Collaborative maternity and newborn dashboard (CoMaND) for the COVID-19 pandemic: a protocol for timely, adaptive monitoring of perinatal outcomes in Melbourne, Australia

BackgroundThe COVID-19 pandemic has resulted in a range of unprecedented disruptions to maternity care with documented impacts on perinatal outcomes such as stillbirth and preterm birth. Metropolitan Melbourne has endured one of the longest and most stringent lockdowns in globally. This paper presents the protocol for a multicentre study to monitor perinatal outcomes in Melbourne, Australia, during the COVID-19 pandemic.MethodsMulticentre observational study analysing monthly deidentified maternal and newborn outcomes from births >20 weeks at all 12 public maternity services in Melbourne. Data will be merged centrally to analyse outcomes and create run charts according to established methods for detecting non-random ‘signals’ in healthcare. Perinatal outcomes will include weekly rates of total births, stillbirths, preterm births, neonatal intensive care admissions, low Apgar scores and fetal growth restriction. Maternal outcomes will include weekly rates of: induced labour, caesarean section, births before arrival to hospital, postpartum haemorrhage, length of stay, general anaesthesia for caesarean birth, influenza and COVID-19 vaccination status, and gestation at first antenatal visit. A prepandemic median for all outcomes will be calculated for the period of January 2018 to March 2020. A significant shift is defined as ≥6 consecutive weeks, all above or below the prepandemic median. Additional statistical analyses such as regression, time series and survival analyses will be performed for an in-depth examination of maternal and perinatal outcomes of interests.Ethics and disseminationEthics approval for the collaborative maternity and newborn dashboard project has been obtained from the Austin Health (HREC/64722/Austin-2020) and Mercy Health (ref. 2020-031).Trial registration numberACTRN12620000878976; Pre-results.

COVID-Care – a safe and successful digital self-assessment tool for outpatients with proven and suspected coronavirus-2019

Introduction The coronavirus-2019 (COVID-19) pandemic and restrictions placed on movement to prevent its transmission have led to a surge in demand for remote medical care. We investigated whether COVID-Care, a patient-reported, telehealth, symptom monitoring system, was successful at delivering safe monitoring and care for these patients leading to decreased hospital presentations. Methods We performed a single centre, prospective, interventional cohort study with symptomatic outpatients who presented for COVID-19 screening at Austin Health, Australia. Participants were invited to take part in the COVID-Care programme, entering common COVID-19 symptoms on a purpose-built, online survey monitored by infectious diseases physicians, and matched with clinical data including date of symptom onset, hospital admission, and screening clinic presentations. Results 42,158 COVID-19 swabs were performed in 31,626 patients from March to October 2020, with 414 positive cases. 20,768 people used the COVID-Care survey at least once. COVID-Care users were significantly younger than non-users. Of the 414 positive cases, 254 (61.3%) used COVID-Care, with 160 (38.6%) non-users. Excluding presentations on the same day or prior to the COVID-19 swab, of the positive cases there were 56 hospital presentations. 4.3% (11) of COVID-Care users and 28.1% (45) non-users were admitted to hospital or the emergency department ( p < 0.001), with 3.9% (10) versus 22.5% (36) requiring inpatient admission ( p < 0.001). There were no deaths in COVID-Care users versus 2 deaths in non-users. Conclusion COVID-Care, a digitally integrated, outpatient, symptom tracking and telemedical service for patients with COVID-19, was safe and successful at reducing hospital and emergency department admissions, suggesting a strong role for telemedicine for future healthcare delivery in this logistically challenging setting.

Staff to staff transmission as a driver of healthcare worker infections with COVID-19

ABSTRACTObjectivesTo investigate the COVID-19 infections among staff at our institution and determine the interventions required to prevent subsequent staff infections.DesignRetrospective cohort studyParticipants and settingStaff working at a single tertiary referral hospital who returned a positive test result for SARS-CoV-2 between 25 January 2020 and 25 November 2020.Main outcome measuresSource of COVID-19 infection.ResultsOf 45 staff who returned a positive test result for SARS-CoV-2, 19 were determined to be acquired at Austin Health. Fifteen (15/19; 79% [95% CI: 54–94%]) of these were identified through contact tracing and testing following exposures to other infected staff and were presumed to be staff-staff transmission, including 10 healthcare workers (HCWs) linked to a single ward that cared for COVID-19 patients. Investigation of the outbreak identified the staff tearoom as the likely location for transmission, with subsequent reduction in HCW infections and resolution of the outbreak following implementation of enhanced control measures in tearoom facilities. No HCW contacts (0/204; 0% [95% CI: 0–2%]) developed COVID-19 infection following exposure to unrecognised patients with COVID-19.ConclusionsUnrecognised infections among staff may be a significant driver of HCW infections in healthcare settings. Control measures should be implemented to prevent acquisition from other staff as well as patient-staff transmission.

A Simple Cleaning Intervention to Prevent Transmission of Carbapenemase-Producing Enterobacterales from Hospital Sinks

Background: A prolonged outbreak of carbapenemase-producing Serratia marcescens (CPSM) was identified in our quaternary healthcare center over a 2-year period from 2015 through 2017. A reservoir of IMP-4–producing S. marcescens in sink drains of clinical hand basins (CHB) was implicated in propagating transmission, supported by evidence from whole-genome sequencing (WGS). We assessed the impact of manual bioburden reduction intervention on further transmission of CPSM. Methods: Environmental sampling of frequently touched wet and dry areas around CPSM clinical cases was undertaken to identify potential reservoirs and transmission pathways. After identifying CHB as a source of CPSM, a widespread annual CHB cleaning intervention involving manual scrubbing of sink drains and the proximal pipes was implemented. Pre- and postintervention point prevalence surveys (PPS) of CHB drains performed to assess for CPSM colonization. Surveillance for subsequent transmission was conducted through weekly screening of patients and annual screening of CHB in transmission areas, and 6-monthly whole-hospital PPS of patients. All CPSM isolates were assessed by WGS. Results: In total, 6 patients were newly identified with CPSM from 2015 to 2017 (4.3 transmission events per 100,000 surveillance bed days [SBD]; 95% CI, 1.6–9.4). All clinical CPSM isolates were linked to CHB isolates by WGS. The CHB cleaning intervention resulted in a reduction in CHB colonization with CPSM in transmission areas from 72% colonization to 28% (ARR, 0.44; 95% CI, 0.25–0.63). A single further clinical case of CPSM linked to the CHB isolates was detected over 2 years of surveillance from 2017 to 2019 following the implementation of the annual CHB cleaning program (0.7 transmissions per 100,000 SBD; 95% CI, 0.0–3.9). No transmissions were linked to undertaking the cleaning intervention. Conclusions: A simple intervention targeted at reducing the biological burden of CPSM in CHB drains at regular intervals was effective in preventing transmission of carbapenemase-producing Enterobacterales from the hospital environment to patients over a prolonged period of intensive surveillance. These findings highlight the importance of detailed cleaning for controlling the spread of multidrug-resistant organisms from healthcare environments.Funding: NoneDisclosures: Jason Kwong, Austin Health

Early-stage KRAS G12C-mutated non-small cell lung cancer (NSCLC) in Australia.

e21053 Background: KRAS is frequently mutated in NSCLC, especially in Caucasian populations. Until recently there have not been effective targeted therapies against KRAS but the recent advent of active agents has thrown a spotlight on this disease. Methods: A database of NSCLC cases undergoing lobectomy or pneumonectomy with curative intent at Austin Health, Victoria, Australia was examined. Analysis for KRAS mutations was carried out using the LungCarta panel. Results: Four hundred and fifty nine cases underwent mutation analysis and 203/459 (44%) were wild type. KRAS mutations were identified in 100/459 cases (21.8%), including 3 cases where the specific mutation was not specified. KRAS G12C cases comprised 40/97 (8.5% of all cases, 41% of specified mutation KRAS cases) and other KRAS mutations comprised 57/97 (59%) - most commonly G12V (25 cases) and G12D (13 cases). Additional mutations were identified in 14/40 (36%) G12C mutation cases (10 dual and 4 triple – most commonly TP53 9, STK11 3 and PIC3CA 2). In non-G12C cases, multiple mutations were identified in 24% of cases. Considering the 40 G12C cases, histology was squamous cell in 21 cases, adenocarcinoma 13 and other 5. Males comprised 21/40 cases, median age at diagnosis was 61 year (range 34 – 78), with stage I 22 cases, stage II 12; stage IIIA 5 and one stage 4 (solitary brain metastasis). Thirty six patients (90%) had smoked tobacco with median exposure of 44 pack years (range 13-100) including 18 ex-smokers who had ceased a median 9 years (range 1 - 28) prior to the diagnosis of lung cancer. PD-L1 expression was analysed using the 28-8 antibody. For the 38 cases analysed, PD-L1 expression was ≥ 50% in 6 (16%), ≥ 5% in 12 (32%) and < 1% in 24 (63%). The estimated median overall survival was 4.9 years with 27% 10 year survival. Twenty three patients (58%) died from the index lung cancer, 8 (20%) remain alive and 9 (23%) died of other causes: 4 from a 2nd lung cancer, 4 from a non-lung cancer and one from liver failure. Data on sites of recurrence were available for 16 of the 23 cases who died from the index lung cancer, with initial recurrence sites being lung/local 7 patients, brain 6, bone 2, liver 1. A total of 9 patients (56%) developed brain metastases at some time. Conclusions: KRAS G12C is a common subgroup of NSCLC in the Australian population and almost all of cases were tobacco smokers. Additional mutations were identified in over a third of cases. Locally recurrent disease or brain metastases are the most frequent sites of relapse and over half of patients with recurrent disease develop brain metastases.

What do doctors value about attending multi-disciplinary cancer case discussions?

e18324 Background: Discussion of cancer cases at multi-disciplinary meetings (MDMs) for treatment planning is expected standard care in Australia. There has been rapid uptake of MDMs in the last 10 - 15 years and in the state of Victoria approximately 70% of cancer cases are discussed. MDMs have strong support from medical staff and we investigated their motivation in attending MDMs. Methods: Over 12 months, Austin Health in Melbourne, Victoria, hosted 452 cancer MDMs discussing 5943 patients. MDMs covered 15 tumour areas: 11 solid tumour, one lymphoma and three haematological. Over a 4-week period, medical staff attending MDMs were surveyed and asked to rank what they valued most about cancer MDMs, over and above the benefits for patients. Results: Responses were received from 84% of the 285 medical staff surveyed, which included consultants as well as trainees (registrars and fellows). For 75% of respondents the highest ranking was given to multi-disciplinary communication, 9% gave the highest ranking to quality assurance and governance, 5% ongoing learning for consultants, 5% collegiate relationships, 2% learning and teaching for non-consultant staff, 2% peer support 1% job satisfaction and 1% clinical trials engagement. Similar results were obtained for consultant staff and for registrars / fellows. For consultant medical staff, if multidisciplinary communication was excluded, 44% of respondents gave the highest ranking to quality assurance and governance, 23% to collegiate relationships, 20% ongoing learning for consultants, 10% peer support and 3% clinical trials engagement. Conclusions: When we asked doctors what they valued most about attending cancer MDMs, besides the benefits for patients, communication between disciplines was clearly the most valued aspect. The benefits for quality and governance was the next most valued, then collegiate relationships and peer support, and ongoing learning.

Case discussion at cancer multidisciplinary meetings: What resourcing is required?

e18026 Background: Discussion of cancer cases at multi-disciplinary meetings (MDMs) is expected standard care in Australia. To our knowledge there are no local, and few international, data on the resourcing required for MDMs. Methods: Data covering 12 months of MDM activity at Austin Health, Victoria, were obtained retrospectively. Prospective data were also collected over 4 weeks focusing on time required for preparation and post-meeting activities. Capital, maintenance and general overhead costs were not included. Results: MDMs covered 15 tumour areas: 11 solid tumour, one lymphoma and 3 haematological. Over 12 months 452 MDMs were held, discussing 5943 patients with highest case volume for hepatoma (1243), breast (1084) and hepato-biliary (HPB, 679). On average 12 cases (range 3.5 – 38.3) were discussed per meeting, with average 3.8 minutes spent per case. An average of 3 imaging studies were reviewed per case and 60% of cases in the high volume MDMs required access to external imaging. Imaging consultants spent an average of 2.9 minutes preparation per imaging study, registrars 5.2 minutes and external imaging required 7.8 minutes per study. Pathologists spent an average of 6.8 minutes preparation per case, which rose to 9.4 minutes for external cases (making up between 3% - 30% of cases per MDM). Pathology administration time was 53 minutes per meeting. The mean cost of medical staff was AUD 1617 per meeting (range $532-$2860), and 78% of the cost was for consultant medical staff. The mean cost for diagnostic staff attendance was $216, and preparation $327. MDM and pathology administrative costs were $273. The MDMs with the highest annual total costs were breast, lung and HPB ($152,904 - $207,289). The overall mean cost for a meeting varied between $847 - $4080. The cost per case discussed varied from $106 - $422, with generally lower per-case costs for the high case volume MDMs. The average per case cost was $255. Conclusions: Data on staff time and costs associated with conducting cancer MDMs were able to be obtained. The average cost per case discussed was $255 (USD 184). These data may be useful in planning to extend MDM discussion to include a higher proportion of cancer cases and in seeking additional funding.

The Integration of an Extra-Corporal Life Support (ECLS) Service at Austin Health

Extra-corporal membrane oxygenation (ECMO), also known as extracorporeal life support (ECLS), is a globally established treatment option in modern intensive care medicine for patients suffering from severe but reversible respiratory and/or cardiac failure. If refractory to other advanced treatment options, early instatement of ECLS therapy is closely associated with reduced mortality and improved long-term patient outcome. ECLS, in many ways, has replaced other, less effective treatments and future modelling predicts increased demand. ECLS has routinely and successfully been applied to neonates and pediatrics for many years. This field study however will exhibit focus only on the viability of the introduction of ECLS therapy in the Victorian adult population at Austin Health.

The Utility of Rapid On-Site Evaluation on Endobronchial Ultrasound Guided Transbronchial Needle Aspiration: Does It Make a Difference?

The purpose of this study was to assess the efficacy of using rapid on-site evaluation (ROSE) for samples taken during endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) at Austin Health, Victoria. This was compared to data collected for cases performed without ROSE. A retrospective analysis was conducted on 188 consecutive patients who underwent EBUS-TBNA from May 2012 to July 2014 whose data was collected prospectively at the time of the procedure. The presence of a cytologist during ROSE resulted in a significant reduction in the number of lesions sampled [mean: 1.5 ± 0.7 (1, 4) versus 1.9 ± 0.8 (1, 4), P = 0.0020] and the number of TBNAs required per case [mean: 3.6 ± 1.4 (1, 8) versus 4.2 ± 1.5 (1, 8), P = 0.0017]. This could potentially result in a shorter procedure time and, ultimately, a reduction in complication rate. The quality of the samples obtained during EBUS-TBNA with ROSE was higher. A larger proportion of samples yielded a satisfactory cell block allowing the potential benefit of additional pathology testing including immunohistochemistry and molecular pathology. In summary, the use of ROSE during EBUS-TBNA was superior to off-site cytological assessment of bronchoscopy specimens.