Reducing inappropriate urine testing at Hutt Valley District Health Board using Choosing Wisely principles.

AIM: Unnecessary treatment of asymptomatic bacteriuria is a concern. Hutt Valley District Health Board sought to reduce clinically inappropriate urine culture requests through removal of urine dipsticks from wards and education of staff using Choosing Wisely principles. The purpose of this research is to quantitatively evaluate the success of these initiatives. METHODS: The numbers and results of urine cultures performed for Hutt Valley DHB were analysed, for the period from January 2015 to October 2017. Urinalyses were compared between those designated as 'inpatient' and those as 'outpatient', with the latter being the control of this study. The numbers of primary and secondary coded discharge diagnoses of UTIs were used as a measure of the negative impact of the interventions. RESULTS: There was a 28% reduction in monthly urine culture requests for inpatients, after staff education and removal of urine dipsticks, with no change in those for outpatients (the negative control). After the intervention, a higher proportion of urine cultures were positive for urinary pathogens (25.2% compared to 23.0%) and the average number of diagnoses of UTI in hospital discharges decreased 17% (from 161 to 134). CONCLUSION: The removal of urine dipsticks from wards and the education of staff significantly reduced the number of urine culture requests and is a useful strategy to reduce the overuse of antibiotics for asymptomatic bacteriuria without an increase in the number of UTIs. These simple interventions could be used at other hospitals as part of measures to reduce unnecessary care and overdiagnosis.

Management of feeding decisions in hospitalised adults with severe oropharyngeal dysphagia.

OBJECTIVE: For patients with dysphagia, decisions must be made for provision of nutrition and hydration. This retrospective audit explored feeding decisions for patients with severe oropharyngeal dysphagia. METHODS: Fifty adult inpatients were identified across a 15-month period as requiring a feeding decision due to severe persisting oropharyngeal dysphagia. For each patient, all admissions (previous and subsequent admissions up to and including six months postrecruitment) where dysphagia or dysphagia-related complications were reported in the discharge summary were audited. RESULTS: A total of 103 admissions were identified with palliation in 22%. Enteral tube feeding (ETF) was initiated in 19% of admissions; and 63% of enteral tube placements failed. Nil-by-mouth with ETF was the final feeding decision in only 8% of admissions, while 43% of admissions led to documented oral feeding despite risk. Dysphagia was documented in only 44% of discharge summaries, with a feeding decision documented in only 34%. CONCLUSION: Variation in management and poor documentation in this cohort suggest the need for a Risk Feeding Clinical Guideline.

New atrial fibrillation diagnosed perioperatively-anticoagulation practices in a secondary hospital.

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia encountered perioperatively in patients undergoing non-cardiac surgery. There is emerging evidence suggesting high risk of ischaemic stroke. There are no clear guidelines surrounding initiation of anticoagulation in this setting. This study evaluates current practice in anticoagulant management of new perioperative AF at Hutt Hospital. METHODS: We have undertaken a retrospective study of 3,558 patients aged 60 years and over admitted for non-cardiac surgery at Hutt Hospital in 2014, to assess incidence of new AF/flutter and review how they were managed in regards to anticoagulation. RESULTS: We identified 28 patients as having "new AF/flutter" with CHA2DS2-VASc scores between 1 and 8. Anticoagulation management was inconsistent, with only some patients receiving anticoagulation if using CHA2DS2-VASc score as a marker of indication for treatment. CONCLUSIONS: There is insufficient evidence and lack of clear guidelines in this area to enable consistent and evidence-based management of patients with new AF identified perioperatively. Until such guidelines are available we suggest all such patients are individually assessed and treated depending on their individual risk/benefit analysis. Multiple factors such as bleeding risk, CHA2DS2-VASc score and perhaps duration of AF need to be considered.

Neurogenic pulmonary oedema secondary to vertebral artery dissection while playing tennis.

We present a case of a patient who developed vertebral artery dissection (VAD) while playing tennis and presented with neurogenic pulmonary oedema. The case highlights two important points: acute pulmonary oedema as an unusual presenting feature of VAD and VAD, an important cause of stroke in young people, as being associated with playing low-impact sports such as tennis. These associations, independent of each other, are under-recognised and can lead to a delay in diagnosis.

Refining metformin prescribing in New Zealand.

Metformin is the mainstay of treatment of type 2 diabetes. However, there has been significant concern on prescribing metformin in patients with renal impairment as a result of metformin-associated lactic acidosis (MALA). Recent studies have cast doubt on the existence of MALA purely related to metformin use. Medsafe recently initiated changes to datasheet so lower doses of metformin could be used in patients with GFR down to 15ml/min. In this paper we outline the context and implications of this change.

Blunt chest trauma in a non-specialist centre: Right treatment, right place?

OBJECTIVES: To compare patient characteristics, management and outcomes for patients admitted with isolated blunt chest trauma, managed by medical or surgical teams. METHODS: We reviewed adult patients admitted with blunt chest trauma between 1 September 2006 and 31 August 2011 to a secondary hospital in New Zealand. Inclusion criteria were: blunt chest trauma, with at least one radiologically demonstrated rib fracture. The primary outcome was in-hospital mortality, and secondary outcomes were development of pneumonia, and use of analgesia. RESULTS: Seventy-two patients were included. Thirty-three patients were managed by medical teams and 39 by surgical teams. In-hospital mortality was greater amongst medical patients 5/33 (15%) versus surgical 0/39 (0%); P = 0.012. Pneumonia occurred in 15/33 (45%); medical patients versus surgical 2/39 (5%), P <0.001. Use of epidural, regional or patient-controlled analgesia was greater in the group managed by surgical teams (12/39 [30.7%] vs 1/33 [3%] P = 0.002). Medically managed patients were older (median 73 vs 63 years; P = 0.02), had a higher Charlson Comorbidity Index (median 5 vs 3; P = 0.013). The mechanism of injury for medically managed patients was more likely to be low trauma fall compared to surgically managed patients (28/33 [85%] vs 9/39 [27%]; P <0.0001). CONCLUSION: Amongst patients with isolated blunt chest trauma, those managed by medical teams were older, had more comorbidities and were more likely to have become injured with a low trauma fall than those managed by surgical teams. They had less access to analgesic options, developed pneumonia more often and had higher mortality.

Cardiopulmonary resuscitation knowledge and opinions on end of life decision making of older adults admitted to an acute medical service.

AIM: To determine the knowledge in cardiopulmonary resuscitation (CPR) process, preference for CPR, and desire to participate in end-of-life decision making amongst older hospitalised patients. METHOD: We prospectively interviewed 100 participants above 65 years of age awaiting discharge from acute medical ward and collected demographics, knowledge of CPR and opinion on CPR in various clinical scenarios. RESULTS: Amongst the participants, 58% had good understanding of all components of CPR and 91% overestimated its success. Fifty-eight percent wished to have CPR in current health status, but this declined if they were presented a hypothetical scenario of critical illness (46%), functional impairment (17%), terminal illness (13%) and dementia (13%). Tertiary education, male gender and not living alone were associated with accepting CPR. Ninety-three percent were comfortable discussing CPR and 84% felt comfortable documenting their wishes in the medical notes. Seventy percent wished such discussion to include themselves and their family. CONCLUSIONS: Older inpatients have a reasonable understanding of the components of CPR and wish to be involved in CPR decision-making. Clinical scenarios with poor prognosis may lead to patients declining CPR. Discussion and documentation of resuscitation wishes is useful in routine assessment process among elderly hospitalised patients.

Investigation of Suspected Pulmonary Embolism at Hutt Valley Hospital with CT Pulmonary Angiography: Current Practice and Opportunities for Improvement.

Aims. To study the use of CT pulmonary angiography (CTPA) at Hutt Hospital and investigate the use of pretest probability scoring in the assessment of patients with suspected pulmonary embolism (PE). Methods. We studied patients with suspected PE that underwent CTPA between January and May 2012 and collected data on demographics, use of pretest probability scoring, and use of D Dimer and compared our practice with the British Thoracic Society (BTS) guideline. Results. 105 patients underwent CTPA and 15% of patients had PE. 13% of patients had a Wells score prior to their scan. Wells score calculated by researchers revealed 54%, 36%, and 8% patients had low, medium, and high risk pretest probabilities and 8%, 20%, and 50% of these patients had positive scans. D Dimer was performed in 58% of patients and no patients with a negative D Dimer had a PE. Conclusion. The CTPA positive rate was similar to other contemporary studies but lower than previous New Zealand studies and some international guidelines. Risk stratification of suspected PE using Wells score and D Dimer was underutilised. A number of scans could have been safely avoided by using accepted guidelines reducing resources use and improving patient safety.

Inequities in provision of seizure care across the Wellington Region.

AIM: We wanted to determine whether adult patients presenting with a seizure to the emergency department (ED) of Wellington Hospital and Hutt Hospital, in the Wellington region, were equally likely to be referred for neurology input. METHODS: A retrospective review was conducted of 250 consecutive patients presenting with a seizure to the ED of each hospital. Patient electronic records were examined to determine the proportion of patients discussed with the inpatient neurology team and referred to neurology outpatient clinic. RESULTS: Fifty-two per cent of the patients presenting to Wellington Hospital ED with a seizure were referred to neurology, compared to 13.4% of those presenting to Hutt Hospital ED. The proportion of 'first seizure' patients referred to neurology was 63.1% for Wellington Hospital and 9.8% for Hutt Hospital. The difference in referral rates was primarily attributable to the difference in inpatient referrals. Maori were over-represented in the patients presenting to ED with a seizure, compared to their population composition. CONCLUSIONS: This study demonstrated unequal referral practices and therefore provision of neurology care for adult seizure patients across the Wellington region, for patients with established epilepsy and those with a first seizure. There were a disproportionately high number of Maori accessing acute seizure care.

Prescriber compliance with renal function monitoring in patients taking dabigatran (Pradaxa).

AIM: To assess whether patients prescribed dabigatran had their renal function monitored in accordance with published guidelines. METHODS: We recruited patients from Hutt Hospital and two large primary care practices if they were prescribed dabigatran between July 2011 and April 2012. We assessed patients prescribed dabigatran for more than a year to ascertain whether renal function was monitored at least annually, in keeping with guidelines. RESULTS: All patients had baseline renal function testing. At baseline, 42 (60%) had an eGFR (estimated Glomerular Filtration Rate) over 60mL/min/1.73m2 and 28 (40%) had eGFR between 30-60mL/min/1.73m2. Median follow up was 46 months. Whilst taking dabigatran, 44 of the 70 patients (63%) had at least annual renal function. CONCLUSIONS: Over one-third of patients taking dabigatran for over a year did not have their renal function monitored in keeping with current guidelines, potentially leading to an increased risk of bleeding. We suggest there is a need for an automated reminder to prompt annual renal function testing.

Are new models needed to optimize the utilization of new medicines to sustain healthcare systems?

Medicines have made an appreciable contribution to improving health. However, even high-income countries are struggling to fund new premium-priced medicines. This will grow necessitating the development of new models to optimize their use. The objective is to review case histories among health authorities to improve the utilization and expenditure on new medicines. Subsequently, use these to develop exemplar models and outline their implications. A number of issues and challenges were identified from the case histories. These included the low number of new medicines seen as innovative alongside increasing requested prices for their reimbursement, especially for oncology, orphan diseases, diabetes and HCV. Proposed models center on the three pillars of pre-, peri- and post-launch including critical drug evaluation, as well as multi-criteria models for valuing medicines for orphan diseases alongside potentially capping pharmaceutical expenditure. In conclusion, the proposed models involving all key stakeholder groups are critical for the sustainability of healthcare systems or enhancing universal access. The models should help stimulate debate as well as restore trust between key stakeholder groups.

Coming to work sick: a survey of hospital doctors in New Zealand.

AIM: To estimate the rate of sickness presenteeism in hospital doctors in a New Zealand tertiary hospital and to also identify reasons for why doctors continue to work whilst sick. METHODS: An anonymous online survey about sickness presenteeism for all hospital doctors at one tertiary care hospital in New Zealand RESULTS: The response rate for the survey was 328/685 (47.8%). Sickness presenteeism was reported by 269/328 (82%) of respondents. The main reasons for sickness presenteeism were: not wanting to burden co-workers and the desire to ensure care for patients. CONCLUSIONS: Sickness presenteeism is highly prevalent in this survey. It is likely a change in attitudes by doctors towards their illnesses, and better allocation of staff resources are necessary to prevent this to avoid potential harm to patients and health care workers.

Dabigatran - a continuing exemplar case history demonstrating the need for comprehensive models to optimize the utilization of new drugs.

BACKGROUND: There are potential conflicts between authorities and companies to fund new premium priced drugs especially where there are effectiveness, safety and/or budget concerns. Dabigatran, a new oral anticoagulant for the prevention of stroke in patients with non-valvular atrial fibrillation (AF), exemplifies this issue. Whilst new effective treatments are needed, there are issues in the elderly with dabigatran due to variable drug concentrations, no known antidote and dependence on renal elimination. Published studies showed dabigatran to be cost-effective but there are budget concerns given the prevalence of AF. These concerns resulted in extensive activities pre- to post-launch to manage its introduction. OBJECTIVE: To (i) review authority activities across countries, (ii) use the findings to develop new models to better manage the entry of new drugs, and (iii) review the implications based on post-launch activities. METHODOLOGY: (i) Descriptive review and appraisal of activities regarding dabigatran, (ii) development of guidance for key stakeholder groups through an iterative process, (iii) refining guidance following post launch studies. RESULTS: Plethora of activities to manage dabigatran including extensive pre-launch activities, risk sharing arrangements, prescribing restrictions and monitoring of prescribing post launch. Reimbursement has been denied in some countries due to concerns with its budget impact and/or excessive bleeding. Development of a new model and future guidance is proposed to better manage the entry of new drugs, centering on three pillars of pre-, peri-, and post-launch activities. Post-launch activities include increasing use of patient registries to monitor the safety and effectiveness of new drugs in clinical practice. CONCLUSION: Models for introducing new drugs are essential to optimize their prescribing especially where concerns. Without such models, new drugs may be withdrawn prematurely and/or struggle for funding.

Improved stroke care processes and outcomes following the institution of an acute stroke unit at a New Zealand district general hospital.

AIMS: To examine whether stroke care processes and outcomes are improved following the institution of an acute stroke unit (ASU) at a medium-sized New Zealand hospital. METHODS: Two retrospective audits over 12-month periods were carried out at Hutt Valley Hospital before and after the institution of a 6-bed ASU. Data was collected on demographics, length of stay, stroke type, investigations, processes of care and outcomes. RESULTS: 139 strokes pre ASU and 155 strokes post ASU were studied. 86.8% of strokes received stroke unit care in the 2009 audit. There were more intracerebral haemorrhages in 2006 (17.2% vs. 9.0%). Significant improvements were seen between 2006 and 2009 in time to aspirin administration (52.7 versus 14.5 hours), swallow assessment within 24 hours (88.5% versus 96.1%), lag time to carotid Doppler studies (21 days versus 4.5 days), pressure risk assessments (19.6%, versus 87.2%) and urinary infection rates (10.8% versus 2.0% ). Total length of stay (TLOS) and mortality were reduced but the difference was not statistically significant. (20.5 days versus 18.3 days p=0.34, Inpatient mortality 16.2% versus 10% p=0.12). CONCLUSIONS: The introduction of an ASU has resulted in improvements in several key processes of stroke care. Overall mortality and total length of stay showed a trend to improvement after the establishment of an ASU.

Chest tube drainage of pleural effusions--an audit of current practice and complications at Hutt Hospital.

AIMS: The aims of the study were to review small-bore chest tube insertion practices for drainage of pleural fluid at Hutt Valley District Health Board (HVDHB), to assess complications, and compare the findings with international data. METHODS: Retrospective analysis of clinical records was completed on all chest tube insertions for drainage of pleural fluid at HVDHB from December 2008 to November 2009. Descriptive statistics were used to present demographics and tube-associated complications. Comparison was made to available similar international data. RESULTS: Small-bore tubes comprised 59/65 (91%) chest tube insertions and 23/25 (92%) complications. Available comparative data was limited. Ultrasound was used in 36% of insertions. Nearly half of chest drains placed for empyema required subsequent cardiothoracic surgical intervention. CONCLUSIONS: Chest drain complication rates at HVDHB were comparable to those seen internationally. Referral rates to cardiothoracic surgery for empyema were within described ranges. The importance of procedural training for junior medical staff, optimising safety of drain insertions with ultrasound guidance, and clear clinical governance for chest tube insertions are important in minimising harm from this procedure. Specialist societies need to take a leadership in providing guidance on chest drain insertions to secondary and tertiary hospitals in Australia and New Zealand.

Clinical and epidemiological characteristics of the hospitalised patients due to pandemic H1N1 2009 viral infection: experience at Hutt Hospital, New Zealand.

AIM: Pandemic H1N1 2009 virus (H1N1 2009) community transmission was first noted in New Zealand in the Wellington region. There is limited information of clinical and epidemiological characteristics of H1N1 2009 patients from USA and Mexico but no published reports available in New Zealand. We studied clinical and epidemiological features of patients with H1N1 2009 infection admitted to Hutt Valley Hospital. METHODS: We collected and analysed clinical and epidemiological information of all adult inpatient admitted to Hutt Hospital with confirmed H1N1 2009 infection over 5- week period from 17 June 2009 to 22 July 2009. RESULTS: There were 54 adult inpatient admissions with confirmed H1N1 2009 infection during the study period. Epidemic curve suggest rapid increase in number of cases during first 2 weeks with abrupt cessation of new cases by mid-July. The majority of the patients were female (74%) and belonged to Maori (38%) and Pacific (25%) races. Most of the patients were below 50 years of age (76%) but mean age of the cases increased weekly with progression of outbreak. The majority had comorbidities (78%) including asthma, obesity, and diabetes. 38% were smokers. 20% had diarrhoea and vomiting. 48% of the patient had multi-lobar infiltrates on chest X-ray. Nine patients received ICU/HDU (intensive care unit/high dependency unit) care and all of these patients had significant comorbidities. There were no deaths during this period. CONCLUSIONS: H1N1 2009 infection predominantly affected young Maori and Pacific women with relative sparing of the elderly. Patient who received ICU/HDU care had significant comorbidities. This study provides a reliable account of clinical and epidemiological features of H1N1 2009 infection in a medium-size hospital in New Zealand.