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Background: Current methods of antimicrobial usage surveillance have limited efficacy in changing practice due to delayed reporting to clinicians and the inability to stratify by medical specialty. This study was undertaken in a tertiary teaching hospital with a well established antimicrobial stewardship (AMS) programme and electronic medicines management (eMM) system in Sydney, Australia. Aims: To describe and analyse the implementation of a novel AMS audit and feedback method, in the context of an eMM system. Methods: The AMS team conducted the audit weekly, and the study design was a prospective, observational study. All acute, adult inpatients were included in this intervention. All active systemic antimicrobial prescriptions on the day of the rounds were included. Results: The prevalence of patients on antimicrobial therapy was 37%. The median time taken per round was 44 min for eMM compared to 58 min for paper. All key performance indicators improved over the study period. Appropriateness compared to guidelines increased from 55% to 71%, and documentation of an indication increased from 75% to 98%. There were 1413 recommendations made, with the most common being to cease an antimicrobial agent. The recommendation uptake rate was 47% at 24 h post-round. Conclusions: AMS rounds are an effective tool for auditing and providing feedback on antimicrobial use and should include all antimicrobials rather than solely 'restricted' agents. These rounds had a high uptake rate, improvements in the appropriateness of antimicrobial use, and a planned duration or review date. A benefit of eMM was improvement in the documentation of indication for antimicrobial agents, and reduced time taken to audit. [ABSTRACT FROM AUTHOR]

Background: Conversion from paper‐based to electronic medical records (EMR) may affect the quality and timeliness of the completion of Goals‐of‐Care (GOC) documents during hospital admissions and this may have been further impacted by the COVID‐19 pandemic. Aims: To determine the impact of EMR and COVID‐19 on the proper completion of GOC forms and the factors associated with inpatient changes in GOC. Methods: We conducted a cross‐sectional study of adult general medicine admissions (August 2018–September 2020) at Dandenong Hospital (Victoria, Australia). We used interrupted time series to model the changes in the rates of proper GOC completion (adequate documented discussion, completed ≤2 days) after the introduction of EMR and the arrival of COVID‐19. Results: We included a total of 5147 patients. The pre‐EMR GOC proper completion rate was 27.7% (overall completion, 86.5%). There was a decrease in the proper completion rate by 2.21% per month (95% confidence interval (CI): −2.83 to −1.58) after EMR implementation despite an increase in overall completion rates (91.2%). The main reason for the negative trend was a decline in adequate documentation despite improvements in timeliness. COVID‐19 arrival saw a reversal of this negative trend, with proper completion rates increasing by 2.25% per month (95% CI: 1.35 to 3.15) compared with the EMR period, but also resulted in a higher proportion of GOC changes within 2 days of admission. Conclusions: EMR improved the timeliness and overall completion rates of GOC at the cost of a lower quality of documented discussion. COVID‐19 reversed the negative trend in proper GOC completion but increased the number of early revisions. [ABSTRACT FROM AUTHOR]

The delivery of healthcare, which includes the informed consent process, is moving to a digital environment. This change in informed consent delivery will be associated with opportunities, risks and also unintentional consequences. Physicians are well placed to contribute to the ongoing dialogue about what is needed to make the informed consent process fit for purpose, in the digital age. [ABSTRACT FROM AUTHOR]

Background: A resuscitation plan is a medically authorised order to use or withhold resuscitation interventions. Absence of appropriate resuscitation orders exposes patients to the risk of invasive medical interventions that may be of questionable benefit depending on individual circumstances. Aims: To describe among junior doctors: (i) self‐reported confidence discussing and completing resuscitation plans; (ii) knowledge of resuscitation policy including whether resuscitation plans are legally enforceable and key triggers for completion; and (iii) the factors associated with higher knowledge of triggers for completing resuscitation plans. Methods: A cross‐sectional survey was conducted at five hospitals. Junior doctors on clinical rotation were approached at scheduled training sessions, before or after ward rounds or at change of rotation orientation days and provided with a pen‐and‐paper survey. Results: A total of 118 junior doctors participated. Most felt confident discussing (79%; n = 92) and documenting (87%; n = 102) resuscitation plans with patients. However, only 45% (n = 52) of doctors correctly identified that resuscitation plans are legally enforceable medical orders. On average, doctors correctly identified 6.8 (standard deviation = 1.8) out of 10 triggers for completing a resuscitation plan. Doctors aged >30 years were four times more likely to have high knowledge of triggers for completing resuscitation plans (odds ratio 4.28 (95% confidence interval 1.54–11.89); P = 0.0053). Conclusion: Most junior doctors feel confident discussing and documenting resuscitation plans. There is a need to improve knowledge about legal obligations to follow completed resuscitation plans, and about when resuscitation plans should be completed to ensure they are completed with patients who are most at risk. [ABSTRACT FROM AUTHOR]

Background: The transition from hospital inpatient care to medical care in the community is a high‐risk period for adverse events. Inadequate communication, including low‐quality or unavailable discharge summaries, has been shown to impact patient care. Aims: To assess use of abbreviations in clinical handover documents from inpatient hospital teams to general practitioners (GP), and the interpretation of these abbreviations by GP and hospital‐based junior doctors. Methods: This is a retrospective audit of 802 discharge summaries completed during a 1‐week period in 2017 by a Queensland regional health service. GP and local junior doctors then attempted interpretation of 20 relevant abbreviations. Results: A total of 99% (794) discharge summaries included abbreviations. A total of 1612 different abbreviations was used on 16 327 occasions. The median number of abbreviations per discharge summary was 17 (range 0–86). A total of 254 GP and 62 junior doctors responded to a survey, which found that no abbreviation was interpreted the same by all respondents. GP and junior doctors were unable to offer any interpretation in 17.9% and 15.2% of cases respectively. GP offered a greater range of interpretations than junior doctors, with a median of 9 and 3 different interpretations per abbreviation respectively. A total of 94% (239) of GP felt that the use of abbreviations in discharge summaries had the potential to impact patient care. A total of 152 (60%) GP felt that time spent clarifying abbreviations in discharge summaries could be excessive. Conclusions: Abbreviations are often used in discharge summaries, yet poorly understood. This has the potential to impact patient care in the transition period after hospitalisation. [ABSTRACT FROM AUTHOR]

Background: Disease activity in juvenile idiopathic arthritis (JIA) commonly persists into adulthood. Transfer of JIA patients to adult healthcare services can be challenging, with prior studies showing poor rates of success. Aims: This audit sought to examine characteristics of patients undergoing transfer of care within the rheumatology unit at the Royal Children's Hospital in Melbourne, with the aim of identifying areas for improvement. Specifically, we sought to determine the rate at which confirmation of established care with an adult service (confirmed transfer of care) was documented in the patient chart. Methods: Patients with a diagnosis of JIA who turned 18 years of age between 2012 and 2019 were identified. A chart review was undertaken to collect relevant data. Results: One hundred and seventy‐seven patients were identified. In all, 64% (114/177) were referred for adult care. The commonest JIA subtypes referred were seronegative polyarticular (35/114; 30.7%) and oligoarticular JIA (22/114; 19.3%). Documentation of confirmed transfer of care occurred in 62.3% (71/114), with correspondence received from adult services in 49.1% (56/114). There was no difference in rate of return correspondence from public versus private providers (45% vs 53.8%; P = 0.38). The use of 'backstop appointments' was more likely in those with confirmed transfer of care (66% vs 30%; P = 0.0002). Conclusions: Lack of confirmed transfer of care for JIA patients is common and carries a risk of suboptimal outcomes. Strategies to improve communication with adult services, the routine use of 'backstop' appointments and vigilance regarding potential loss to follow up at the time of transfer would minimise this risk. [ABSTRACT FROM AUTHOR]

Background: Chronic hepatitis B (CHB) infection remains a significant public health issue for Indigenous Australians, in particular for remote communities. Aim: To evaluate the spectrum of hepatitis B virus (HBV) care provided to a remote Aboriginal community. Measures studied included screening, seroprevalence, vaccination rates and efficacy, and HCC risk and surveillance adherence. Methods: A retrospective audit of HBV care received by all permanent residents currently attending a remote Aboriginal Health service. This study was endorsed by both the local Aboriginal Health service and the Aboriginal Health Council of South Australia. Results: A total of 208 patients attended the clinic, of whom 52% (109) were screened for HBV. Of these, 12% (13) had CHB and 20% (22) had evidence of past infection. Similarly, of the 208 attending patients, complete vaccination was documented in 48% (99). Of the 33 patients with post‐vaccination serology, 24% (8) had subtherapeutic (<10 IU/mL) levels of HBsAb. Subtherapeutic HBsAb was independently associated with higher Charlson Comorbidity scores (odds ratio = 17.1; 95% confidence interval 1.2–243.3; P = 0.036). Definitive breakthrough infection was identified in 6% (2) patients. One HBsAg positive patient was identified as needing HCC surveillance, but had not undertaken HCC surveillance. Conclusion: Opportunities to improve the quality of CHB care through increased HBV vaccination, screening and adherence to HCC surveillance were identified. High rates of subtherapeutic vaccine responses and documented breakthrough infection raises concerns about the effectiveness of current CHB vaccines in this population. [ABSTRACT FROM AUTHOR]

Background: Lung cancer management is characterised by a high disease burden, poor survival and substantial variation in management and outcomes. Service redesign provides opportunities for quality improvement (QI) and this improvement may be leveraged across multiple sites using QI collaboration. Aim This initiative targeted Quality Improvement (QI) in lung cancer management, engaging a QI collaborative using service redesign methodologies in five Victorian hospitals. QI targets included timeliness from referral and diagnosis to treatment, multi‐disciplinary meeting (MDM) presentation and supportive care screening. Redesign strategies targeted process sustainability through enhanced team capability. Methods This study engaged a prospective quality improvement cohort design targeting newly diagnosed tissue confirmed lung cancer with 6‐month pre‐intervention period and 6‐month redesign implementation period, between September 2016 and August 2017, evaluated using Interrupted Time Series Analysis. Hospital sites included three regional and two metropolitan hospitals in Victoria. QI redesign targeted time intervals from referral to first specialist appointment (FSA), referral to diagnosis, diagnosis to first treatment (any intent), MDM documented in medical records and Supportive Care Screening Tool documented in medical records. Results There was a marked reduction in referral to FSA interval across all sites, with median (interquartile range) falling from 6 (0–15) to 4 (1–10) days, and proportion seen by a specialist within 14 days increased from 74.3% to 84.2%. The interval between diagnosis and treatment was not substantively changed in the 6‐month implementation period. The proportion of subjects with documented presentation to the MDM increased from 61% to 67%. The proportion for which Supportive Care Screening documentation remained low at 26.3% post‐intervention. Conclusions Data‐driven redesign initiatives enable identification and analysis of clinical practice variation and may be utilised to enhance timeliness of cancer care and improve local data service capabilities. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article related to the surrogate decision making in patients.

Background: Pregnancy in women with pre‐gestational types 1 (T1DM) and 2 (T2DM) diabetes mellitus can be a clinical challenge. This study assessed the association between introducing a structured diabetes in pregnancy proforma, on the quality of medical record documentation and pregnancy outcomes in women with T1DM and T2DM. Aims: To evaluate the impact of a proforma on the quality of documenting medical records and pregnancy/neonatal outcomes in women with pre‐gestational diabetes. Methods: This was a retrospective two‐cycle audit: pre‐ and post‐proforma introduction. The documentation quality was assessed based on the rate of missing pre‐pregnancy/first trimester haemoglobin A1c (HbA1c), third trimester HbA1c, folate intake and dose, retinopathy and nephropathy progression. Changes in pregnancy outcomes were assessed by mode of delivery, preterm delivery, mean third trimester HbA1c, pre‐eclampsia and foetal outcomes. Results: The pre‐ and post‐proforma periods included 91 and 41 pregnancies, respectively. The quality of documentation improved in the post‐proforma phase with the rate of missing data declining from 63.4% to 36.6% (P = 0.005) for pre‐pregnancy/first trimester HbA1c, 30.8% to 12.2% (P = 0.009) for periconceptional folate intake, 42.9% to 14.6% (P = 0.001) for folate dose, 100% to 31.7% (P < 0.001) for retinopathy progression, 92.3% to 19.5% (P < 0.001) for nephropathy progression and 31.9% to 7.3% (P = 0.016) for third trimester HbA1c. Macrosomia significantly reduced in the second cycle (49% vs 21% P = 0.003). Conclusion: The quality of documentation improved significantly which is likely attributable to the implementation of the proforma. This study supports the use of structured documentation to reduce variation in care and potentially improve pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Background: Activity‐based funding (ABF) is a means of healthcare reimbursement, where hospitals are allocated funding based on the number and mix of clinical activity. The ABF model is based solely on Australian refined diagnosis‐related group (AR‐DRG) classifications of hospital encounters. Each AR‐DRG is allocated a weighted activity unit (WAU) translating to cost value to determine ongoing funding allocations for each hospital annually. Aim: We explored cost consequences of AR‐DRG coding variances within our Medical Oncology department over a 6‐month period. Methods: All inpatient encounters for medical oncology from 1 January to 30 June 2014 were identified and paired with actual AR‐DRG coding sheets submitted by the hospital coders. Inpatient charts were manually reviewed by a Medical Oncology Registrar to capture any changes or additional AR‐DRGs, which were subsequently evaluated for total WAU value variance. Applying 1 WAU = $4676 as per the 2014 Queensland model, cost consequences were calculated. Results: A total of 116 encounters was identified for 72 patients. Of 116 patients, 95 (81%) had additional diagnoses captured, leading to an AR‐DRG and WAU change in 26 encounters. The total reimbursement variance for this period was $143 404.07. Cost consequences resulted from: (i) use of abbreviations in clinical notes unable to be coded; and (ii) diagnoses not documented despite treatment delivered as per medication charts. Conclusion: Clinical note documentation ultimately determines the future funding of our healthcare system. Appropriate communication and education of medical staff and hospital coders are vital to ensure precise documentation and accurate AR‐DRG coding for optimal and appropriate reimbursement in this funding model. [ABSTRACT FROM AUTHOR]

Background: Australia has among the highest prevalence of Crohn disease and ulcerative colitis in the world. Management of the chronic gastrointestinal disorders results in significant societal costs and the standard of care is inconsistent across Australia. Aim: To audit the quality of care received by patients admitted for inflammatory bowel disease (IBD) across Australia against national IBD standards. Methods: A retrospective cross‐sectional survey and clinical audit was undertaken assessing organisational resources, clinical processes and outcome measures. This study was conducted in Australian hospitals that care for inpatients with Crohn disease or ulcerative colitis. The main outcome measures were adherence to national IBD standards and comparison of quality of care between hospitals with and without multidisciplinary IBD services. Results: A total of 71 hospitals completed the organisational survey. Only one hospital had a complete multidisciplinary IBD service and 17 had a partial IBD service (IBD nurse, helpline and clinical lead). A total of 1440 inpatient records was reviewed from 52 hospitals (mean age 37 years; 51% female, 53% Crohn disease), approximately 26% of IBD inpatient episodes over a 12‐month period in Australia. These patients were chronically unwell with high rates of anaemia (30%) and frequent readmissions (40% within 2 years). In general, care was inconsistent, and documentation was poor. Hospitals with a partial IBD service performed better in many processes and outcome measures: for example, 22% reduction in admissions through emergency departments and greater adherence to standards for safety monitoring of biological (89% vs 59%) and immunosuppressive drugs (79% vs 55%) in those hospitals than those without. Conclusion: Patients admitted to hospital suffering from IBD are young, chronically unwell and are subject to substantial variations in clinical documentation and quality of care. Only one hospital met accepted standards for multidisciplinary care; hospitals with even a minimal IBD service provided improved care. [ABSTRACT FROM AUTHOR]

Healthcare professionals have limited formal end‐of‐life care training despite the large proportion of hospital deaths. A retrospective review of 201 acute hospital deaths revealed 166 (82.6%) had documentation to suggest the patient was dying but this was performed late with a median time between documentation and death of 0.84 days. Furthermore, 132 (66%) patients received an intervention in the final 48 h of life. This highlights the need to improve the recognition and management of dying patients in acute hospitals. [ABSTRACT FROM AUTHOR]

Recently, the Australian Digital Health Agency launched MyHealth Record to the public. As of July 2019, 90.1% of Australians hold records with this service, allowing 16 400 health organisations access to >28 million clinical documents. The streamlining of patient data was intended to facilitate sharing of information and improve communication between medical providers, while promoting efficiency in clinical practice. We have identified a hitherto unrecognised application of this infrastructure in the identification and management of factitious disorder, a rare yet highly diagnostically challenging condition involving intentional feigning of illness, which presents a significant resource burden to the Australian health system. [ABSTRACT FROM AUTHOR]

Background The 'Acute Resuscitation Plan' ( ARP) is a document for recording the resuscitation plans of patients at a tertiary hospital for adult patients. The ARP was introduced at the hospital in September 2014, superseding the 'Not for Cardiopulmonary Resuscitation ( CPR)' form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits. Aim To evaluate the introduction of the ARP. Methods This study is a retrospective audit of the records of all admissions to the hospital from January to June 2014 (Not for CPR period) and January to June 2015 ( ARP period). The main outcomes are the incidence of resuscitation plans, the proportion of ARP specifying consultation with the patient (or representative) and with senior medical staff, and the proportion of ARP among older patients and those with significant comorbidity. Results Resuscitation plans were present for 453 of 23 325 (1.9%) admissions in the Not for CPR period versus 1801 of 24 037 (7.5%) in the ARP period (odds ratio ( OR) 4.1, 95% confidence interval ( CI) 3.7-4.5, P < 0.001). A total of 42% of ARP specified 'care of the dying' in the event of arrest. Acknowledgement of the views of the patient (or representative) was indicated on 37% of ARP and of a senior physician on 28%. An ARP was not present for 67% of patients aged ≥90 years, 59% from aged care, 90% with metastatic cancer and 64% aged ≥80 years and with a Charlson comorbidity index ≥3. Conclusions More patients had resuscitation plans after introducing the ARP. However, patients and senior physicians were often remote from the consultation process, and an ARP was not present for many patients likely to have a poor outcome from cardiopulmonary arrest. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article related to the wishes for surrogate decision-making in patients.

Background Discharge summaries remain a critical communication tool with primary care physicians. In a previous study of over 200 general medicine discharge summaries, we demonstrated that only 50% contain information regarding the indication and follow up required of any medicine changes on discharge. Aim In this follow up pilot study, we assess the role of feedback and token incentives in improving discharge documentation. Methods Over a 14-week period, we randomly audited a selection of discharge summaries on a fortnightly basis. The results of these audits were fed back to the junior medical staff who compiled these summaries. If over 80% of the audited discharge summaries adequately documented the indication, with required follow up for new medication changes, junior doctors were provided with a token, non-monetary incentive for their efforts. At the end of the study period, we then conducted a survey of the junior doctors involved and collected feedback regarding their impressions of the study. Results Over the study period, 722 discharge summaries were completed and eligible for analysis. Over this time, mean appropriate documentation regarding medicine indication improved by 32%, and follow-up documentation improved by 10%. Overall, the participants felt the interventions were beneficial and that they should be continued beyond the study period. Conclusions Education coupled with regular feedback and non-monetary incentives can potentially lead to improvements in the quality of discharge summaries. [ABSTRACT FROM AUTHOR]

Background In Australia, antimicrobial stewardship programmes are a compulsory component of hospital accreditation. Good documentation around anti-microbial prescribing aids communication and can improve prescribing practice in environments with multiple decision makers. Aim This study aims to develop and implement an intervention to improve antimicrobial prescribing practice in a 24-bed intensive care unit in a tertiary referral adult hospital. Methods We conducted a four-phase (observation, reflection, implementation, evaluation) prospective collaborative before-after quality improvement study. Baseline audits and surveys of antimicrobial prescribing practices identified barriers to and enablers of good prescribing practice. A customised intervention was then implemented over 6 weeks and included a yellow medication record sticker, quarterly education sessions and intensive care unit-specific empiric antimicrobial prescribing guidelines. Post-implementation, the effects were monitored by serial antimicrobial prescribing audits for 1 year. The primary outcomes were clear documentation of the start date, the planned stop date or review date and the indication for an antibiotic. These were all considered the 'minimum standards' for an antimicrobial prescription on the medication record. Results Documentation of minimum standards specifically addressed by the sticker improved (start date (72% to 90%, P < 0.001), stop date (16% to 63%, P < 0.001), antimicrobial indication documented on medication chart (58% to 83%, P < 0.01)). Overall, adherence to all three minimum standards (start date, stop date and indication) improved from 41/306 (13%) to 306/492 (63%) ( P < 0.001). One-year post-implementation, the yellow sticker had become embedded into daily practice. Conclusion A systematic approach to quality improvement combined with the implementation of a tailored, multi-faceted intervention can improve antimicrobial prescribing practices. [ABSTRACT FROM AUTHOR]

Background Within Australian hospitals, cardiac and respiratory arrests result in a resuscitation attempt unless the patient is documented as not for resuscitation. Aim To examine the consistency of policies and documentation for withholding in-hospital resuscitation across health services. Method An observational, qualitative review of hospital policy and documentation was conducted in June 2013 in three public and two private sector hospitals in metropolitan Melbourne. Not for resuscitation ( NFR) forms were evaluated for physical characteristics, content, authorisation and decision-making. Hospital policies were coded for alerts, definition of futility and burden of treatment and management of discussions and dissent. Results There was a lack of standardisation, with each site using its own unique NFR form and accompanying site-specific policies. Differences were found in who could authorise the decision, what was included on the form, the role of patients and families, and how discussions were managed and dissent resolved. Futility and burden of treatment were not defined independently. These inconsistencies across sites contribute to a lack of clarity regarding the decision to withhold resuscitation, and have implications for staff employed across multiple hospitals. Conclusions NFR forms should be reviewed and standardised so as to be clear, uniform and consistent with the legislative framework. We propose a two-stage process of documentation. Stage 1 facilitates discussion of patient-specific goals of care and consideration of limitations of treatment. Stage 2 serves to communicate a NFR order. Decisions to withhold resuscitation are inherently complex but could be aided by separating the decision-making process from the communication of the decision, resulting in improved end-of-life care. [ABSTRACT FROM AUTHOR]

Background/Aim The aim of this study was to describe the time and documentation needed to gain ethics and governance approvals in Australian states with and without a centralised ethical review system. Methods This is a prospective descriptive study undertaken between February 2012 and March 2015. Paediatric and adult hospitals ( n = 67) in Australian states were approached to allow the review of their medical records. Participants included 15- to 24-year-olds diagnosed with cancer between 2008 and 2012. The main outcomes measures were time (weeks) to approval for ethics and governance and the number and type of documents submitted. Results Centralised ethics approval processes were used in five states, with approval taking between 2 and 18 weeks. One state did not use a centralised process, with ethics approval taking a median of 4.5 weeks (range: 0-15) per site. In four states using a centralised ethics process, 33 governance applications were submitted, with 20 requiring a site clinician listed as an investigator. Governance applications required the submission of 11 documents on average, including a Site-Specific Assessment form. Thirty-two governance applications required original signatures from a median of 3.5 (range: 1-10) non-research persons, which took a median of 5 weeks (range: 0-15) to obtain. Governance approval took a median of 6 weeks (range: 1-45). Twelve research study agreements were needed, each taking a median of 7.5 weeks (range: 1-20) to finalise. Conclusion The benefits of centralised ethics review systems have not been realised due to duplicative, inflexible governance processes. A system that allowed the recognition of prior ethical approval and low-risk applications was more efficient than a central ethics and site-specific governance process. [ABSTRACT FROM AUTHOR]