Health services administration

TO THE EDITOR: After a high‐pressure injection injury with an oil‐adjuvant vaccine many patients are triaged exclusively as a needlestick injury. This incomplete classification reduces the likelihood for early identification of local or systemic infections or injury, zoonoses or allergic or anaphylactic reactions.1 A review of European agricultural workers showed that of 59 patients who experienced needlestick injuries, 20 cases (34%) involved oil‐adjuvant vaccines.2 Surgical intervention was reported in only 25 patients (42%),2 contradicting product label directions, which instruct that the wound should be incised and irrigated to remove the vaccine. A similar need for an improved treatment plan was recently articulated after a high‐pressure injection injury from a ruptured hydraulic hose in an Australian farmer.3,4 Oil in water emulsions are commonly used by Australian farmers to vaccinate sheep and goats against Mycobacterium avium subsp. paratuberculosis, which causes the chronic wasting condition ovine Johne disease in ruminants and camelids. The Australian Pesticides and Veterinary Medicines Authority (APVMA) is the independent federal authority that regulates the safe supply and use of veterinary medicines and agricultural chemicals for sale in Australia. The APVMA maintains the Australian Adverse Experience Reporting Program, which is a post‐market program that monitors roughly 5500 reports received annually from product registrants, medical and veterinary professionals, and members of the public. An epidemiological review shows that the peak time of year for high‐pressure oil‐adjuvant injection injuries in Australian adverse experience reports is in spring and summer (October–February), when livestock vaccination programs for young animals are at their peak. Potentially serious long term adverse outcomes, including amputation, are possible without appropriate early intervention as described on the product label.2,3,4 Of the 210 adverse experience reports in humans related to mineral oil injections reported over the life of all registered products, the most common immediate reactions mimicked those of a sharps injury: needlestick injury, a reaction at the injection site, pain and swelling (Australian Adverse Experience Reporting Program data). In order to be prepared for the high volume season for livestock vaccination programs, the APVMA recommends that medical professionals, particularly those serving populations heavily involved with primary production, revisit best practices for the management of this type of injury (Box). Health services are encouraged to include “high‐pressure injection injury” as a triage entry option to reduce the potential misinterpretation of a “needlestick injury” entry.4 Appropriate early intervention reduces the risk of subsequent complications and adverse outcomes. Underpinning the entire process is a need for health care professionals to receive appropriate training to recognise injuries of this type and initiate early intervention as per the product label and the manufacturer's instructions. Box – An example of appropriate triage and treatment for a patient presenting with a high‐pressure injection injury* *The green box indicates the occurrence of an injection incident, based on data from the Australian Adverse Experience Reporting Program. Checkpoint steps in the process that can have a significant impact on patient outcomes if omitted are indicated by orange boxes. † This is the most common formulation for injections containing Mycobacteria

Elvira Currie · Rhian Cope · Margaret C Hardy

My Health Record will foster a more connected health system that will help prevent avoidable harm

Meredith AB Makeham · Angela Ryan

New digital health services and technologies are transforming how health care is provided and experienced in Australia

Steven J Hambleton · John Aloizos AM

My Health Record can support emergency department clinicians by providing timely and secure access to patients’ clinical histories

Paul Miles · Andrew Hugman · Angela Ryan · Fiona Landgren · Grace Liong

Despite most Australians having most of their health‐related interactions in the primary care sector, primary care‐based research is disproportionately low. Access to quality EMR data, lack of resources to remunerate GPs, and a lack of understanding among some GPs of the value and importance of secondary use of EMR data are barriers to data sharing. Data extraction tools that enable ethical, secure and privacy‐protected access to routinely collected datasets nationally have been developed. The task now is to build trustworthy primary care data repositories for research that will provide researchers with timely access to quality‐assured general practice data. Linkage with other datasets could enable significant scale‐up of primary care‐based research in Australia, contributing new knowledge in public health, health promotion, economics and evidence‐based clinical care. Technologies that allow consumers to have greater control over how their data are used can provide better options to policy makers, hence investment in this area is essential. Educating clinicians and the public about the need for, and existence of, research based on de‐identified patient medical records has the potential to generate greater social licence and acceptance of this emerging area of study. This has the potential to generate significant gains in terms of service delivery, economics and patient health. We can “do the right thing” now, but we must never become complacent.

Rachel Canaway · Douglas IR Boyle · Jo‐Anne E Manski‐Nankervis · Jessica Bell · Jane S Hocking · Ken Clarke · Malcolm Clark · Jane M Gunn · Jon D Emery

The known: Large amounts of clinical data are collected in electronic health records (eHRs). This information is largely untapped by clinicians for purposes of performance review or professional development.

Tim Shaw · Anna Janssen · Roslyn Crampton · Fenton O'Leary · Philip Hoyle · Aaron Jones · Amith Shetty · Naren Gunja · Angus G Ritchie · Heiko Spallek · Annette Solman · Judy Kay · Meredith AB Makeham · Paul Harnett

Gaining value from decision support in electronic medication management systems requires a well evidenced approach

Johanna I Westbrook · Melissa T Baysari

Widespread adoption of digital health tools requires comprehensive evidence of their effectiveness and value

Andre Q Andrade · Elizabeth E Roughead

Specialist practices may benefit from the implementation framework and resources developed at Melbourne Hand Surgery

Jillian Tomlinson

My Health Record is an easy‐to‐use and effective clinical tool for specialists

Elizabeth Jackson

Decision support tools driven by artificial intelligence are a new clinical method that clinicians need to embrace

Christopher Pearce · Adam McLeod · Natalie Rinehart · Robin Whyte · Elizabeth Deveny · Marianne Shearer

TO THE EDITOR: We commend Heldens and colleagues1 for publishing their data on the incidence and in‐hospital mortality of sepsis and septic shock among patients admitted to Australian intensive care units (ICUs). The incidence of sepsis and septic shock in ICUs is estimated to be 101.8 and 19.3 per 100 000 patient‐years, respectively, at an attributable cost of $32 421.2 We concur that sepsis cases captured using the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation database criteria, compared with prospective clinical diagnoses,3 has poor sensitivity for sepsis case ascertainment. Notwithstanding, we propose that the application of a third surveillance metric using coded discharge data could be a viable alternative for sepsis case ascertainment and monitoring in ICUs. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD‐10‐AM) diagnostic coding data are feasible to collect with a reduced risk of sampling bias and minimal loss to follow‐up. Using tandem dataset comparison following the implementation of a hospital‐wide sepsis pathway,4 we explored the utility of coding data for sepsis surveillance. We noted that 78% and 74% of ICU cases were designated an ICD‐10‐AM code denoting sepsis at admission and patient level, respectively (Box). Alarmingly, the concordance rate between coded administrative data and clinically verified sepsis diagnoses was even lower in non‐ICU settings. These data are in keeping with international reports.2 Robust and reproducible data are required to evaluate quality improvement regarding sepsis management. Given the poor sensitivity of research criteria and coding data, used in isolation for sepsis identification, a multifaceted approach is required. We hypothesise that the combination of administrative coding data and electronic medical record data, augmented with sepsis screening algorithms, may improve the sensitivity for sepsis case ascertainment in both cancer and non‐cancer settings.5 We encourage Heldens and colleagues to consider these suggestions as an alternative reproducible method needed to elucidate the incidence of sepsis and septic shock in Australian ICUs. Box – Relationship between sepsis cases satisfying clinical criteria and designated coded discharge data in intensive care unit (ICU) and non‐ICU settings, 2012–2014 Year Admission level ICU Non‐ICU All new admissions* ICD‐10‐AM captured cases Concordance All new admissions* ICD‐10‐AM captured cases Concordance 2012 38 27 71% 70 62 89% 2013 39 34 87% 175 103 59% 2014 81 61 75% 331 149 45% Mean (± SD) – – 78% (± 8.3%) – – 64% (± 22%) ICD‐10‐AM = International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification; SD = standard deviation. * Clinically diagnosed sepsis cases according to consensus diagnostic criteria.◆

Jake C Valentine · Gabrielle Haeusler · Leon Worth · Karin Thursky

To the Editor: Schilling and colleagues1 state that the Australasian Rehabilitation Outcomes Centre (AROC) — the national rehabilitation clinical quality registry for Australia and New Zealand — does not routinely collect data on post‐surgery outcomes for private total knee replacement (TKR) recipients. This statement is factually incorrect. All private inpatient rehabilitation services in Australia are members of AROC and routinely submit data (including functional outcomes as assessed by a functional independence measure) describing all episodes of rehabilitation they provide. More specifically, over the period described by Schilling and colleagues,1 AROC received data on outcomes for 93 278 TKRs receiving private rehabilitation. If we restrict the AROC data to match the study data (patients aged 40–89, single TKR, first admission), AROC received data describing 76 847 privately rehabilitated TKRs. In rehabilitation, the Australian National Subacute and Non‐Acute Patient Classification2 is routinely used to classify episodes into resource‐homogeneous groups. In interrogating the AROC TKR data, we concur with Schilling et al1 that the average length of stay in rehabilitation has been declining, with this decline accelerating over the past 5 years. Concurrent with the decline in length of stay, the functional change achieved (both absolute and relative) during rehabilitation has been increasing, and has in fact accelerated over the past 5 years. Achieving more functional change in a shorter length of stay shows that services are becoming more efficient while also continuing to produce positive outcomes for their patients. Moreover, it is also factually incorrect that AROC does not collect data outside of the inpatient setting. In fact, AROC also runs an ambulatory benchmarking initiative, and while coverage is not 100%, it is growing. There are currently 35 private ambulatory rehabilitation services that participate and routinely provide data describing their ambulatory rehabilitation outcomes. In conclusion, we suggest that while the authors provide an interesting analysis, it is incomplete, given that they did not include function — the key driver of cost and outcomes in rehabilitation — as one of the variables they used.

Frances Simmonds · John H Olver