Impact of a prospective feedback loop aimed at reducing non-beneficial treatments in older people admitted to hospital and potentially nearing the end of life. A cluster stepped-wedge randomised controlled trial.

Objectives: To investigate if a prospective feedback loop that flags older patients at risk of death can reduce non-beneficial treatment at end of life.

Design: Prospective stepped-wedge cluster randomised trial with usual care and intervention phases.

Setting: Three large tertiary public hospitals in south-east Queensland, Australia.

Process evaluation of a tailored nudge intervention to promote appropriate care and treatment of older patients at the end-of-life.

Background: Non-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) intervention was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop.

Impact of a prospective feedback loop on care review activities in older patients at the end of life. A stepped-wedge randomised trial.

Background: Hospitalisation rates for older people are increasing, with end-of-life care becoming a more medicalised experience. Innovative approaches are warranted to support early identification of the end-of-life phase, communicate prognosis, provide care consistent with people's preferences, and improve the use of healthcare resources. The Intervention for Appropriate Care and Treatment (InterACT) trial aimed to increase appropriate care and treatment decisions for older people at the end of life, through implementation of a prospective feedback loop.

Frailty, delirium and hospital mortality of older adults admitted to intensive care: the Delirium (Deli) in ICU study.

Background: Clinical frailty among older adults admitted to intensive care has been proposed as an important determinant of patient outcomes. Among this group of patients, an acute episode of delirium is also common, but its relationship to frailty and increased risk of mortality has not been extensively explored. Therefore, the aim of this study was to explore the relationship between clinical frailty, delirium and hospital mortality of older adults admitted to intensive care.

The concept of frailty in intensive care.

Our population is ageing, and this is also reflected in the ageing of the hospital and intensive care population. Along with ageing, there is also an increase in age-related chronic health conditions or comorbidities, which in turn affects the patient's functional state. There is an increasing need to describe a patient's clinical condition in terms of their functional capacity, such as frailty.

Chlorhexidine bathing and health care-associated infections among adult intensive care patients: a systematic review and meta-analysis.

Background: Health care-associated infections (HAI) have been shown to increase length of stay, the cost of care, and rates of hospital deaths (Kaye and Marchaim, J Am Geriatr Soc 62(2):306-11, 2014; Roberts and Scott, Med Care 48(11):1026-35, 2010; Warren and Quadir, Crit Care Med 34(8):2084-9, 2006; Zimlichman and Henderson, JAMA Intern Med 173(22):2039-46, 2013). Importantly, infections acquired during a hospital stay have been shown to be preventable (Loveday and Wilson, J Hosp Infect 86:S1-70, 2014). In particular, due to more invasive procedures, mechanical ventilation, and critical illness, patients cared for in the intensive care unit (ICU) are at greater risk of HAI and associated poor outcomes.

Incidence and mortality of postoperative sepsis in New South Wales, Australia, 2002-2009.

Objective: To describe the incidence and mortality of postoperative sepsis in New South Wales, Australia.

Design, Setting And Participants: A retrospective study of adult elective surgical admissions (n = 229 918) in 82 public acute care hospitals in NSW, 2002-2009.

Main Outcome Measures: Changes in the incidence rate of post-operative sepsis and sepsis-related mortality.

Patient safety and rapid response systems.

Attention was drawn to the safety of patients in acute care hospitals in the early 1990s when studies found large numbers of potentially preventable deaths. Errors were initially ascribed to individual doctors and nurses, but later it was recognised that errors were mainly related to failure of systems rather than individuals. Mortality is not necessarily a good measure of hospital safety.

Rapid response systems.

Rapid response systems (RRSs) are one of the first organisation-wide, patient-focused systems to be developed to prevent potentially avoidable deaths and serious adverse events such as cardiac arrests. RRSs identify seriously ill and at-risk patients and those whose condition is deteriorating, using abnormal vital signs and observations that trigger an urgent response by staff who are able to deal with any medical emergency. RRS teams also respond to staff concern--any bedside nurse or doctor who is concerned about his or her patient can seek assistance.

Geographic variation of failure-to-rescue in public acute hospitals in New South Wales, Australia.

Despite the wide acceptance of Failure-to-Rescue (FTR) as a patient safety indicator (defined as the deaths among surgical patients with treatable complications), no study has explored the geographic variation of FTR in a large health jurisdiction. Our study aimed to explore the spatiotemporal variations of FTR rates across New South Wales (NSW), Australia. We conducted a population-based study using all admitted surgical patients in public acute hospitals during 2002-2009 in NSW, Australia.

Rate of venous thromboembolism among surgical patients in Australian hospitals: a multicentre retrospective cohort study.

Objectives: Despite the burden of venous thromboembolism (VTE) among surgical patients on health systems in Australia, data on VTE incidence and its variation within Australia are lacking. We aim to explore VTE and subsequent mortality rates, trends and variations across Australian acute public hospitals.

Setting: A large retrospective cohort study using all elective surgical patients in 82 acute public hospitals during 2002-2009 in New South Wales, Australia.

Do large-scale hospital- and system-wide interventions improve patient outcomes: a systematic review.

Background: While health care services are beginning to implement system-wide patient safety interventions, evidence on the efficacy of these interventions is sparse. We know that uptake can be variable, but we do not know the factors that affect uptake or how the interventions establish change and, in particular, whether they influence patient outcomes. We conducted a systematic review to identify how organisational and cultural factors mediate or are mediated by hospital-wide interventions, and to assess the effects of those factors on patient outcomes.

Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion.

Objectives: To understand the changes in the population incidence of inhospital cardiopulmonary arrest (IHCA) and mortality associated with the introduction of rapid response systems (RRSs).

Design, Setting And Participants: Population-based study of 9 221 138 hospital admissions in 82 public acute hospitals in New South Wales, using data linked to a death registry, from 1 Jan 2002 to 31 Dec 2009.

Main Outcome Measures: Changes in IHCA, IHCA-related mortality, hospital mortality and proportion of IHCA patients surviving to hospital discharge.

'Between the flags': implementing a rapid response system at scale.

While many hospitals are implementing rapid response systems (RRSs) to attend to deteriorating patients in a systematic way, there is little documented evidence on system-wide approaches to adopting RRSs. Here, we report on an initiative which enrolled 220 hospitals in New South Wales, Australia. The 'between the flags' approach was modelled on Australia's surf lifesaving experience, where qualified lifesavers perform thousands of rescues each year.

Access block and ED overcrowding.

Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20-30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand.