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Background Frailty is common among acute hospital patients and might adversely affect recovery from inpatient cardiac arrest. Aim To assess the relationship between hospital admission characteristics, including frailty, and discharge outcome after in-hospital cardiac arrest. Methods Prospectively collected data were retrospectively analysed for all separations from a tertiary hospital during 2008-2017 that involved rapid response team attendance for cardiac arrest. Hospital Frailty Risk Score (HFRS) and Charlson index of comorbidity were calculated from 'primary' and 'associated' International Classification of Diseases, 10th revision, Australian Modification diagnoses. HFRS ≥5 was taken to signify frailty. Discharge home from hospital and death in hospital were modelled using logistic regression. Results There were 388 in-hospital arrest patients: 91% were aged ≥50 years, 34% were previously discharged in the past 6 months, 66% were unplanned admissions, 63% were non-cardiology-cardiothoracic admissions, 45% had a Charlson comorbidity index ≥2 and 19% were identified as frail. Discharge home occurred in 22%, discharge to another hospital 17% and death 62%. Of the frail patients, only 3 (4%) were discharged home, 12 (17%) were discharged to another hospital and 57 (79%) died in hospital. Fewer frail patients were discharged home compared with non-frail patients (4 vs 26%; odds ratio (OR) 0.13, P = 0.001). On multivariable analysis, patients were less likely to be discharged home if they had frailty (OR 0.24, P = 0.02), age ≥ 50 years (OR 0.36, P = 0.01), non-cardiology-cardiothoracic unit admission (OR 0.40, P = 0.001) and unplanned admission (OR 0.57, P = 0.04). Frail patients discharged to another hospital spent a median of 15 days (interquartile range 11-23) in the hospital post-arrest before leaving to continue inpatient care elsewhere. Frailty was associated with death in hospital on univariate analysis (79 vs 58%; OR 2.80, P = 0.001) but not after controlling for other factors. Conclusion Frail patients are unlikely to make a good recovery after in-hospital arrest. This should be taken into account when planning care with patients and their families.

BACKGROUND: Diabetic ketoacidosis (DKA) is an acute life-threatening metabolic complication of diabetes that imposes substantial burden on our healthcare system. There is a paucity of published data in Australia assessing factors influencing time to resolution of DKA and length of stay (LOS). AIMS: To identify factors that predict a slower time to resolution of DKA in adults with diabetes. METHODS: Retrospective audit of patients admitted to St Vincent's Hospital Melbourne between 2010 to 2014 coded with a diagnosis of 'Diabetic Ketoacidosis'. The primary outcome was time to resolution of DKA based on normalisation of biochemical markers. Episodes of DKA within the wider Victorian hospital network were also explored. RESULTS: Seventy-one patients met biochemical criteria for DKA; median age 31 years (26-45 years), 59% were male and 23% had newly diagnosed diabetes. Insulin omission was the most common precipitant (42%). Median time to resolution of DKA was 11 h (6.5-16.5 h). Individual factors associated with slower resolution of DKA were lower admission pH (P < 0.001) and higher admission serum potassium level (P = 0.03). Median LOS was 3 days (2-5 days), compared to a Victorian state-wide LOS of 2 days. Higher comorbidity scores were associated with longer LOS (P < 0.001). CONCLUSIONS: Lower admission pH levels and higher admission serum potassium levels are independent predictors of slower time to resolution of DKA. This may assist to stratify patients with DKA using markers of severity to determine who may benefit from closer monitoring and to predict LOS.

Objectives To evaluate the introduction of a document for recording the resuscitation plans of patients at a tertiary hospital. The ‘Acute Resuscitation Plan’ (ARP) was introduced 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. Design Retrospective audit of the records of all admissions to the hospital from January-June 2014 (Not for CPR period) and January-June 2015 (ARP period). Main outcomes Incidence of resuscitation plans; proportion of ARPs specifying consultation with the patient (or representative) and with senior medical staff and; proportion of ARPs among older patients and those with significant comorbidity. Results Resuscitation plans were present for 453/23,325 (1.9%) admissions in the Not for CPR period vs. 1,801/24,037 (7.5%) in the ARP period (OR 4.1, 95%CI 3.7-4.5, P

Opioid prescriptions have significantly increased in recent years and are used for a wide variety of indications. Electronic medical records of 45 patients who received naloxone by a rapid response team over an 18-month period were retrospectively reviewed. This study found inconsistencies in the management of possible opioid toxicity with variation in the total naloxone dose and number of doses administered. This highlights the importance of a standardised protocol for recognition and management of opioid overdose.

Background and Aim We have previously found high incidence of inflammatory bowel disease (IBD) in Australia. A population-based registry was established to assess disease severity, frequency of complications, and prognostic factors. Methods Incident cases were prospectively identified over 4 years. Early disease severity was assessed according to need for hospitalization and resective surgery and medication use. Results We report on the early outcomes (median 18 months, range 12–60 months) for 252 patients comprising 146 with Crohn's disease (CD), 96 with ulcerative colitis (UC), and 10 IBD undifferentiated. Eighty-seven percent of CD patients had inflammatory disease at diagnosis, and this reduced to 73% at 5 years (n = 38). Immunomodulators were prescribed in 57% of CD patients and 19% with UC. A third of all CD patients were hospitalized, the majority (77%) in the first 12 months. Risk factors for hospitalization included penetrating, perianal, and ileocolonic disease (P

Background The background of the study is a comparison of risk-adjusted mortality across hospitals from different jurisdictions is now common worldwide. Aim To examine temporal trends in risk-adjusted mortality in Victoria over the last decade. Methods Retrospective cohort study of 6.89 million adult (>14 years) patient episodes from 23 major Victorian public hospitals between 1999 and 2009. The primary outcome was in-hospital death. Three measures were calculated: the crude mortality rate, risk-adjusted mortality rate and standardised mortality ratio (SMR). The Hospital Outcome Prediction Equation (HOPE) was applied to generate estimates of predicted mortality that were used to compute the SMR and risk-adjusted mortality rates. The HOPE model includes 26 exogenous risk factors for which providers have no influence. The model was calibrated using the 2004–2005 data. Temporal mortality trends from 1999–2009 were evaluated using negative binomial regression for crude mortality and SMR estimates and random-intercept hierarchical logistic regression for risk-adjusted mortality. Results The study population included 84 423 in-hospital deaths (1.2%). Crude mortality risk declined from 1.5% in 2000 to 1.1% in 2005–2009 (incidence rate ratio (IRR): 0.96; 95% confidence interval (CI): 0.95–0.97; P < 0.001). There were 1.39 million episodes in the HOPE calibration cohort. Between 1999 and 2009, the SMR decreased from 1.4 to 0.9 (IRR = 0.91; 95% CI: 0.90–0.97; P < 0.001) and adjusted mortality risk declined from 2.1% to 0.9% (odds ratio = 0.94, 95% CI: 0.94–0.94, P < 0.001). Declining mortality trends were evident in the tertiary, metropolitan and regional peer groups (P < 0.001). Conclusion Analysis of in-hospital risk-adjusted mortality trends using the HOPE model indicates significant improvement in patient outcomes in the State of Victoria over the past decade.

BACKGROUND: Bleeding into the chest is a life-threatening complication of cardiac surgery. Blood transfusion has been implicated as an important cause of harm associated with bleeding, based largely on studies demonstrating an independent association between transfusion and mortality. These studies did not, however, consider the possibility that bleeding may in itself be harmful, inasmuch as drains are inefficient at clearing blood from the chest and retained blood may compromise cardiac and lung function. STUDY DESIGN AND METHODS: We undertook a multivariate logistic regression analysis of the risk factors associated with mortality in 2599 consecutive patients undergoing cardiac surgery. Unlike previous studies the risk factors examined included the volume of chest tube drainage at 24 hours. A stratified analysis was also undertaken that compared the adjusted risk of death for patients exposed or not exposed to a postoperative blood transfusion. RESULTS: Blood transfusion was not an independent predictor of mortality (p = 0.4). Chest tube drainage was the strongest independent predictor of mortality (p

Background: The aim of this study was to validate a risk-adjusted hospital outcome prediction equation (HOPE) using a statewide administrative dataset. Methods: Retrospective observational study using multivariate logistic regression modelling. Calibration and discrimination were assessed by standardized mortality ratio (SMR), area under the receiver operating characteristic plot (ROC AUC), Hosmer–Lemeshow contingency tables and goodness-of-fit statistic in an independent dataset, and in all 23 important tertiary, metropolitan and regional hospitals. The dependent variable was in-hospital death. All consecutive adult hospital separations between 1 July 2004 and 30 June 2006, excluding obstetric and day-case only admissions, from all acute health services within the State of Victoria, Australia were included. Results: A total of 379 676 consecutive records (1 July 2004 to 30 June 2005) was used to derive the HOPE model. Six variables (age, male sex, admission diagnosis, emergency admission, aged-care resident and inter-hospital transfer) were selected for inclusion in the final model. It was validated in the 384 489 consecutive records from the following year (1 July 2005 to 30 June 2006). The 95% confidence interval for the SMR was 0.98–1.02, and for the ROC AUC, 0.87–0.88. Discrimination and (one or more) calibration criteria were achieved in 22 (96%) of the 23 hospitals. Conclusion: The HOPE model is a simple risk-adjusted outcome prediction tool, based on six variables from data that are routinely collected for administrative purposes and appears to be a reliable predictor of hospital outcome.

BACKGROUND AND OBJECTIVE Salbutamol (SAL) has systemic effects that may adversely influence ventilation in asthmatic patients. The authors sought to determine the magnitude of this effect and mechanisms by which i.v. SAL affects ventilation. METHODS A prospective study of nine healthy subjects (eight men, one woman; age 23 +/- 1.4 years (SD)) was undertaken. Each subject received i.v. SAL at 5, 10 and 20 microg/min each for 30 min at each dose and was observed for 1 h post infusion. Minute ventilation ((VE)), oxygen consumption (VO(2)), CO(2) production (VCO(2)), occlusion pressure (P(0.1)), heart rate, blood pressure, respiratory rate, glucose, arterial blood gases, lactate and potassium (K(+)) were recorded at baseline and at 30-min intervals. The effect of 100% oxygen on (VE) and P(0.1) during SAL infusion at 20 microg/min was observed. Results are expressed as mean +/- SEM. RESULTS V(E) was significantly increased at 20 microg/min SAL (37.8 +/- 12.1%, P = 0.01), as were VO(2) (22.5 +/- 5.1%, P < 0.01) and VCO(2) (40.9 +/- 10.6%, P < 0.01). Ventilation was in excess of metabolic needs as demonstrated by a rise in the respiratory exchange ratio (0.87 +/- 0.03 to 0.99 +/- 0.04, P < 0.05). Serum lactate rose by 124 +/- 30.4% from baseline to 20 microg/min (1.1 +/- 0.1 to 2.3 +/- 0.25 mmol/L, P < 0.01) and base excess decreased (0.89 +/- 0.56 to vs. -1.75 +/- 0.52 mmol/L, P < 0.01) consistent with a lactic acidosis contributing to the excess ventilation. There was no significant differences in (VE) or P(0.1) with F(I)O(2) = 1.0, suggesting peripheral chemoreceptor stimulation was not responsible for the rise in (VE). At 20 microg/min SAL, K(+) fell significantly from baseline (3.8 +/- 0.06 to 2.8 +/- 0.09 mmol/L, P < 0.001). CONCLUSION Systemic SAL imposes ventilatory demands by increasing metabolic rate and serum lactate. This may adversely affect patients with severe asthma with limited ventilatory reserve.

Background: Hepatitis C virus (HCV) infection is a significant problem in the Australian community. Over the past few years, the number of patients with diagnosed hepatitis C has increased greatly. The aims of the present study were to define the clinical features of a large group of patients with chronic HCV infection and to examine changes occurring in the referral base and epidemiological characteristics of this group since analysis of the first 342 patients in 1994. Methods: The study included 1546 consecutive anti-HCV-positive patients who had been referred to St Vincent's Hospital from January 1990 to June 1998. Clinical and laboratory data were collected on all patients. Results: Referrals from general practitioners increased from 31% to 70% of all patients between 1990–1993 and 1994–1998. A history of injecting drug use (IDU) was present in 64% of the patients. While 89% of the IDU group was Australasian born, 49% of those in the sporadic group were born overseas. Cirrhosis was found in 18% of biopsied patients. Age, infection duration, age at infection, Mediterranean or Asian origin and a history of transfusion or lack of HCV risk factors were associated with cirrhosis on univariate analysis. Patient age was the only independent predictor of cirrhosis. Conclusion: The majority of patients with HCV are diagnosed in general practice. A risk factor for infection is identified in 82% of patients. While our reported prevalence of cirrhosis may be an overestimate of that in the overall HCV community, the ultimate disease burden is likely to be significant. (Intern Med J 2001; 31: 90–96)