterweight delivery cost was pound59.83 per patient entered. Even assuming drop-outs/non-attenders at 12 months (55%) lost no weight and gained at the background rate, Counterweight was 'dominant' (cost-saving) under 'base-case scenario', where 12-month achieved weight loss was entirely regained over the next 2 years, returning to the expected background weight gain of 1 kg/year. Quality-adjusted Life-Year cost was pound2017 where background weight gain was limited to 0.5 kg/year, and pound2651 at 0.3 kg/year. Under a 'best-case scenario', where weights of 12-month-attenders were assumed thereafter to rise at the background rate, 4 kg below non-intervention trajectory (very close to the observed weight change), Counterweight remained 'dominant' with background weight gains 1 kg, 0.5 kg or 0.3 kg/year. CONCLUSION: Weight management for obesity in primary care is highly cost-effective even considering only three clinical consequences. Reduced healthcare resources use could offset the total cost of providing the Counterweight Programme, as well as bringing multiple health and Quality of Life benefits.