Each year 300 million people undergo surgery; 2.5 million in Australia. Early mortality exceeds 5 in 1,000 and complication rates exceed 150 per 1,000 patients: globally 1.5 million patients die and 45 million suffer complications. In Australia, deterioration after surgery is associated with 10,000 deaths and over 100,00 major complications. Few realise that early deterioration after surgery is among the top five causes of death in Australia. Further, early complications are associated with poor long-term health and quality of life including persisting post-surgical pain. These problems bring enormous personal and community cost.
Most of these deaths, and many major complications, are not due to medical mistakes but instead due to the physiological stresses of surgery and anaesthesia particularly among older, sicker people; and those undergoing emergency surgery. There are no silver bullets, but co-ordinated, multidisciplinary work-up before surgery with enhanced surveillance and rescue after surgery are fundamental elements for reducing complications and death.
A key feature in preventing and managing deterioration is to understand patient, surgical, and health system risk factors. While some risk factors for early complications and death are well described including patient age and comorbidity and surgical complexity and urgency, many, including frailty and socioeconomic status are inadequately understood.
The perioperative risk theme aims to better define and quantify risk, investigating complications and mortality in older surgical patients.
Sepsis is a major health challenge on a global scale and has now been endorsed a World Health Assembly resolution (co-sponsored by Australia) as an area of global health care priority. As a consequence, the World Health Organization has now promoted programs to improve the detection and management of this condition, which kills millions of patients worldwide and is responsible for more 13% of all ICU admissions in Australia.
In Australia, in response to the WHO directive, funds are being allocated for trauma advertising, awareness, detection and treatment in every state and nationally. Sepsis involves patients presenting to the Emergency Department (ED), being admitted to the ICU, having emergency surgery and often develops in the wards.
A major challenge with improving the care of sepsis in the acute care environment is that the condition occurs in patients across the entire sector and in different specialties and wards, where clinicians who are experts in their field (orthopedic surgery, cardiac surgery, cardiology, hepatobiliary surgery, urology, etc) are not experts in the identification, monitoring and management of sepsis and septic shock.
The sepsis theme will investigate the epidemiology of sepsis, develop effective diagnositic tools and test a range of interventions to prevent sepsis.
Delirium is emerging as a major health care problem in acute care health services. In hospital wards, approximately 2-3 patients are coded at discharge as having experienced delirium and in the ICU, depending on age and condition, between 30 and 50% of patients develop delirium. In the ED, with the epidemic of substance abuse, agitated and aggressive delirium is a dramatic and major clinical problem (see Toxicology section).
Despite the obvious importance of delirium and new developments in its treatment and understanding of its likely pathophysiology, its management continues to be ad-hoc and based on off-label prescription and administration of anti-psychotic drugs or deliriogenic benzodiazepines. This is despite evidence that they may increase the risk of death and lack of evidence that they effect the development, severity and duration of delirium in ward patients. Moreover, non-pharmacologic therapy, which are both safe and supported by evidence are also unpredictably applied. Finally, no systematic, widely accepted and reproducible diagnostic tool is applied in Australian hospitals and ICUs to detect the development of delirium.
We will conduct an epidemiological study of hospital patients coded for delirium, examine the use of a range of drugs to treat delirium and investigate management of acute behavioural disturbance and delirium.
In developed countries, diabetes (together with is associated disorders of obesity and hypertension) is perhaps the major public health care challenge of the century. While many interventions are taking place outside the acute care environment to improve the diagnosis, monitoring and management of diabetes, the acute care sector has lagged behind. In particular, it is deficient in its recognition of the impact of poor preadmission glucose control, the impact of and the opportunity associated with new monitoring technologies, the advent of new medications for type II diabetes (dipeptidyl peptidate-4 inhibitors and sodium glucose transport-type 2 inhibitors).
A major challenge with improving the care of patients with diabetes in the acute care environment is that the condition occurs in patients across the entire sector and in different specialties and wards. In response to these challenges, we plan to develop a collaboration with diabetologists within Melbourne University and set an agenda dedicated to diabetes in the acute care setting.
Estimates of Emergency department (ED) presentations that are alcohol related vary but are approximately 10%. Approximately 1/3 of injury related presentations are alcohol related. The escalating use of methamphetamine (ICE) has resulted in increased hospital presentations for crisis care and admission. In NSW there has been an 8-fold increase in adult methamphetamine-related ED presentations over in the last 9 years.
This epidemic impacts not only the ED but also trauma services, psychiatric services, intensive care and other downstream services. Studies have demonstrated that substance abuse is closely related to other social determinants of health particularly income, education, employment, social inclusion, gender and indigenous status and hence any impact on patient outcomes must be comprehensive and address key psychosocial and behavioural issues. Evidence suggests that prescription opioid analgesics are often prescribed to patients at risk of opioid-related harm, are prescribed for inappropriate indications, and are prescribed in excessive quantities.
The Austin, Royal Melbourne and St Vincent’s Hospitals have been involved in 10 years of research into the safer containment of patients in acute behavioural crises, including the use of novel agents and improved methods of sedation in poisoned patients that reduce rates of intubation and critical care service utilisation, while maintaining patient safety.
The toxicology stream will ensure that the needs of the most vulnerable patients are addressed through a multidisciplinary program aimed at managing both acute needs and the determinants that lead to ongoing harm.
With the development of global terrorism, the use of the lethal power of motor vehicle for mass violence (Bourke St incident), the risk of major accidents involving trains or airplanes, the occurrence of sudden disease mini-epidemics (recent Thunderstorm Asthma event) and the emergence of new toxic and lethal forms of poisoning (recent Novichok attacks), Disaster Medicine has become a key aspect of modern Public Health.
Disaster medicine is a systems orientated specialty that intersects clinical medicine and a diverse group of responding agencies. It is a subspecialty of critical care medicine that brings together prevention, policy and management. The reality of disaster medicine is that while a major disaster occurs almost daily in some part of the world the individual doctor or emergency responder is unlikely to see “disaster” patients on a regular basis. Hence it is a specialty that addresses the “worst case scenario” potential and is underpinned by the need to be prepared.