Impact of a codesigned and coproduced patient-centred discharge form on communication and understanding.

INTRODUCTION: Adverse clinical outcomes and patient dissatisfaction with care often have elements of poor communication. Factors such as illness and pharmacotherapy can affect cognition, and overestimation of patients' health literacy may contribute to suboptimal communication with patients regarding their hospitalisation and post-discharge instructions. Improved patient understanding and recall of their diagnoses and treatment is critical for adherence to treatment, follow-up and optimal clinical outcomes. The aim of the study was to assess whether a coproduced and codesigned patient-centred discharge form (PCDF) improves patients' understanding of their discharge diagnosis, in-hospital treatment and post-discharge plan. METHODS: A sample of 111 patients was enrolled through simple randomisation by admission to one of two identically operating general medicine wards. Over a 3-month period, 59 patients received the coproduced and codesigned form and 52 patients were controls. Assessment of patients' understanding of diagnosis, in-hospital management, post-discharge instructions and overall experience of care was undertaken by a blinded phone survey conducted approximately 6 days after discharge. RESULTS: Patients who received PCDF were significantly more likely to report adequate understanding of their hospital management (P < 0.001) and the post-discharge plan (P < 0.001). There was no statistically significant difference between the intervention and control groups in terms of understanding of diagnosis. Patients who received PCDF reported better understanding of care and recall of admission. CONCLUSION: The use of PCDF is associated with improved patient understanding with respect to their hospital management and post-discharge instructions. It is also associated with high levels of satisfaction as assessed by measures of patient experience.

Do early-life allergic sensitization and respiratory infection interact to increase asthma risk?

OBJECTIVE: The 'two-hit' hypothesis theorizes that early life allergic sensitization and respiratory infection interact to increase asthma risk. METHODS: We sought to determine in a high allergy risk birth cohort whether interactions between early life allergic sensitization and respiratory infection were associated with increased risk for asthma at ages 6-7 years and 18 years. Allergic sensitization was assessed at 6, 12, and 24 months by skin prick testing to 3 food and 3 aeroallergens. Respiratory infection was defined as reported "cough, rattle, or wheeze" and assessed 4-weekly for 15 months, at 18 months, and age 2 years. Regression analysis was undertaken with parent-reported asthma at age 6-7 years and doctor diagnosed asthma at 18 years as distinct outcomes. Interactions between allergic sensitization and respiratory infection were explored with adjustment made for potential confounders. RESULTS: Odds of asthma were higher in sensitized compared to nonsensitized children at age 6-7 years (OR = 14.46; 95% CI 3.99-52.4), There was no evidence for interactions between allergic sensitization and early life respiratory infection, with a greater frequency of respiratory infection up to 2 years of age associated with increased odds for asthma at age 6-7 years in both sensitized (OR = 1.13; 95% CI 1.02-1.25, n = 199) and nonsensitized children (OR = 1.31; 1.11-1.53, n = 211) (p interaction = 0.089). At age 18 years, these associations were weaker. CONCLUSIONS: Our findings do not support 'two-hit' interactions between early life allergic sensitization and respiratory infection on asthma risk. Both early life respiratory infections and allergic sensitization were risk factors and children with either should be monitored closely for development of asthma.

Evolution of Humoral and Cellular Immunity Post-Breakthrough Coronavirus Disease 2019 in Vaccinated Patients With Hematologic Malignancy Receiving Tixagevimab-Cilgavimab.

Background: In-depth immunogenicity studies of tixagevimab-cilgavimab (T-C) are lacking, including following breakthrough coronavirus disease 2019 (COVID-19) in vaccinated patients with hematologic malignancy (HM) receiving T-C as pre-exposure prophylaxis. Methods: We performed a prospective, observational cohort study and detailed immunological analyses of 93 patients with HM who received T-C from May 2022, with and without breakthrough infection, during a follow-up period of 6 months and dominant Omicron BA.5 variant. Results: In 93 patients who received T-C, there was an increase in Omicron BA.4/5 receptor-binding domain (RBD) immunoglobulin G (IgG) antibody titers that persisted for 6 months and was equivalent to 3-dose-vaccinated uninfected healthy controls at 1 month postinjection. Omicron BA.4/5 neutralizing antibody was lower in patients receiving B-cell-depleting therapy within 12 months despite receipt of T-C. COVID-19 vaccination during T-C treatment did not incrementally improve RBD or neutralizing antibody levels. In 16 patients with predominantly mild breakthrough infection, no change in serum neutralization of Omicron BA.4/5 postinfection was detected. Activation-induced marker assay revealed an increase in CD4+ (but not CD8+) T cells post infection, comparable to previously infected healthy controls. Conclusions: Our study provides proof-of-principle for a pre-exposure prophylaxis strategy and highlights the importance of humoral and cellular immunity post-breakthrough COVID-19 in vaccinated patients with HM.

Risk perception and emotional wellbeing in healthcare workers involved in rapid response calls during the COVID-19 pandemic: A substudy of a cross-sectional survey.

BACKGROUND: Coronavirus disease-2019 (COVID-19) has effected major changes to healthcare delivery within acute care settings. Rapid response calls (RRCs) in healthcare organisations have been effective at identifying and urgently managing acute clinical deterioration. Code-95 RRC were introduced to prewarn healthcare workers (HCWs) attending to patients suspected or confirmed with COVID-19 infection. AIMS: The primary aim of the study was to identify the personal impact of the COVID-19 pandemic on HCWs involved in attending Code-95 RRC. We sought to evaluate their perception of risks and effects on wellbeing and identify potential opportunities for improvement at organisational levels. METHODS: We undertook a detailed survey on HCWs attending Code-95 RRCs, including questions that sought to understand the impact of the pandemic as well as their perception of infection risk and emotional wellbeing. This was a substudy of the prospective cross-sectional single-centre survey of HCWs that was conducted over a 3-week period at Frankston Hospital, Victoria, Australia. We adopted a quantitative content analysis approach for free-text responses in this secondary analysis. RESULTS: Four hundred two free-text comments were received from 297 respondents and were analysed. More than two-thirds (68%, 223/297) were female. Of all comments, 39% (155/402) were related to organisational issues including communication, confusion due to constantly changing infection control policies, and insufficient training. Thirty-three percent of comments (133/402) raised issues regarding the adequacy of personal protective equipment. Anxiety was reported in 25% of comments (101/402) with concerns predominantly relating to emotional stress and fatigue, risks of virus exposure and transmitting the infection to others, and COVID-19 precautions impairing care delivery. CONCLUSION(S): Our study raises important issues that have relevance for all healthcare organisations in the management of patients with COVID-19. These include the importance of improving communication, especially when infection control policies are revised, optimising training, maintaining adequate personal protective equipment, and HCW support. Early recognition and management of these issues are crucial to maintain optimal healthcare delivery.

'Code-95' rapid response calls for patients under airborne precautions in the COVID-19-era: a cross-sectional survey of healthcare worker perceptions.

BACKGROUND: To allow better allocation of staff and resources, rapid response teams attending to acutely deteriorating or aggressive patients with suspected or confirmed COVID-19 infection were pre-warned with the announcement of 'Code-95' with calls. AIM: To assess healthcare worker (HCW) perspectives on pre-warning rapid response calls (RRC) with 'Code-95' in announcements when attending to deteriorating or aggressive patients with suspected/confirmed COVID-19 infection. METHODS: Design: prospective cross-sectional single-centre survey of HCW over a 3-week period. SETTING: tertiary public hospital. PARTICIPANTS: HCW caring for deteriorating or aggressive patients. MAIN OUTCOME MEASURES: the primary outcome was to assess HCW perspectives in attending Code-95 calls. Secondary outcomes were to identify any differences related to craft group, age, experience or presence of comorbidities. RESULTS: A total of 297 responses was analysed; 86.7% of HCW (n = 257) attending Code-95 calls reported anxiety. Medical staff reported greater anxiety in comparison to nursing staff (93.8% vs 78.5%; P = 0.002). Efferent team reported higher anxiety in contrast to afferent team (92.6% vs 58.8%; P = 0.021). There was no significant difference in perceived anxiety based on age (≤40 vs >40 years of age), years of experience (≤5 vs >5 years), comorbidities or mental illness; 54% reported concerns about adequacy of infection-control policies and personal protective equipment; 45% were worried about inadequate training for responding to Code-95 calls. CONCLUSIONS: Most surveyed HCW supported Code-95 announcements pre-warning them of potential COVID-19 exposure when attending a RRC. However, the majority of HCW reported anxiety when attending these calls. Medical and efferent team HCW perceived greater anxiety compared to nursing and afferent team HCW. The Code-95 system to pre-warn rapid response teams may be a useful addition to protecting HCW from infectious diseases, although broader implementation will require greater resourcing, training and support.

The Association of Early Life Viral Respiratory Illness and Atopy on Asthma in Children: Systematic Review and Meta-Analysis.

BACKGROUND: The interaction between early life viral respiratory illness and atopy in the genesis of asthma has been widely discussed in the literature as the "two-hit hypothesis." OBJECTIVE: To synthesize evidence regarding the association of childhood viral respiratory illness and atopy in the development of persistent wheezing and asthma. METHODS: A systematic review was performed, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Human studies investigating early life associations between atopy and viral respiratory illness with outcomes of asthma and wheezing were included. Meta-analysis was performed to investigate the association of viral illness across atopic and nonatopic groups. Subgroup analysis was undertaken to investigate potential effect modification of age at outcome. RESULTS: Nine cohort studies were included, with data available for meta-analysis in 4 birth cohort studies. There was a stronger association of viral respiratory illness with persistent asthma/wheeze in atopic (odds ratio [OR], 4.02; 95% CI, 1.46-11.06) compared with nonatopic (OR, 2.32; 95% CI, 1.22-4.40) individuals; however, the evidence for this was limited. In 3 studies amenable to subanalysis based on outcome age, a stronger effect was observed up to 7 years for those with atopy (OR, 7.27; 95% CI 4.65-11.36) compared with those without atopy (OR, 3.19; 95% CI, 2.09-4.87). CONCLUSIONS: There was a stronger association between viral respiratory illness and asthma/wheeze outcomes in individuals with atopy as compared with those without atopy. When outcomes were considered at younger ages, a greater differential effect was observed. Within the limitations of the few available studies however, definite conclusions cannot be made. There was also insufficient evidence for differential effects of early versus late atopy. Further research, in particular regarding virus type, timing of atopy, and atopic phenotype, would contribute to untangling this complex association.

Thunderstorm asthma: revealing a hidden at-risk population.

BACKGROUND: Epidemic thunderstorm asthma (ETSA) refers to large-scale acute bronchospasm events associated with thunderstorm. The most serious episode ever recorded occurred in Melbourne, Australia, in November 2016, where more than 3500 patients were treated in hospitals and 10 died. Previous work has been focused primarily on patient presentations to emergency departments. The prevalence of individuals with milder, non-emergent symptoms and who may be at risk of more serious episodes in the future has not previously been explored. AIM: To characterise the nature and extent of respiratory symptoms in healthcare workers during the Melbourne ETSA event. METHODS: A survey was conducted among staff and volunteers across Eastern Health, distributed on the intranet homepage, by email and by word of mouth. Anonymous survey questions were constructed to assess prior and current diagnoses of relevance, symptoms, and demography. RESULTS: There were 515 participants (80% female, n = 411) of approximately 9000 potential respondents (~6% response rate) who completed the survey; 132 (25.6%) had symptoms suggestive of asthma during the Melbourne ETSA event, the majority of whom did not seek professional medical help. Notably, of those with ETSA-like symptoms, only 58 (43.9%) had a history of asthma, while 97 (73.5%) had a history of allergic rhinitis. Specifically, a history of allergic rhinitis (OR 2.77, P < 0.001), a history of asthma (OR 1.67, P = 0.037) and being of self-identified Asian ethnicity (OR 3.24, P < 0.001) were all strong predictors of ETSA-like symptoms. Being predominantly indoors was not protective. CONCLUSIONS: Our study provides evidence of the presence of a large cohort of sufferers during the Melbourne ETSA event of 2016 that did not come to the attention of medical services, implying a potentially hidden and significant susceptible population. Further research should help clarify the true prevalence of vulnerability in the general population, with important public health implications.

Low accuracy and confidence in chest radiograph interpretation amongst junior doctors and medical students.

Accurate chest X-ray (CXR) interpretation is an essential skill in clinical practice. Previous studies have shown poor accuracy and confidence rates (CR) of CXR interpretation by junior doctors and medical students. We presented 10 chest radiographs via an online questionnaire to Australian medical students and junior doctors, who were asked to identify the radiographic abnormality from a list of 15 options and to rate their confidence for each answer. Of 67 complete responses, junior doctors achieved a mean score of 57.6% and medical students 56.1%, with CR of 67 versus 58% respectively. There was a significant positive relationship between accuracy and CR among junior doctors (Pearson's coefficient + 0.798, P = 0.006) and students (Pearson's coefficient + 0.716, P = 0.020). This study identified similarities in strength and weakness in CXR interpretation between medical students and junior doctors. There was a positive association between test scores and self-rated confidence scores.

Staggering shifts to rebalance night medical registrar workload.

BACKGROUND: Lone night medical registrars, particularly those working at busy urban hospitals have high workloads and low job satisfaction. Handover of pending referrals from day staff can contribute to further delays in providing care with increased risks for patient safety. AIM: To evaluate the impact of a staggered roster for daytime medical registrar on the workload of night registrar. METHODS: Prospective data were collected of the night medical registrar workload over a 6-month period. The first 3 months included standard shifts from 1330 to 2130 hours with two registrars. The second 3 months followed the introduction of a staggered shift for one registrar to 1530 hour-midnight, providing a 3-h overlap with the night registrar commencing at 2100 hour. Parameters recorded included the number of total admissions, pending admissions, referrals from emergency department, ward reviews and Medical Emergency Team (MET) calls/CODE Blues. Data from weekends and public holidays were not recorded. RESULTS: During the standard rostering period, the average number of medical admissions completed per night shift was 8.66 (n = 60, SD = 3.58). With staggered shifts, the average number was significantly reduced at 6.38 (n = 65, SD = 2.74, P = 0.000057). In addition, there was greater number of ward reviews conducted by the night registrar in the staggered roster period, potentially reflecting greater time availability and reduction in MET calls/codes. CONCLUSION: Rearranging medical registrar shifts can result in significant reduction in night medical registrar workload. It may also have other potential benefits in terms of increased capacity for ward reviews and reduced MET calls/codes.