The antimicrobial susceptibilities of 100 clinical isolates of Pseudomonas aeruginosa to six antipseudomonal antibiotics were tested by five methods: the National Committee for Clinical Laboratory Standards (NCCLS) methods for broth microdilution, agar dilution, and agar disk diffusion; the Vitek Automicrobic System method (Vitek Systems, Hazelwood, Mo.); and the PDM Epsilometer test (E test) (AB Biodisk, Solna, Sweden). The E test results showed excellent correlation with agar dilution results, with over 90% agreement within 1 doubling dilution between the E test and reference agar dilution MICs for all antimicrobial agents tested. The E test results also showed good correlation with the results from the reference agar disk diffusion method, with 90 to 99% complete agreement and 100% essential agreement on categories for all antibiotics tested (essential agreement is the agreement obtained when minor discrepancies are ignored). Comparison of categories with the E test and broth microdilution methods, using the broth microdilution method as the reference method, gave only 59% complete agreement for gentamicin, with 28 minor discrepancies and 13 very major discrepancies. Some discrepancies were observed between results from the E test and broth methods for gentamicin, with the broth microdilution and Vitek methods giving higher MICs than the E test and other methods using agar. The most recent NCCLS guidelines for broth dilution testing have reduced the recommended levels of cation supplementation, which may enhance future agreement between results for the aminoglycosides and P. aeruginosa on broth and on agar. We found that the E test offers a simple, labor-efficient, and accurate method for MIC determination on an agar medium.

Prophylactic antibiotics are used in an attempt to avoid the septic complications of endoscopic retrograde cholangiopancreatography (ERCP). We prospectively performed blood cultures and surveyed patients for complications. The aims were first, to determine the incidence of bacteraemia associated with ERCP, second, to assess the incidence of clinical sepsis following the procedure and third, to evaluate the effectiveness of our antibiotic prophylaxis. One hundred and fifty successive patients underwent 179 ERCP. Bacteraemia related to the procedure or the underlying pathology was found in nine procedures (5.2%). Bacteraemias were more likely to complicate therapeutic procedures (P = 0.015), biliary obstruction (P = 0.045) or underlying pathology (P = 0.022). Although 61% of ERCP received antibiotics, 22 septic events occurred. Five bacteraemic patients were septic despite antibiotics. Septic complications were associated with the same factors as bacteraemia. It was concluded that patients with biliary obstruction and undergoing therapeutic endoscopic procedures are at greatest risk of bacteraemia. Single dose prophylactic antibiotics may not prevent sepsis in these patients and longer-acting drugs or repeated dosing may be necessary.

Purpose: Potentially preventable hospitalizations (PPH) are minimized when adults (usually with multiple morbidities ± frailty) benefit from alternatives to emergency hospital use. A complex systems and anticipatory journey approach to PPH, the Patient Journey Record System (PaJR) is proposed.Application: PaJR is a web-based service supporting ≥weekly telephone calls by trained lay Care Guides (CG) to individuals at risk of PPH. The Victorian HealthLinks Chronic Care algorithm provides case finding from hospital big data. Prediction algorithms on call data helps optimize emergency hospital use through adaptive and anticipatory care. MonashWatch deployment incorporating PaJR is conducted by Monash Health in its Dandenong urban catchment area, Victoria, Australia.Theory: A Complex Adaptive Systems (CAS) framework underpins PaJR, and recognizes unique individual journeys, their dependence on historical and biopsychosocial influences, and difficult to predict tipping points. Rosen's modeling relationship and anticipation theory additionally informed the CAS framework with data sense-making and care delivery. PaJR uses perceptions of current and future health (interoception) through ongoing conversations to anticipate possible tipping points. This allows for possible timely intervention in trajectories in the biopsychosocial dimensions of patients as “particulars” in their unique trajectories.Evaluation: Monash Watch is actively monitoring 272 of 376 intervention patients, with 195 controls over 22 months (ongoing). Trajectories of poor health (SRH) and anticipation of worse/uncertain health (AH), and CG concerns statistically shifted at a tipping point, 3 days before admission in the subset who experienced ≥1 acute admission. The −3 day point was generally consistent across age and gender. Three randomly selected case studies demonstrate the processes of anticipatory and reactive care. PaJR-supported services achieved higher than pre-set targets—consistent reduction in acute bed days (20–25%) vs. target 10% and high levels of patient satisfaction.Discussion: Anticipatory care is an emerging trajectory data analytic approach that uses human sense-making as its core metric demonstrates improvements in processes and outcomes. Multiple sources can provide big data to inform trajectory care, however simple tailored data collections may prove effective if they embrace human interoception and anticipation. Admission risk may be addressed with a simple data collections including SRH, AH, and CG perceptions, where practical.Conclusion: Anticipatory care, as operationalized through PaJR approaches applied in MonashWatch, demonstrates processes and outcomes that successfully ameliorate PPH.

ObjectivesThe COVID-19 pandemic has changed the way people are accessing healthcare. The aim of this study was to examine the impact of COVID-19 on emergency department (ED) attendance for frequent attenders and to explore potential reasons for changes in attendance.DesignThis convergent parallel mixed methods study comprised two parts.SettingAn interrupted time-series analysis evaluated changes in ED presentation rates; interviews investigated reasons for changes for frequent ED users in a culturally and linguistically diverse setting.ParticipantsA total of 4868 patients were included in the time series. A subgroup of 200 patients were interviewed, mean age 66 years (range 23–99).ResultsInterrupted time-series analysis from 4868 eligible participants showed an instantaneous decrease in weekly ED presentations by 36% (p<0.001), with reduction between 45% and 67% across emergency triage categories. 32% did not know they could leave home to seek care with differences seen in English versus non-English speakers (p<0.001). 35% reported postponing medical care. There was a high fear about the health system becoming overloaded (mean 4.2 (±2) on 6-point scale). Four key themes emerged influencing health-seeking behaviour: fear and/or avoidance of hospital care; use of telehealth for remote assessment; no fear or avoidance of hospital care; not leaving the house for any reason.ConclusionsThis study demonstrated reduced ED use by a vulnerable population of previously frequent attenders. COVID-19 has resulted in some fear and avoidance of hospitals, but has also offered new opportunity for alternative care through telehealth.