Maja Garcia

Background: Burn patients are highly susceptible to hospital-acquired infections (HAIs), and contaminated near-patient surfaces can act as reservoirs for multidrug-resistant organisms (MROs). Ultraviolet-C (UV-C) room disinfection is increasingly used as an adjunct to manual cleaning, but real-world data in adult burns settings remain limited. Methods: We evaluated adjunctive UV-C disinfection in a tertiary adult trauma and burns surgical ward using a two-part observational design. Part A compares MRO-related HAI incidence before UV-C implementation (12 May 2015–11 May 2020; retrospective) with its incidence after implementation (14 July 2020–13 July 2021; prospective). Part B is a matched pre/post environmental sampling study (December 2022–December 2024) of 44 vacant rooms. Paired swabs from a single randomised high-touch surface per room were collected immediately before and after UV-C disinfection and processed by an independent laboratory. Results: Part A included 7589 admissions (6415 before-UV-C; 1174 after-UV-C) with 2728 UV-C cycles delivered after implementation. MRO-related HAI incidence decreased from 18.3 to 10.2 per 1000 bed-days (p < 0.01). In Part B, the proportion of swabs with p = 0.02). Among swabs with non-negligible baseline contamination and excluding increases, the median CFU reduction was 97% (SD 12%; p < 0.001), with no significant differences in reduction across sampled surface types. Conclusion: In an adult burns surgical ward, adjunctive UV-C disinfection was associated with reduced MRO-related HAI incidence and a substantial reduction in environmental bioburden on high-touch surfaces. These real-world findings support UV-C as a feasible adjunct to standard cleaning in high-risk burn services and inform future controlled evaluations.

Purpose: Pancreatic cancer poses significant challenges in symptom management. Many people have intractable pain and anorexia which is often not amenable to current available options for palliation. This study aims to outline the longitudinal patterns and assess the burden of distress related to pain and appetite experienced by individuals with pancreatic cancer in people referred to Australian palliative care services. Methods: Consecutive national cohort study using point-of-care data on symptom distress in people referred to specialist palliative care services. Results: From 2013 to 2022, information from 20,558 care episodes involving 15,536 people with pancreatic cancer referred to 203 palliative care services nationally were included. Similar numbers of people were admitted to inpatient and community services, with 69% and 60% reporting distress due to pain and appetite, respectively. Distress extended to sleeping (79%, 82%), nausea (83%, 85%), bowels (80%, 83%), breathing (70%, 77%) and fatigue (77%, 77%) for pain and appetite, respectively. Strongest associations were with psychological/spiritual issues (inpatient OR 1.78, 95% CI 1.66–1.90) and pain severity (community OR 1.51, 95% CI 1.42–1.60) for appetite-related distress and pain severity (inpatient OR 1.60, 95% CI 1.49–1.72; community OR 1.35, 95% CI 1.27–1.44) for pain distress. Trends within the cohort revealed increased mild appetite-related distress (+ 10%) and decreased moderate (- 22%) and severe (- 11%) distress, with similar trends for pain. Conclusion: This study underscores prevalent distress in people with pancreatic cancer in Australian palliative care, highlighting the need for optimised referrals and strategies targeting pain severity, appetite-related concerns and psychological and spiritual aspects for improved care outcomes.

Background: The global need for focused improvements in palliative care within the acute hospital setting is well noted. A large volume of evidence exists detailing what hospitalised patients with palliative care needs and their families note as important for high quality care. Patient Reported Experience Measures (PREMs) are one mechanism that hospitals could use to inform improvement work. To date there has not been a review of PREMs available for hospitalised patients with palliative care needs and/or their family, nor how they align with noted priorities for high quality care. Aim: To identify and describe PREMs designed for hospitalised patients with palliative care needs and their families; and their alignment with patient and family identified domains for high quality care. Design: A systematic review. Data sources: A systematic search of CINAHL, Medline and PsycInfo was conducted up to September 23, 2022 and supplemented by handsearching article reference lists and internet searches. PREMs written in English and designed for patients with palliative care needs in acute hospitals were eligible for inclusion. Included PREMs were described by: summarising key characteristics; and mapping their items to domains noted to be important to hospitalised patients with palliative care needs and their families informed by outcomes from a published study completed in 2021. Evidence for psychometric properties were reviewed. Results: Forty-four PREMs with 827 items were included. Items per PREM varied from 2 to 85 (median 25, IQR 13–42). Two-thirds ( n = 534, 65%) of the items were designed for families and a third ( n = 283, 34%) for hospitalised patients, and very few ( n = 10, 1%) for both. Sixty-six percent of items measured person-centred care, 30% expert care and 4% environmental aspects of care. Available PREMs address between 1 and 11 of the 14 domains of importance for quality palliative care. PREMs had a median of 38% (IQR 25.4–56.3) of items >Grade 8 measured by the Flesch-Kincaid readability test, with Grade 8 or lower recommended to ensure health information is as accessible as possible across the population. Conclusions: Whilst 44 PREMs are available for hospitalised patients with palliative care needs or their families, a varied number of items are available for some domains of care provision that are important, compared to others. Few are suitable for people with lower levels of literacy or limited cognitive capacity due to illness.

Background: Palliative populations are at risk for dehydration which can cause discomfort, distress and cognitive symptoms. Subcutaneous hydration (‘hypodermoclysis’) has been used as an alternative administration route to the more invasive intravenous route, but research is lacking on its net clinical effects (harms and benefits) for palliative populations, particularly in real world settings. Aim: To quantify prospectively the net clinical effects of hypodermoclysis in palliative patients with advanced disease who required supplementary fluids. Design: Multisite, multinational consecutive cohort study. Setting/participants: Patients receiving hypodermoclysis in an inpatient palliative care setting. Results: Twenty sites contributed data for 99 patients, of which 88 had complete benefits and harms data. The most common primary target symptom for infusion was generalised weakness (18.2%), and the most common non-symptom indication was supplemental hydration (31.8%). Benefits were experienced in 33% of patients in their primary target symptom, and in any symptom in 56.8%. Harms were experienced in 38.7% of patients (42% at Grade 1). Benefits increased with higher performance status, while harms were more frequent in patients with lower performance status (Australia-modified Karnofsky performance status ⩽40). Patients in the terminal phase of their illness experienced the least benefit (15.4% in any indication only) and had more frequent harms (38%). Conclusions: Hypodermoclysis may improve certain symptoms in patients in palliative care but frequency of harms and benefits may differ at certain timepoints in the illness trajectory. Further research is needed to better delineate which patients will derive the most net clinical benefit from hypodermoclysis.

Trials of interventions for delirium in various patient populations report disparate outcomes and measures but little is known about those used in palliative care trials. A core outcome set promotes consistency of outcome selection and measurement. To inform core outcome set development by examining outcomes, their definitions, measures and time-points in published palliative care studies of delirium prevention or treatment delirium interventions. Prospectively registered systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched six electronic databases (1980–November 2020) for original studies, three for relevant reviews and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We included randomised, quasi-randomised and non-randomised intervention studies of pharmacological and non-pharmacological delirium prevention and/or treatment interventions. From 13/3244 studies (2863 adult participants), we identified 9 delirium-specific and 13 non-delirium specific outcome domains within eight Core Outcome Measures in Effectiveness Trials (COMET) taxonomy categories. There were multiple and varied outcomes and time points in each domain. The commonest delirium specific outcome was delirium severity (n = 7), commonly using the Memorial Delirium Assessment Scale (6/8 studies, 75%). Four studies reported delirium incidence. Non-delirium specific outcomes included mortality, agitation, adverse events, other symptoms and quality of life. The review identified few delirium interventions with heterogeneity in outcomes, their definition and measurement, highlighting the need for a uniform approach. Findings will inform the next stage to develop consensus for a core outcome set to inform delirium interventional palliative care research.

Background: Delirium is a common debilitating complication of advanced cancer. Objective: To determine if a multicomponent nonpharmacological delirium prevention intervention was feasible for adult patients with advanced cancer, before a phase III (efficacy) trial. Design: Phase II (feasibility) cluster randomized controlled trial. All sites implemented delirium screening and diagnostic assessment. Strategies within sleep, vision and hearing, hydration, orientation, mobility, and family domains were delivered to enrolled patients at intervention site admission days 1–7. Control sites then implemented the intervention (“waitlist sites”). Setting: Four Australian palliative care units. Measurements: The primary outcome was adherence, with an a priori endpoint of at least 60% patients achieving full adherence. Secondary outcomes were interdisciplinary care delivery, delirium measures, and adverse events, analyzed descriptively and inferentially. Results: Sixty-five enrolled patients (25 control, 20 intervention, and 20 waitlist) had 98% delirium screens and 75% diagnostic assessments completed. Nurses (67%), physicians (16%), allied health (8.4%), family (7%), patients (1%), and volunteers (0.5%) delivered the intervention. There was full adherence for 5% patients at intervention sites, partial for 25%. Both full and partial adherence were higher at waitlist sites: 25% and 45%, respectively. One-third of control site patients (32%) became delirious within seven days of admission compared to one-fifth (20%) at both intervention and waitlist sites ( p = 0.5). Mean (standard deviation) Delirium Rating Scale-Revised-1998 scores were 16.8 + 12.0 control sites versus 18.4 + 8.2 ( p = 0.6) intervention and 18.7 + 7.8 ( p = 0.5) waitlist sites. The intervention caused no adverse events. Conclusion: The intervention requires modification for optimal adherence in a phase III trial.

Background: People with dementia requiring palliative care have multiple needs, which are amplified in long-term care settings. The European Association for Palliative Care White Paper offers recommendations for optimal palliative care in dementia integral for this population, providing useful guidance to inform interventions addressing their specific needs. Aim: The aim of this study is to describe the components of palliative care interventions for people with dementia in long-term care focusing on shared decision-making and examine their alignment to the European Association for Palliative Care domains of care. Design: Systematic review with narrative synthesis (PROSPERO ID: CRD42018095649). Data sources: Four databases (MEDLINE, CINAHL, PsycINFO and CENTRAL) were searched (earliest records – July 2019) for peer-reviewed articles and protocols in English, reporting on palliative care interventions for people with dementia in long-term care, addressing European Association for Palliative Care Domains 2 (person-centred) or 3 (setting care goals) and ⩾1 other domain. Results: Fifty-one papers were included, reporting on 32 studies. For each domain (1–10), there were interventions found aiming to address its goal, although no single intervention addressed all domains. Domain 7 (symptom management; n = 19), 6 (avoiding overly aggressive treatment; n = 18) and 10 (education; n = 17) were the most commonly addressed; Domain 5 (prognostication; n = 7) and 4 (continuity of care; n = 2) were the least addressed. Conclusion: Almost all domains were addressed across all interventions currently offered for this population to various degrees, but not within a singular intervention. Future research optimally needs to be theory driven when developing dementia-specific interventions at the end of life, with the European Association for Palliative Care domains serving as a foundation to inform the best care for this population.

Aim To explore the role of coping moderators in self‐management of breathlessness crises by people with advanced respiratory disease. Design A secondary analysis of semi‐structured interview data. Methods Interviews with patients who had advanced respiratory disease, chronic breathlessness and at least one experience where they considered presenting to Emergency but self‐managed instead (a ‘near miss’). Participants were recruited from New South Wales, Queensland, Victoria, South Australia or Tasmania. Eligible caregivers were those who contributed to Emergency‐related decision‐making. Interviews were coded inductively and then deductively against the coping moderators social support and dispositional coping style, defined by the Transactional Model of Stress and Coping. Results Interviews were conducted between October 2015 ‐ April 2016 with 20 patients and 3 caregivers. Social networks offered emotional and practical support but also had potential for conflict with patients’ ‘hardy’ coping style. Patient hardiness (characterized by a sense of ‘commitment’ and ‘challenge’) promoted a proactive approach to self‐management but made some patients less willing to accept support. Information‐seeking tendencies varied between patients and was sometimes shared with caregivers. An optimistic coping style appeared to be less equivocally beneficial. Conclusion This study shows that social support and coping style may influence how people self‐manage through their breathlessness crises and identified ways coping moderators can facilitate or hinder effective self‐management. Impact This study confers insights into how social‐support and coping style can be supported and optimised to facilitate breathlessness self‐management. Acknowledging coping moderator interactions is beneficial for developing resources and strategies that recognise patient mastery.

Objectives Breathlessness ‘crises’ in people with chronic respiratory conditions are a common precipitant for emergency department (ED) presentations, many of which might be avoided through improved self-management and support. This study sought insights from people with experience of ED ‘near misses’ where they considered going to the ED but successfully self-managed instead. Design and methods A qualitative approach was used with a phenomenological orientation. Participants were eligible if they reported breathlessness on most days from a diagnosed respiratory condition and experience of ≥1 ED near miss. Recruitment was through respiratory support groups and pulmonary rehabilitation clinics. Semistructured interviews were conducted with each participant via telephone or face-to-face. Questions focused on ED-related decision-making, information finding, breathlessness management and support. This analysis used an integrative approach and independent coding by two researchers. Lazarus and Cohen’s Transactional Model of Stress and Coping informed interpretive themes. Results Interviews were conducted with 20 participants, 15 of whom had chronic obstructive pulmonary disease. Nineteen interviews were conducted via telephone. Analysis identified important factors in avoiding ED presentation to include perceived control over breathlessness, self-efficacy in coping with a crisis and desire not to be hospitalised. Effective coping strategies included: taking a project management approach that involved goal setting, monitoring and risk management; managing the affective dimension of breathlessness separately from the sensory perceptual and building three-way partnerships with primary care and respiratory services. Conclusions In addition to teaching non-pharmacological and pharmacological management of breathlessness, interventions should aim to develop patients’ generic self-management skills. Interventions to improve self-efficacy should ensure this is substantiated by transfer of skills and support, including knowledge about when ED presentation is necessary. Complementary initiatives are needed to improve coordinated, person-centred care. Future research should seek ways to break the cyclical relationship between affective and sensory-perceptual dimensions of breathlessness.