Redland Hospital

BackgroundClosed reduction of upper limb fractures and/or dislocations are common in the emergency department (ED), which involves physically re-aligning the injured part prior to immobilisation. As this is painful, numerous techniques are available to provide regional anaesthesia to ensure patient tolerance. A Bier block (BB) is typically performed as part of routine care. An alternative technique gaining interest in the ED is ultrasound-guided supraclavicular block (UGSCB), which involves injecting local anaesthetic around the brachial plexus at the supraclavicular fossa under ultrasound guidance. It is unclear whether UGSCB is effective and safe when performed in the ED.MethodsSUPERB (SUPraclavicular block for Emergency Reduction versus Bier block) is a prospective open-label, non-inferiority randomised controlled trial that compares the effectiveness of UGSCB versus BB for closed reduction of upper limb fractures and/or dislocations. Adult patients presenting with an upper limb fracture and/or dislocation that requires emergent closed reduction in the ED will be eligible. After screening, participants will be randomised to either UGSCB or BB. Once regional anaesthesia is obtained, closed reduction of the injured part will be performed and appropriately immobilised. The primary outcome is maximal pain experienced during closed reduction measured via a visual analogue scale (VAS). Secondary outcomes include baseline and post-reduction pain, patient satisfaction, total opioid requirement in ED, ED length of stay, adverse events and regional anaesthesia failure.DiscussionExisting evidence suggests UGSCB is effective when performed in the operating theatre by trained anaesthetists. SUPERB will be the first randomised controlled trial to elucidate the effectiveness and safety of UGSCB in the ED. The findings have the potential to provide an alternative safe and effective option for the management of upper extremity emergencies in the ED.Trial registrationThis trial has been registered on 21 October 2022 with Australia and New Zealand Clinical Trials Registry (ACTRN12622001356752).

BackgroundQuantitative surveillance of antimicrobial use is a valuable tool used to support antimicrobial stewardship, identify overprescribing, monitor unexpected changes in usage, and assess the impact of interventions to improve prescribing. Smaller, more remote hospitals face many challenges in conducting effective antimicrobial surveillance.AimTo investigate the impact of expired stock on reported antimicrobial usage rates in smaller, more remote hospitals.MethodAntimicrobial usage rates (defined daily doses [DDDs] per 1000 occupied bed days [OBDs]) were calculated using monthly dispensing data and hospital activity data from 12 rural South Australian facilities for the period January 2018 to December 2020. Usage rates were re‐calculated, excluding expired stock, to estimate the impact expired stock had on reported usage rates and to quantify stock wastage.ResultsBetween 2018 and 2020, the average monthly aggregate usage rate for all 12 hospitals was 650 DDD/1000 OBDs, with the exclusion of expired stock resulting in an average monthly reduction of 37 DDD/1000 OBDs (5.7%). Analysis by the Australian Institute of Health and Welfare peer group demonstrated that the exclusion of expired stock reduced average monthly usage rates by 6.0% for Public Acute Group C sites and 10.6% for Public Acute Group D and Very Small Hospitals.ConclusionReplacement of expired stock may account for a substantial proportion of perceived antimicrobial usage in rural and remote hospitals, particularly for agents infrequently prescribed. Pharmacy distribution data is a surrogate measure for actual patient consumption; utilisation reports for smaller rural facilities should be interpreted with acknowledgment of the challenges of stock management in remote locations.

Objective The provision of medicines through state public hospitals is comparatively restrictive compared with the federally funded Pharmaceutical Benefits Scheme (PBS). Individual states are progressively moving towards statewide medicines formularies. Although a statewide formulary has existed in Queensland for some time. The effects of hospital formularies on medicines utilisation and policy in Australia has not been quantified. Thus, the aim of the present study was to quantify the effects of the Queensland Health List of Approved Medicines (LAM) on medicines utilisation in Queensland at a state and PBS-purchasing level and describe the implications for medicines policy. Methods This study used a quasi-experimental design with an interrupted time series (with control for PBS) examining utilisation effects of medicines within the therapeutic classes of proton pump inhibitors and non-vitamin K oral anticoagulants with LAM listing or delisting. Results The LAM was demonstrated to be highly effective at controlling utilisation within Queensland Health purchasing. Effects on PBS utilisation were evident, resulting in increases in generic utilisation (where available) and associated reduced total costs both within Queensland Health and to the PBS. The full benefit is likely underestimated due to limitations in the PBS datasets. Conclusion The LAM is a highly effective state medicines policy tool with demonstrable effects on PBS utilisation. With increased use of statewide medicines formularies, this will be an increasingly relevant aspect of Australia's overall medicines policy. What is known about the topic? State medicines policy is comparatively restrictive compared with the federal PBS. Most Australian states have, or are developing, statewide medicines formularies. What does this paper add? By examining several classes of medicines, a substantial quantitative effect of the Queensland state formulary on both state and PBS medicines utilisation can be demonstrated. Increased use of generic medicines and reduced costs are seen. What are the implications for practitioners? With increased use of state medicines formularies, state medicines formularies will become increasingly relevant to medicines policy makers and advocates at both the state and federal level.

ABSTRACTBackgroundThe pericapsular nerve group (PENG) block was first described for the treatment of hip fracture, including neck of femur, in 2018. We hypothesise that the PENG block is safe and effective for patients with hip fracture when provided by emergency physicians and trainees in the emergency department (ED), for which it may be superior to fascia iliaca compartment block (FICB) and femoral nerve block (FNB).MethodsFrom October 2019 to July 2020, consecutive patients receiving regional anaesthesia for hip fracture in the ED of a single large regional hospital were prospectively enrolled. Pain scores were assessed prior to regional anaesthesia then at 15, 30 and 60 minutes after regional anaesthesia. Maximal reduction in pain scores within 60 minutes were assessed using the Visual Analogue Scale (at rest and on movement) or the Pain Assessment IN Advanced Dementia tool (at rest). Patients were followed for opioid use for 12 hours after regional anaesthesia and adverse events over the duration of their admission.ResultsThere were 67 eligible patients during the enrolment period, with 52 (78%) prospectively enrolled. Thirty-three received femoral blocks (19 FICB, 14 FNB) and 19 received a PENG block. There was no difference in maximum pain score reduction between the groups whether measured at rest or on movement. Clinicians providing the PENG block were less experienced in the technique than those providing FICB or FNB. There was no difference in adverse effects between groups. Although opioid use was similar between the groups, more patients were opioid free after a PENG block.ConclusionsAlthough there was no difference in maximal pain score reduction, this study demonstrated that the PENG block was feasible and could be provided safely and effectively to patients with hip fracture in the ED. On this basis, a larger randomised controlled study should now be designed.Key MessagesWhat is already known on this subject□There is a solid neuroanatomical rationale to suggest the PENG block may provide superior anaesthesia of hip fractures than FNB or FICB.□The technique utilises bony sonographic and tactile landmarks which make it an ideal block for emergency physicians to safely and effectively perform.□What this study adds□This is the first comparative study of the PENG block to FNB or FICB in patients with hip fracture in ED, which will provide a scaffold for future research.□This pragmatic observation of evolving practice showed that emergency physicians and trainees inexperienced in the technique could provide it safely and effectively in the ED

Elective lower segment caesarean section patients are routinely instructed to fast from food for 6h before surgery, with clear fluids up until 2h before surgery. We conducted an audit examining the true fasting times of mothers undergoing an elective caesarean section and the incidence of urinary ketones before and after introducing a preop carbohydrate drink (Nutricia preOp 400ml) to be administered to all patients at 6am on the day of surgery. We audited 50 patients prior to introducing the preop carbohydrate drink and 54 patients after the introduction of a carbohydrate drink. We found the mean fasting time from last caloric intake was reduced from 13h 35min to 5h 5min after the introduction of a preoperative carbohydrate drink. We found that the incidence of urinary ketones was 40.4% prior to the introduction of a preoperative carbohydrate drink and 38.3% after the introduction of a preop drink (p = 1). If fasting times were limited to under 4h, the incidence of urinary ketones is 10%. Our audit demonstrates that reducing preoperative fasting times is possible and preventing metabolic derangements may be possible, requiring an approach targeted at keeping fasting times to a minimum.

Obesity and adverse metabolic outcomes in patients with severe mental illness are clinically significant but potentially preventable. Importantly, the evidence for switching to antipsychotics to reduce cardiometabolic burden is unclear. PubMED, Embase, PsycINFO, and Cochrane were searched from inception to March 8, 2020. Articles reporting weight and metabolic changes after antipsychotic switching vs staying on the previous antipsychotic were meta-analyzed both across and within group. Of 61 identified studies, 59 were meta-analyzed (40% rated high quality). In the switch-vs-stay pairwise meta-analyses, only aripiprazole significantly reduced weight (-5.52 kg, 95% CI -10.63, -0.42, P = .03), while olanzapine significantly increased weight (2.46 kg, 95% CI 0.34, 4.57, P = .02). Switching to aripiprazole also significantly improved fasting glucose (-3.99 mg/dl, 95% CI -7.34, -0.64, P = .02) and triglycerides (-31.03 mg/dl, 95% CI -48.73, -13.34, P = .0001). Dropout and psychosis ratings did not differ between switch and stay groups for aripiprazole and olanzapine. In before-to-after switch meta-analyses, aripiprazole (-1.96 kg, 95% CI -3.07, -0.85, P < .001) and ziprasidone (-2.22 kg, 95% CI -3.84, -0.60, P = .007) were associated with weight loss, whereas olanzapine (2.71 kg, 95% CI 1.87, 3.55, P < .001), and clozapine (2.80 kg, 95% CI 0.26, 5.34, P = .03) were associated with weight gain. No significant weight or other cardiometabolic changes were observed when switching to amisulpride, paliperidone/risperidone, quetiapine, or lurasidone. Switching antipsychotics to agents with lower weight gain potential, notably to aripiprazole and ziprasidone, can improve weight profile and other cardiometabolic outcomes. When choosing switch agents, both the weight gain potential of the pre- and post-switch antipsychotic must be considered. Antipsychotic switching in psychiatrically stable patients must be weighed against the risk of psychiatric worsening.

In the Australian southeast, the saltmarsh mosquito Aedes vigilax (Skuse) is the focus of area-wide larviciding campaigns employing the biological agent Bacillus thuringiensis var. israelensis (Bti). Although generally effective, frequent inundating tides and considerable mangrove cover can make control challenging. Here, we describe the efficacy and persistence of an aqueous Bti suspension (potency: 1200 International Toxic Units; strain AM65-52) within a mixed saltmarsh-mangrove system and the use of affordable unmanned aerial systems (UAS) to identify and map problematic levels of mangrove canopy cover. High mangrove canopy density (>40% cover) reduced product deposition by 75.2% (0.01 ± 0.002 μL cm-2 versus 0.05 ± 0.006 μL cm-2 ), larval mortality by 27.7% (60.7 ± 4.1% versus 84.0 ± 2.4%), and ground level Bti concentrations by 32.03% (1144 ± 462.6 versus 1683 ± 447.8 spores mL-1 ) relative to open saltmarsh. Persistence of product post-application was found to be low (80.6% loss at 6 h) resulting in negligible additional losses to tidal inundation 24 h post-application. UAS surveys accurately identified areas of high mangrove cover using both standard and multispectral imagery, although derived index values for this vegetation class were only moderately correlated with ground measurements (R2 = 0.17-0.38) at their most informative scales. These findings highlight the complex operational challenges that affect coastal mosquito control in heterogeneous environments. The problem is exacerbated by continued mangrove transgression into saltmarsh habitat in the region. Emerging UAS technology can help operators optimize treatments by accurately identifying and mapping challenging canopy cover using both standard and multispectral imaging. © 2020 Society of Chemical Industry.

While the Australasian College for Emergency Medicine (ACEM) encourages all emergency physicians to be competent in at least the five core areas of emergency ultrasound (US), departmental training in most hospitals does woefully little to prepare most ACEM members to attain these competencies. While full day courses are a common method of mandatory and discretionary in-service training, that method has not been adopted for US training. We propose the development of full day courses for each of the five core competencies, taught by accredited US instructors and with emphasis on hands-on training. These courses alone will not produce fully competent US users but will provide a solid foundation for further training.

While malnutrition is prevalent in hospitals, little is known about patients who first become malnourished during the hospital stay. This study aimed to determine the incidence and describe the characteristics of patients who developed hospital-acquired malnutrition (HAM) across five Australian public hospitals. A retrospective clinical audit of hospital data was conducted. Adult patients (aged ≥ 18 years) with a length of stay (LOS) > 14 days in a Metro South Health hospital between July 2015 and January 2019 were eligible. Demographic and clinical data were sourced from hospital data and medical records. Dietitians reviewed the medical records of patients clinically coded with malnutrition to determine HAM incidence. Univariate and logistic regression analyses were used to determine patient descriptors associated with HAM, compared with those not malnourished or those malnourished on admission. A total of 17,717 patients were eligible (45% F, 63 ± 20 years, LOS 24 (15-606) days). HAM incidence in long-stay patients was 1%, with an overall malnutrition prevalence of 18%. Patients with HAM had an ~26 days longer LOS than patients who were malnourished on admission or not malnourished (p < 0.001). Longer LOS; patient inter-hospital transfer from or to another hospital; or experiencing cognitive impairment, pressure injury or a fall while in hospital were associated with HAM (OR 1.006-3.6, p < 0.05). Incidence of HAM, defined as malnutrition first diagnosed >14 days after admission, was in the low end of the published range. HAM was significantly associated with long LOS, transferring between hospitals and developing a cognitive impairment, pressure injury or fall during admission.