A community of practice to address system-based issues and promote clinical leadership among trainee medical officers in a large public health service: an evaluation of a trainee-led forum.

Clinical leadership is necessary to improve the performance of large public hospitals. Trainee medical officers (TMOs) are important stakeholders in organisation-wide initiatives that affect the medical workforce and support clinician engagement. This case study describes the development of a representative body known as the 'TMO Forum' within the Central Adelaide Local Health Network as a mechanism to promote engagement between medical trainees and the hospital executive to facilitate escalation and discussion of system-based issues. Over the past 8 years, this group has evolved into a community of practice with steady and sustained growth since inception. Trainees have fostered relationships with the executive, and have engaged in leadership and quality improvement initiatives. Here we explore the evolution, value and barriers to success of the TMO Forum. Our discussion is supplemented with findings from anonymous online evaluation surveys of both the TMO and executive stakeholder groups. We propose that initiatives such as the described may offer reciprocal benefits to both constituent groups regarding communication, and that the development of a dedicated community of practice will enhance engagement of TMOs in health service improvement initiatives and advocacy. However, there are obstacles to overcome in order to attract a greater number of trainees and maximise the benefits from this initiative.

Establishing a clinical ethics support service: lessons from the first 18 months of a new Australian service - a case study.

BACKGROUND: Although the importance of clinical ethics in contemporary clinical environments is established, development of formal clinical ethics services in the Australia health system has, to date, been ad hoc. This study was designed to systematically follow and reflect upon the first 18 months of activity by a newly established service, to examine key barriers and facilitators to establishing a new service in an Australian hospital setting. METHODS: HOW THE STUDY WAS PERFORMED AND STATISTICAL TESTS USED: A qualitative case study approach was utilised. The study gathered and analysed data using observations of service committee meetings, document analysis of agendas and minutes, and semi-structured interviews with committee members to generate semantic themes. By interpreting the thematic findings in reference to national capacity building resources, this study also aimed to provide practice-based reflections for other health agencies. RESULTS: THE MAIN FINDINGS: An overarching theme identified in the data was a strong commitment to supporting clinicians facing difficult patient care decisions and navigating difficult discussions with patients and families. Another key theme was the role of the new clinical ethics support service in providing clinicians with a pathway to raise system-wide issues with the organisation Executive. While there was strong clinical engagement, consumer and community participation remained a challenge, as did unresolved governance issues and a need for clearer policy relationship between the service and the organisation. Considering these themes in relation to the national capacity building resources, the study identifies three areas likely to require ongoing development and negotiation. These are: the role of the clinical ethics support service as a link between the workforce and the Executive; the incorporation of consumers and patients; and ethical reasoning. To improve the effectiveness of the service, it is necessary to increase clarity on the service's role at the governance and policy level, as well as develop strategies for engaging consumers, patients and families. Finally, the capacity of the service to reflect on complex cases may be enhanced through explicit discussions of various different ethical frameworks and ways of deliberating.

Are clinical registries an effective tool for hospital health services to address unwarranted clinical variation?

OBJECTIVE: To map clinical registries within the Central Adelaide Local Health Network (CALHN); and to identify how these registries were currently used for addressing unwarranted clinical variation in care. METHOD: An online survey was sent to all Heads of Units (HoUs) within CALHN. The survey addressed participation, type of data, reporting processes and use of the clinical registries for research, quality assurance (QA), quality improvement (QI) and clinical variation in health care. RESULTS: Twenty-six HoUs responded (26%); 25 contributed to a clinical registry (96%); all provided data to more than one registry, but only 34.6% had an existing financial and governance arrangement with the network. Health outcomes were the most common datapoints; 77% of all data were collected manually; and 38.5% of data analysis was risk adjusted. Access to aggregated data varied across the registries; and 65.4% of reports included benchmarks and outliers. Clinical registries were used for research in 65.4%, and QA and QI in 73.1 and 69.2%, respectively. Most used external comparators and measured clinical variation, but there was marked inconsistency in the exploring clinical variation, improving care and reporting activities. CONCLUSION: Based on this sample, clinical registries within CALHN did not currently appear to be a reliable resource to consistently address unwarranted clinical variation but were shown to be valuable resources for research and quality initiatives at a high level. Further research is required to facilitate effective integration of clinical registries with administrative and quality systems.

SAFety, Effectiveness of care and Resource use among Australian Hospitals (SAFER Hospitals): a protocol for a population-wide cohort study of outcomes of hospital care.

INTRODUCTION: Despite global concerns about the safety and quality of health care, population-wide studies of hospital outcomes are uncommon. The SAFety, Effectiveness of care and Resource use among Australian Hospitals (SAFER Hospitals) study seeks to estimate the incidence of serious adverse events, mortality, unplanned rehospitalisations and direct costs following hospital encounters using nationwide data, and to assess the variation and trends in these outcomes. METHODS AND ANALYSIS: SAFER Hospitals is a cohort study with retrospective and prospective components. The retrospective component uses data from 2012 to 2018 on all hospitalised patients age ≥18 years included in each State and Territories' Admitted Patient Collections. These routinely collected datasets record every hospital encounter from all public and most private hospitals using a standardised set of variables including patient demographics, primary and secondary diagnoses, procedures and patient status at discharge. The study outcomes are deaths, adverse events, readmissions and emergency care visits. Hospitalisation data will be linked to subsequent hospitalisations and each region's Emergency Department Data Collections and Death Registries to assess readmissions, emergency care encounters and deaths after discharge. Direct hospital costs associated with adverse outcomes will be estimated using data from the National Cost Data Collection. Variation in these outcomes among hospitals will be assessed adjusting for differences in hospitals' case-mix. The prospective component of the study will evaluate the temporal change in outcomes every 4 years from 2019 until 2030. ETHICS AND DISSEMINATION: Human Research Ethics Committees of the respective Australian states and territories provided ethical approval to conduct this study. A waiver of informed consent was granted for the use of de-identified patient data. Study findings will be disseminated via presentations at conferences and publications in peer-reviewed journals.

Bursting pressure of triple-lumen central venous catheters under static and dynamic loads.

INTRODUCTION: Central venous catheter (CVC) access is commonplace in intensive care units. Patients undergoing computed tomographic angiography require injection of contrast at high flow rates (4.5 mL/s), often CVC access is not used due to safety concerns. The CVC might rupture at high flow rates, resulting in CVC fragmentation and embolization or contrast extravasation.The objective of this study is to determine the pressure required to burst a CVC under static load and compare this to the pressure generated by injection of contrast at high flow rates (dynamic load) through the distal (16-g) lumen of a triple-lumen CVC. METHODS: We gathered 16-cm long triple-lumen CVCs (n = 14) from patients with an average dwell time of 5.2 days (±2.7 days). Half the CVCs (n = 7) were subjected to static testing, where the distal lumen was occluded with the guidewire and super glue at the distal end of the catheter. The CVC was then placed into a 10-cm deep water bath at 37°C to simulate in vivo conditions and water was injected until catheter rupture. Dynamic pressure testing was done with the remaining catheters, with radio-contrast injected through the unoccluded distal lumen at flow rates of 4.5 mL/s, then 7 mL/s. Pressures were recorded throughout injection. RESULTS: During static testing, 6/7 CVCs burst at the distal lumen where the glue was applied, the remaining CVC burst proximal to the hub. PSI at burst during static testing was 184.2 PSI (95% confidence interval [CI] 174.3-194.1 PSI). During dynamic testing the mean peak pressures at 7 mL/s was 81.1 PSI (95% CI 73-89.2 PSI). At 4.5 mL/s the mean peak pressure was 47.9 PSI (95% CI 42.9-52.9 PSI). CONCLUSIONS: No CVCs failed under dynamic loading with injection of contrast at flow rates (4.5 and 7 mL/s) high enough to support computed tomographic angiography. This suggests 16-cm triple-lumen CVCs can be used safely.

Is donation after cardiac death reducing the brain-dead donor pool in Australia?

BACKGROUND: Donation after cardiac death (DCD) has increased faster than donation after brain death (DBD) in Australia. However, DBD is the preferred pathway because it provides more organs per donor, the donation process is simpler and transplant outcomes are optimised. OBJECTIVE: To determine if the increase in DCD has reduced the brain-dead donor pool in Australia. DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of records of organ donors (intended and actual) with brain injury as the cause of death from 2001 to 2011 in Australian intensive care units. MAIN OUTCOME MEASURES: Change in median ventilation period, over time, before brain-death determination in DBD donors (as DCD increased); a decreased median ventilation period in DBD donors being consistent with the conversion of DBD to DCD. RESULTS: As DCD (n = 311) increased, the median ventilation period in DBD donors (n = 2218) did not fall overall (P = 0.83), in all jurisdictions (P > 0.25) and for all causes of death (P > 0.3). The proportion of patients ventilated for less than 2 days was unchanged over time in both DBD (P = 1) and DCD (P = 0.99). The overall ventilation period in DCD donors (3.8 days; interquartile range [IQR], 2.1-6.3 days), exceeded the ventilation period in DBD donors (1.3 days; IQR, 1.0-2.4 days; P < 0.0001). DCD ventilation period was significantly longer in all jurisdictions, for all causes of death and annually (P < 0.05). CONCLUSIONS: In Australia, brain-injured donors appear to be ventilated long enough to allow progression to brain death before proceeding to DCD. Therefore, DCD is unlikely to have reduced the brain-dead donor pool.

A systematic review and meta-analysis of clinical trials of thyroid hormone administration to brain dead potential organ donors.

OBJECTIVES: To review all published clinical studies of thyroid hormone administration to brain-dead potential organ donors. METHODS: A search of PubMed using multiple search terms retrieved 401 publications including 35 original reports describing administration of thyroid hormone to brain-dead potential organ donors. Detailed review of the 35 original reports led to identification of two additional publications not retrieved in the original search. The 37 original publications reported findings from 16 separate case series or retrospective audits and seven randomized controlled trials, four of which were placebo-controlled. Meta-analysis was restricted to the four placebo-controlled randomized controlled trials. RESULTS: Whereas all case series and retrospective audits reported a beneficial effect of thyroid hormone administration, all seven randomized controlled trials reported no benefit of thyroid hormone administration either alone or in combination with other hormonal therapies. In four placebo-controlled trials including 209 donors, administration of thyroid hormone (n=108) compared with placebo (n=101) had no significant effect on donor cardiac index (pooled mean difference, 0.15 L/min/m²; 95% confidence interval -0.18 to 0.48). The major limitation of the case series and retrospective audits was the lack of consideration of uncontrolled variables that confound interpretation of the results. A limitation of the randomized controlled trials was that the proportion of donors who were hemodynamically unstable or marginal in other ways was too small to exclude a benefit of thyroid hormone in this subgroup. CONCLUSIONS: The findings of this systematic review do not support a role for routine administration of thyroid hormone in the brain-dead potential organ donor. Existing recommendations regarding the use of thyroid hormone in marginal donors are based on low-level evidence.

Percutaneous tracheostomy in patients with severe liver disease and a high incidence of refractory coagulopathy: a prospective trial.

BACKGROUND: To assess the safety of percutaneous dilational tracheostomy (PDT) performed by experienced operators in critically ill patients with liver disease and coagulopathy. METHODS: Prospective cohort study in a ten bed specialist liver intensive care unit of a tertiary university teaching hospital. Sixty consecutive patients in need of tracheostomy insertion. Patients were categorized as having refractory coagulopathy if their platelet count was < or = 50 x 10(9) cells/L or the INR > 1.5 on the day of and the subsequent 72 hours following PDT despite clotting support. RESULTS: Twenty five patients fulfilled the definition criteria of refractory coagulopathy. There was no significant difference in the number of adverse incidents between groups. Only 1 patient in the coagulopathy group had a severe bleeding complication, however this did not require open surgical intervention. The rate of clinically relevant early complications in all patients was not higher than expected (n = 7, 12%). Resource utilisation was higher for patients with coagulopathy, who received significantly more platelet transfusions over the 3 day period (80 vs 49 units, p = 0.009) and demonstrated a trend towards increased fresh frozen plasma requirements (p = 0.059). The number of patients requiring platelet transfusion was higher in the coagulopathy group (21/25 versus 20/35 p = 0.029). Hospital survival did not differ between groups. CONCLUSION: PDT is safe and not contraindicated in patients with severe liver disease and refractory coagulopathy.