Guidelines and statements

Introduction: Type 1 diabetes presents significant challenges for optimal management. Despite intensive glycaemic control being the standard of care for several decades, glycaemic targets are infrequently achieved and the burden of complications remains high. Therefore, the advancement of diabetes management technologies has a major role in reducing the clinical and economic impact of the disease on people living with type 1 diabetes and on health care systems. However, a national framework is needed to ensure equitable and sustainable implementation of these technologies as part of holistic care. Main recommendations: This consensus statement considers technologies for insulin delivery, glucose sensing and insulin dose advice that are commercially available in Australia. While international position statements have provided recommendations for technology implementation, the ADS/ADEA/APEG/ADIPS Working Group believes that focus needs to shift from strict trial‐based glycaemic criteria towards engagement and individualised management goals that consider the broad spectrum of benefits offered by technologies. Changes in management as result of this statement: This Australian consensus statement from peak national bodies for the management of diabetes across the lifespan outlines a national framework for the optimal implementation of technologies for people with type 1 diabetes. The Working Group highlights issues regarding equity of access to technologies and services, scope of clinical practice, credentialling and accreditation requirements, regulatory issues with “do‐it‐yourself” technology, national benchmarking, safety reporting, and ongoing patient advocacy.

Anthony J Pease · Sofianos Andrikopoulos · Mary B Abraham · Maria E Craig · Brett Fenton · Jane Overland · Sarah Price · David Simmons · Glynis P Ross

Introduction: The Australian Council on Healthcare Standards (ACHS) sponsored an expert‐led, consensus‐driven, four‐stage process, based on a modified Delphi methodology, to determine a set of clinical indicators as quality measures of cancer service provision in Australia. This was done in response to requests from institutional health care providers seeking accreditation, which were additional and complementary to the existing radiation oncology set. The steering group members comprised multidisciplinary key opinion leaders and a consumer representative. Five additional participants constituted the stakeholder group, who deliberated on the final indicator set. Methods and recommendations: An initial meeting of the steering group scoped the high level nature of the desired set. In stage 2, 65 candidate indicators were identified by a literature review and a search of international metrics. These were ranked by survey, based on ease of data accessibility and collectability and clinical relevance. The top 27 candidates were debated by the stakeholder group and culled to a final set of 16 indicators. A user manual was created with indicators mapped to clinical codes. The indicator set was ratified by the Clinical Oncology Society of Australia and is now available for use by health care organisations participating in the ACHS Clinical Indicator Program. This inaugural cancer clinical indicator set covers high level assessment of various critical processes in cancer service provision in Australia. Regular reviews and updates will ensure usability. Changes in management as a result of this statement: This is the inaugural indicator set for cancer care for use across Australia and internationally under the ACHS Clinical Indicator Program. Multidisciplinary involvement through a modified Delphi process selected indicators representing both generic and specific aspects of care across the cancer journey pathway and will provide a functional tool to compare health care delivery across multiple settings. It is anticipated that this will drive continual improvement in cancer care provision.

Eva Segelov · Christine Carrington · Sanchia Aranda · David Currow · John R Zalcberg · Alexander G Heriot · Linda Mileshkin · John Coutsouvelis · Jeremy L Millar · Brian T Collopy · Jon D Emery · Phoebe Zhang · Simon Cooper · Carmel O’Kane · Janet Wale · Stephen J Hancock · Anthony Sulkowski · John Bashford

The use of coronary artery calcium scoring can assist in defining risk in the primary prevention of cardiovascular disease in Australia.

Garry LR Jennings · Ralph Audehm · Warrick Bishop · Clara K Chow · Siaw-Teng Liaw · Danny Liew · Sara M Linton

Introduction: The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main recommendations: We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions. Changes in management as a result of the guidelines: A GRADE approach is used. Targeted recommendations for both high and low risk children. New tympanostomy tube otorrhoea section. New Priority 5 for health services: annual and catch‐up ear health checks for at‐risk children. Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children. Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration. Concurrent audiology and surgical referrals are recommended where delays are likely. Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis. The use of autoinflation devices is recommended for some children with persistent otitis media with effusion. Definitions for mild (21–30 dB) and moderate (> 30 dB) hearing impairment have been updated. New “OMapp” enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

Amanda J Leach · Peter S Morris · Harvey LC Coates · Sandra Nelson · Stephen J O'Leary · Peter C Richmond · Hasantha Gunasekera · Samantha Harkus · Kelvin Kong · Christopher G Brennan‐Jones · Sam Brophy‐Williams · Kathy Currie · Sumon K Das · David Isaacs · Katherine Jarosz · Deborah Lehmann · Jarod Pak · Hemi Patel · Chris Perry · Jennifer S Reath · Jessica Sommer · Paul J Torzillo

Introduction: Hepatocellular carcinoma (HCC) is a leading cause of cancer deaths both globally and in Australia. Surveillance for HCC in at‐risk populations allows diagnosis at an early stage, when potentially curable. However, most Australians diagnosed with HCC die of the cancer or of liver disease. In the changing landscape of HCC management, unique challenges may lead to clinical practice variation. As a result, there is a need to identify best practice management of HCC in an Australian context. This consensus statement has been developed for health professionals involved in the care of adult patients with HCC in Australia. It is applicable to specialists, general medical practitioners, nurses, health coordinators and hospital administrators. Methods and recommendations: This statement has been developed by specialists in hepatology, radiology, surgery, oncology, palliative care, and primary care, including medical practitioners and nurses. The statement addresses four main areas relevant to HCC management: epidemiology and incidence, diagnosis, treatment, and patient management. A modified Delphi process was used to reach consensus on 31 recommendations. Principal recommendations include the adoption of surveillance strategies, use of multidisciplinary meetings, diagnosis, treatment options and patient management. Changes in management as a result of this statement: This consensus statement will simplify HCC patient management and reduce clinical variation. Ultimately, this should result in better outcomes for patients with HCC.

John S Lubel · Stuart K Roberts · Simone I Strasser · Alexander J Thompson · Jennifer Philip · Mark Goodwin · Stephen Clarke · Darrell HG Crawford · Miriam T Levy · Nick Shackel

Introduction: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) cause significant morbidity and premature mortality among Australian Aboriginal and Torres Strait Islander peoples. RHDAustralia has produced a fully updated clinical guideline in response to new knowledge gained since the 2012 edition. The guideline aligns with major international ARF and RHD practice guidelines from the American Heart Association and World Heart Federation to ensure best practice. The GRADE system was used to assess the quality and strength of evidence where appropriate.Main recommendations: The 2020 Australian guideline details best practice care for people with or at risk of ARF and RHD. It provides up‐to‐date guidance on primordial, primary and secondary prevention, diagnosis and management, preconception and perinatal management of women with RHD, culturally safe practice, provision of a trained and supported Aboriginal and Torres Strait Islander workforce, disease burden, RHD screening, control programs and new technologies.Changes in management as a result of the guideline: Key changes include updating of ARF and RHD diagnostic criteria; change in secondary prophylaxis duration; improved pain management for intramuscular injections; and changes to antibiotic regimens for primary prevention. Other changes include an emphasis on provision of culturally appropriate care; updated burden of disease data using linked register and hospitalisations data; primordial prevention strategies to reduce streptococcal infection addressing household overcrowding and personal hygiene; recommendations for population‐based echocardiographic screening for RHD in select populations; expanded management guidance for women with RHD or ARF to cover contraception, antenatal, delivery and postnatal care, and to stratify pregnancy risks according to RHD severity; and a priority classification system for presence and severity of RHD to align with appropriate timing of follow‐up.

Anna P Ralph · Sara Noonan · Vicki Wade · Bart J Currie

Introduction: Coronavirus disease 2019 (COVID‐19) is a contagious disease that is caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Health care workers are at risk of infection from aerosolisation of respiratory secretions, droplet and contact spread. There are a number of procedures that represent a high risk of aerosol generation during cardiothoracic surgery. It is important that adequate training, equipment and procedures are in place to reduce that risk. Recommendations: We provide a number of key recommendations, which reduce the risk of aerosol generation during cardiothoracic surgery and help protect patients and staff. These include general measures such as patient risk stratification, appropriate use of personal protective equipment, consideration to delay surgery in positive patients, and careful attention to theatre planning and preparation. There are also recommended procedural interventions during airway management, transoesophageal echocardiography, cardiopulmonary bypass, chest drain management and specific cardiothoracic surgical procedures. Controversies exist regarding the management of low risk patients undergoing procedures at high risk of aerosol generation, and recommendations for these patients will change depending on the regional prevalence, risk of community transmission and the potential for asymptomatic patients attending for these procedures. Changes in management as a result of this statement: This statement reflects changes in management based on expert opinion, national guidelines and available evidence. Our knowledge with regard to COVID‐19 continues to evolve and with this, guidance may change and develop. Our colleagues are urged to follow national guidelines and institutional recommendations regarding best practices to protect their patients and themselves. Endorsed by: Australian and New Zealand Society of Cardiac and Thoracic Surgeons and the Anaesthetic Continuing Education Cardiac Thoracic Vascular and Perfusion Special Interest Group.

Joanne F Irons · Warren Pavey · Jayme S Bennetts · Emily Granger · Elli Tutungi · Aubrey Almeida

Introduction: The coronavirus 2019 disease (COVID‐19) pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Pre‐existing cardiovascular disease (CVD) increases the morbidity and mortality of COVID‐19, and COVID‐19 itself causes serious cardiac sequelae. Strategies to minimise the risk of viral transmission to health care workers and uninfected cardiac patients while prioritising high quality cardiac care are urgently needed. We conducted a rapid literature appraisal and review of key documents identified by the Cardiac Society of Australia and New Zealand Board and Council members, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, and key cardiology, surgical and public health opinion leaders. Main recommendations: Common acute cardiac manifestations of COVID‐19 include left ventricular dysfunction, heart failure, arrhythmias and acute coronary syndromes. The presence of underlying CVD confers a five‐ to tenfold higher case fatality rate with COVID‐19 disease. Special precautions are needed to avoid viral transmission to this population at risk. Adaptive health care delivery models and resource allocation are required throughout the health care system to address this need. Changes in management as a result of this statement: Cardiovascular health services and cardiovascular health care providers need to recognise the increased risk of COVID‐19 among CVD patients, upskill in the management of COVID‐19 cardiac manifestations, and reorganise and innovate in service delivery models to meet demands. This consensus statement, endorsed by the Cardiac Society of Australia and New Zealand, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, the National Heart Foundation of Australia and the High Blood Pressure Research Council of Australia summarises important issues and proposes practical approaches to cardiovascular health care delivery to patients with and without SARS‐CoV‐2 infection.

Sarah Zaman · Andrew I MacIsaac · Garry LR Jennings · Markus P Schlaich · Sally C Inglis · Ruth Arnold · Saurabh Kumar · Liza Thomas · Sudhir Wahi · Sidney Lo · Carolyn Naismith · Stephen J Duffy · Stephen J Nicholls · Andrew Newcomb · Aubrey A Almeida · Selwyn Wong · Mayanna Lund · Derek P Chew · Leonard Kritharides · Clara K Chow · Ravinay Bhindi

Although infection risks posed by COVID-19 influence all aspects of adult cardiac arrest management, the basic principles of resuscitation remain the same

Simon Craig · Mya Cubitt · Ashish Jaison · Steven Troupakis · Natalie Hood · Christina Fong · Adnan Bilgrami · Peter Leman · Juan Carlos Ascencio‐Lane · Guruprasad Nagaraj · John Bonning · Gabriel Blecher · Rob Mitchell · Ellen Burkett · Sally M McCarthy · Amanda M Rojek · Kim Hansen · Helen Psihogios · Peter Allely · Simon Judkins · Lai Heng Foong · Stephen Bernard · Peter A Cameron

The incidence of paediatric type 2 diabetes has increased in Australasia parallel to paediatric obesity and international guidelines available do not address the specifics for high risk ethnic groups

Alexia S Peña · Jacqueline A Curran · Michelle Fuery · Catherine George · Craig A Jefferies · Kristine Lobley · Karissa Ludwig · Ann M Maguire · Emily Papadimos · Aimee Peters · Fiona Sellars · Jane Speight · Angela Titmuss · Dyanne Wilson · Jencia Wong · Caroline Worth · Rachana Dahiya

Advice for clinicians managing patients with cancer during the pandemic

Robert Weinkove · Zoe K McQuilten · Jonathan Adler · Meera R Agar · Emily Blyth · Allen C Cheng · Rachel Conyers · Gabrielle M Haeusler · Claire Hardie · Christopher Jackson · Steven W Lane · Tom Middlemiss · Peter Mollee · Stephen P Mulligan · David Ritchie · Myra Ruka · Benjamin Solomon · Jeffrey Szer · Karin A Thursky · Erica M Wood · Leon J Worth · Michelle K Yong · Monica A Slavin · Benjamin W Teh

Introduction: This statement was planned on 11 March 2020 to provide clinical guidance and aid staff preparation for the coronavirus disease 2019 (COVID‐19) pandemic in Australia and New Zealand. It has been widely endorsed by relevant specialty colleges and societies. Main recommendations: Generic guidelines exist for the intubation of different patient groups, as do resources to facilitate airway rescue and transition to the “can't intubate, can't oxygenate” scenario. They should be followed where they do not contradict our specific recommendations for the COVID‐19 patient group. Consideration should be given to using a checklist that has been specifically modified for the COVID‐19 patient group. Early intubation should be considered to prevent the additional risk to staff of emergency intubation and to avoid prolonged use of high flow nasal oxygen or non‐invasive ventilation. Significant institutional preparation is required to optimise staff and patient safety in preparing for the airway management of the COVID‐19 patient group. The principles for airway management should be the same for all patients with COVID‐19 (asymptomatic, mild or critically unwell). Safe, simple, familiar, reliable and robust practices should be adopted for all episodes of airway management for patients with COVID‐19. Changes in management as a result of this statement: Airway clinicians in Australia and New Zealand should now already be involved in regular intensive training for the airway management of the COVID‐19 patient group. This training should focus on the principles of early intervention, meticulous planning, vigilant infection control, efficient processes, clear communication and standardised practice.

David J Brewster · Nicholas Chrimes · Thy BT Do · Kirstin Fraser · Christopher J Groombridge · Andy Higgs · Matthew J Humar · Timothy J Leeuwenburg · Steven McGloughlin · Fiona G Newman · Chris P Nickson · Adam Rehak · David Vokes · Jonathan J Gatward

Cardiovascular disease (CVD) is a leading cause of preventable morbidity and mortality in Aboriginal and Torres Strait Islander peoples. This statement from the Australian Chronic Disease Prevention Alliance, the Royal Australian College of General Practitioners, the National Aboriginal Community Controlled Health Organisation and the Editorial Committee for Remote Primary Health Care Manuals communicates the latest consensus advice of guideline developers, aligning recommendations on the age to commence Aboriginal and Torres Strait Islander CVD risk assessment across three guidelines. Main recommendations: In Aboriginal and Torres Strait Islander peoples without existing CVD: CVD risk factor screening should commence from the age of 18 years at the latest, including for blood glucose level or glycated haemoglobin, estimated glomerular filtration rate, serum lipids, urine albumin to creatinine ratio, and other risk factors such as blood pressure, history of familial hypercholesterolaemia, and smoking status. Individuals aged 18–29 years with the following clinical conditions are automatically conferred high CVD risk: ▶type 2 diabetes and microalbuminuria; ▶moderate to severe chronic kidney disease; ▶systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg; ▶familial hypercholesterolaemia; or ▶serum total cholesterol > 7.5 mmol/L. Assessment using the National Vascular Disease Prevention Alliance absolute CVD risk algorithm should commence from the age of 30 years at the latest — consider upward adjustment of calculated CVD risk score, accounting for local guideline use, risk factor and CVD epidemiology, and clinical discretion. Assessment should occur as part of an annual health check or opportunistically. Subsequent review should be conducted according to level of risk. Changes in management as a result of this statement: From age 18 years (at the latest), Aboriginal and Torres Strait Islander adults should undergo CVD risk factor screening, and from age 30 years (at the latest), they should undergo absolute CVD risk assessment using the NVDPA risk algorithm.

Jason W Agostino · Deborah Wong · Ellie Paige · Vicki Wade · Cia Connell · Maureen E Davey · David P Peiris · Dana Fitzsimmons · C Paul Burgess · Ray Mahoney · Emma Lonsdale · Peter Fernando · Leone Malamoo · Sandra Eades · Alex Brown · Garry Jennings · Raymond W Lovett · Emily Banks

Since the publication of the previous guidelines in 2015, further evidence has emerged that has led to a change in management of paracetamol poisoning

Angela L Chiew · David Reith · Adam Pomerleau · Anselm Wong · Katherine Z Isoardi · Jessamine Soderstrom · Nicholas A Buckley

Increasing numbers of TGD individuals are seeking health care in Australia; new guidelines will help clinicians provide appropriate gender-affirming care

Ada S Cheung · Katie Wynne · Jaco Erasmus · Sally Murray · Jeffrey D Zajac

Management should be individualised, using a multidisciplinary approach

Mathis Grossmann · Sabashini K Ramchand · Frances Milat · Amanda Vincent · Elgene Lim · Mark A Kotowicz · Jill Hicks · Helena J Teede

New Australian clinical practice guideline recommendations to assist GPs with the diagnosis and management of work-related mental health conditions

Danielle Mazza · Samantha P Chakraborty · Bianca Brijnath · Heather Nowak · Cate Howell · Trevor Brott · Michelle Atchison · David Gras · Justin Kenardy · Richard Buchanan · Seyram Tawia

These are the first Australasian recommendations for diagnosis and management of HIT, with a focus on locally available diagnostic assays and therapeutic options

Joanne Joseph · David Rabbolini · Anoop K Enjeti · Emmanuel Favaloro · Marie‐Christine Kopp · Simon McRae · Leonardo Pasalic · Chee Wee Tan · Christopher M Ward · Beng H Chong

Testing for hepatitis B in all patients with haematological and solid tumour malignancies, and prophylactic treatment in for people with chronic HBV or past exposure to HBV, is recommended to avoid HBV reactivation during cancer therapy

Joseph Doyle · Michelle Raggatt · Monica Slavin · Sue‐Anne McLachlan · Simone I Strasser · Joseph J Sasadeusz · Jessica Howell · Krispin Hajkowicz · Harshal Nandurkar · Anna Johnston · Narin Bak · Alexander J Thompson

Updated statement reflects significant advances in the past decade

Scott Dunkley · Julie A Curtin · Anthony J Marren · Robert P Heavener · Simon McRae · Jennifer L Curnow

New guidelines recommend shared decision making to reduce adverse drug reactions and medication burden, leading to improved quality of life in people with dementia

Emily Reeve · Barbara Farrell · Wade Thompson · Nathan Herrmann · Ingrid Sketris · Parker J Magin · Lynn Chenoweth · Mary Gorman · Lyntara Quirke · Graeme Bethune · Sarah N Hilmer

The THANZ guideline for the diagnosis and management of VTE has been developed by the VTE Working Group based on up‐to‐date evidence and using an evidence‐based approach. The guideline aims to promote optimal management of VTE. The extended version of the guideline can be found on the THANZ website (www.thanz.org.au/resources/thanz-guidelines).

Huyen A Tran · Harry Gibbs · Eileen Merriman · Jennifer L Curnow · Laura Young · Ashwini Bennett · Chee Wee Tan · Sanjeev D Chunilal · Chris M Ward · Ross Baker · Harshal Nandurkar

Food allergy has been increasing in incidence worldwide, with rates in Australia the highest in the world

Preeti A Joshi · Jill Smith · Sandra Vale · Dianne E Campbell

Early detection of primary melanoma remains an effective strategy to reduce melanoma‐related mortality. This article presents multiple methods of monitoring the skin in patients at high risk of developing melanoma. Determining the relative indications for each method and how each method should be introduced into the surveillance of a patient requires careful consideration and an individualised approach.TBP and SDDI provide different methods for the detection of change in the context of melanoma surveillance and, therefore, these methods should be applied to different, but overlapping (ie, non‐mutually exclusive), settings. TBP permits identification of most new or changed lesions on the skin surface. TBP is particularly suited to patients at elevated risk with high naevus counts and multiple dysplastic naevi. SDDI fulfils a different need for monitoring one or many individual flat lesions of concern that lack diagnostic clinical or dermoscopic features of melanoma. Of note, both TBP and SDDI rely on patient adherence to follow‐up appointments, and poor compliance would thus compromise the benefits that these methods confer. It is therefore crucial to emphasise to patients the importance of regular follow‐up.Much of the existing literature has been conducted in high risk patient cohorts; however, these techniques, particularly TBP, are less tested in lower risk populations and may not have the same value. To undertake a randomised controlled trial evaluating these methods in high risk patients would present ethical difficulties; nevertheless, a randomised controlled trial of TBP and SDDI in a large cohort of lower risk individuals might be justifiable. Further research is needed to elucidate the optimal risk thresholds for the introduction of both TBP and SDDI to surveillance programs. Research regarding cost‐effectiveness for the above‐mentioned diagnostic aids in different risk cohorts is also required. Specialised surveillance with TBP and SDDI has been shown to be a cost‐effective strategy for the management of individuals at high risk of melanoma. Notwithstanding the demonstrated cost‐effectiveness in high risk patients, these modalities are not currently reimbursed by the Australian Medicare system.Furthermore, RCM may be used to assist with the identification of melanoma for suspicious lesions located on the head and neck, lesions in areas that are subject to chronic sun exposure, lesions dermoscopically typified by regression and amelanotic tumours. At present, there is insufficient evidence to recommend the routine use of automated instruments for the clinical diagnosis of melanoma. Nonetheless, the use of both automatic instruments and of artificial intelligence for the clinical diagnosis of melanoma represents an exciting area for future research. Further research should also be directed at assessing the performance of new methods of skin imaging, such as three dimensional imaging, the role of teledermatology using TBP, dermoscopy and SDDI, and skin self‐assessment of suspicious lesions using smartphone applications. Of note, TBP also has the potential to aid skin self‐examination; yet, evidence to date would appear to indicate limited uptake by consumers. An important area for future research might also be to explore barriers to and determinants of skin self‐examination, and to investigate appropriate methods of educating consumers with respect to melanoma surveillance.

Nikki R Adler · John W Kelly · Pascale Guitera · Scott W Menzies · Alex J Chamberlain · Paul Fishburn · Alison E Button‐Sloan · Clinton Heal · H Peter Soyer · John F Thompson

Updated pregnancy care guidelines provide new recommendations regarding hepatitis C and vitamin D testing and maternal weight gain management

Caroline SE Homer · Jeremy Oats · Philippa Middleton · Jenny Ramson · Samantha Diplock